Year : 2020 | Volume
: 2 | Issue : 3 | Page : 184--188
In All Candour: Taking Off the Mask
Mental Health Commission of Canada, Ottawa, Ontario, Canada
350 Albert Street, Suite 1210, Ottawa, Ontario K1R 1A4
Louise Bradley, president and CEO of the Mental Health Commission of Canada, reflects on more than a decade of challenges and opportunities faced by the country's first such commission. She delivered the following speech at the 23rd World Congress of Social Psychiatry on October 24, 2019, in Bucharest, Romania. Using her own lived experience as a springboard for combating stigma and spurring discussion, Bradley is a mental health advocate who has straddled both sides of the care divide. Amplifying the voices of lived experience and caregivers is among her proudest achievements. Through her extensive international exposure, she is convinced that every country is a developing country when it comes to mental health – and this is particularly true when one trains a lens on the mental health outcomes of Indigenous peoples – in Canada and around the world. As a former clinical practitioner and hospital administrator – and a lauded voice for equity and inclusion – Bradley's goal is to challenge her audience to acknowledge their own biases, confront self-stigma, and find our shared humanity
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Bradley L. In All Candour: Taking Off the Mask.World Soc Psychiatry 2020;2:184-188
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Bradley L. In All Candour: Taking Off the Mask. World Soc Psychiatry [serial online] 2020 [cited 2021 Apr 22 ];2:184-188
Available from: https://www.worldsocpsychiatry.org/text.asp?2020/2/3/184/304818
Thank you for inviting me to speak to you today, and special thanks to Dr. Eliot Sorel for urging me to come, despite my hesitation that I might not be the most well-suited presenter for this group. You are indeed an intimidating bunch, but I'm on what I like to call my “Freedom Tour.”
For a very long time I toed the party line and did and said exactly what was expected of me. In recent years, however, I've come to appreciate the value of speaking with the candor born from decades of experience. If I don't tell it like it is, I fear I'm setting an example of complacency to those following behind me.
This is an exciting time for social psychiatry in Canada. We're seeing a resurgence of the Canadian Association of Social Psychiatry and a reinvigorated movement into the mainstream. We've even put in a bid to host the next meeting in Montreal. I do hope we're successful and we can return the gracious hospitality and warm welcome we received here in Bucharest.
My dear friend, and former Mental Health Commission of Canada board director, Dr. Manon Charbonneau, is here with us today. She's also the vice president of the Canadian Association of Social Psychiatry. I credit her with rehabilitating my failing opinion of psychiatrists! I know, a bold thing to say in this group, but I'll talk a little bit about that later.
First, I'd like to tell you a little bit about myself.
As a child of the foster system growing up in Newfoundland, I've come by my knowledge of the importance of the social determinants of health honestly. I grew up with adverse childhood experiences. At the time, of course, I didn't know that being poor and being bounced around a lot had a fancy name. I just thought life was tough and tried to get on with it.
That worked until I was about 12. Then I hit a wall.
Everything I'd been trying to suppress came rushing up like a tsunami. And I didn't see a way out. I understand on a deeply visceral level the feeling of not wanting to die but not wanting to live, though it's taken me a long time to talk openly about my lived experience of mental illness. Making yourself vulnerable is terrifying on many levels.
This is especially true if, like me, you are steeped in the culture of giving care to others – if you see yourself as a healer, not as someone who needs to be healed. As a nurse, clinical counselor, and former hospital administrator, I hadn't seen anyone in my peer group come forward with a story of recovery from mental illness. But as a nurse working in mental health I had seen plenty of unwell people I couldn't relate to.
I didn't relate to the woman who kept coming through the doors because she didn't have a home and a safe place to heal.
I didn't relate to the young man who drowned himself in two inches of bathtub water on my very first shift as a nurse.
I didn't relate to them because I was denying my own trauma and wearing a mask of competence that enabled me to be a cog in the wheel of the medical model.
As a nurse, I have inflicted trauma on others. That was a hard thing to come to terms with. I've helped hold someone down to shoot them full of something that makes them quiet and compliant. As a staunch advocate of recovery, my own complicity in a system that habitually incorporated seclusion and restraint as “treatment” is morally repugnant to me today. We aren't born with the knowledge we accrue over a lifetime, and our understanding of our own power to effect change grows as we gain confidence born from experience.
Conquering Stimga Through Shared Humanity
My life changed the first time I saw a health care provider owning her experience as a person living with mental illness. That person was none other than Dr. Charbonneau. She got up in front of a room full of her peers, as head of the Canadian Psychiatric Association, and talked openly, honestly, and with raw emotion about her battle with depression. For me, it was nothing short of a revelation.
To see a psychiatrist with clout, influence, and an unimpeachable reputation ignore the protocols of stoicism and repression, to see her reflect on her experience on both sides of the care divide, and to see her pull back the curtain on her humanity was intensely inspiring. And while I was inspired, I also felt the shame of hypocrisy.
Here I was, safely ensconced in my office, delivering talks on the work of a commission whose mandate – mental health and wellness for all – reflects the values I hold dear to my very core, yet I was being gun-shy. I was worried about what a disclosure would mean. Would I be perceived as competent, or would this truth about me be used to undermine or discredit me?
That's a problem we still face when addressing mental illness. It's not taken as a given that the disease we have is separate from our person. There is no single word to describe someone with cancer, but we have schizophrenic, bipolar, crazy, loopy, mad as a hatter, insane, addict. We could fill a book with the words used to describe a person with a mental illness while erasing their humanity.
We say “person with cancer.” A cancer survivor. A warrior. People with cancer are accorded automatic and well-deserved respect by virtue of their illness. Sadly, we're a far cry from this when it comes to mental illness.
The commission has created several products over the years to help people understand the importance of language. We tackle work that requires the kind of partnership and collaboration that's harder to achieve from within a bureaucracy. As an arm's-length organization, we're able to engage the right experts, and let them lead when that's most appropriate.
A great example is the Mindset media guide, written by journalists for journalists to help the media talk safely and respectfully about suicide and mental illness. I should mention, as an aside, that this guide is readily accessible to everyone. If you think journalists in your home country would benefit from a safe-language primer, download ours. We also have a Language Matters cheat-sheet, for lack of a better word, to help people recognize when their language might be hurtful. We distributed it during our last federal election campaign to all the candidates in Canada's 338 ridings.
So, while we've come a long way on the stigma front, if we still need to have reference guides to prevent us from saying something cutting – intentionally or not – then I think we're a long way out from where we need to be.
That said, in Canada anyway, our progress has been such that people who once stayed silent are finding their voice and coming forward in search of help. We've had countless anti-stigma campaigns over the years – October 2019 was FACES of mental illness – which showcases people living well in recovery from a mental illness, with the goal to debunk the many myths and stereotypes that refuse to dissipate. We've had Bell Let's Talk – a yearly campaign from Canada's largest telecommunications company – tackling stigma head on and pouring millions of dollars into community mental health resources. We've seen Heads Together, started by the Royal Foundation Mental Health program in the U.K.
Leveraging Best Practices
There is no shortage of initiatives to open dialogue and spark real talk. But what's happening is that people are inspired to seek help yet are stymied by months-long waitlists, a lack of access to services and, oftentimes, care that is color- and culture-blind (which has been proven to be ineffective).
The commission has been working for 12 years to bridge some of those gaps, piggyback on international best practices, and demonstrate the value of a program or project on a small scale – with the goal of pollinating those best practices, once proven effective. Our organization has made international agreements with similar bodies to parse out the work and prevent duplication. One such agreement is with Australia's National Mental Health Commission, in which we seek to advance respective priority areas. In Canada we put our energy into addressing workplace mental health, while in Australia the focus is on seclusion and restraint. By doing so, we reap twice the benefits at half the cost.
As a federal commission in Canada, we've got to work with the provinces and territories that hold the purse strings. In some ways, you might say our hands are bound. We don't have a big stick to brandish. But I've always found you get more flies with honey than vinegar and, slowly but surely, as we find our niche and play to our strengths, the power of our influence is leading to major changes, even without the legislative authority to back them up.
Take, for instance, Stepped Care 2.0, a project we've been shepherding at the commission for over 2 years. We wanted to examine whether adding e-mental health and new technologies, combined with single session walk-in counseling, to the existing menu of services, could be an effective means to address the stagnant waitlists.
We got the demonstration program into upwards of 15 primary care clinics across my home province of Newfoundland and Labrador, reaching some 300,000 people. Astonishingly, wait times were slashed by 68%, and now that we've proven this can work, the provinces and territories are knocking on our door to find out how they can replicate this success. So we can take risks as an arm's-length organization without the fear of political reprisal.
My own feelings about mental health care delivery have changed a lot over the years. There was a time early in my career when I believed there was a place for institutionalization. I slowly began to realize, however, that community care is at the heart of success. Back in Newfoundland, I fought tooth and nail against the rebuilding of an inpatient facility that served the needs of <1% of the population. I fought largely with psychiatrists, who failed to see the value of things the commission has long touted as necessary to mental wellness: a home, a job, a friend.
Our At Home/Chez Soi research project, the largest of its kind in the world, proved beyond a doubt that giving a person living with serious mental illness a home – no strings attached – followed by appropriate treatments and supports, is the best, most successful, and most cost-effective solution to the scourge of homelessness afflicting them. This project saw the commission steward a federal investment of $110 million over 5 years and resulted in a major policy shift.
It's safe to say my opinion of psychiatrists was imprinted on my mind as a young nurse. I felt powerless in the face of medicine's relentless refusal to see the humanity in patients and by the dogma that hounds some corners of psychiatry, where biology and neurology are king and our relationships, cultures, kinships, and social contexts are moot.
Today, however, I can say that all is not lost.
Earlier this month, while in the Netherlands, I met Dr. René Keet, an inspired psychiatrist. He is a bright spark and a brilliant mind who has married his creative spirit to his commitment to recovery-oriented care to overhaul an old psychiatric hospital in Heiloo, North Holland. Dr. Keet reinvented it as a warm, inviting space filled with light and laughter, where people living with severe mental illness practice trades like cheesemaking and woodworking or serve in restaurants and staff the on-site theater. It has become a hub for tourists and a true home for the people who live there and are actively working to build a community founded on the pillars of recovery: hope, dignity, and inclusion. Thankfully, this kind of person-centered approach is becoming more common.
Another example is the work of Dr. Brian Mishara, an exceptional psychiatrist leading the commission's signature project this year: Roots of Hope. This community-led suicide prevention initiative aims to reduce suicide by as much as 20% in eight participating communities by harnessing the strengths of the very places beset by suicide.
We had to knock on a lot of doors to get this project funded, and the bulk of the investment is coming from the provinces and territories. But because the commission has the flexibility to source funds outside of Health Canada (our primary funder), we can shepherd projects that are resonating in the communities themselves.
Roots of Hope gives them the equivalent of a model airplane box. Communities then decide how to put it together, what colors to paint it, where to display it. No two solutions will look alike, even though they have similar beginnings.
When Dr. Mishara spoke at our national Roots of Hope launch in September, he gave the most poignant example of why social context is so important – and cannot be assumed. He talked of Rwanda, where psychologists and psychiatrists descended in the wake of the horrific genocide and began to “treat” patients for their traumas. Well, lo and behold, despite Western medicine's best efforts, people were not coming away from their sessions feeling unburdened. They came away feeling worse.
The culprit, as it turns out, was being utterly blind and deaf to the needs of the community in question. When asked, they indicated that warm sunshine, happy memories, and the healing touch of family and friends were the tickets to improved mental wellness – not a sterile room, in isolation, while being forced to relive their trauma.
Is it any wonder, then, that assuming we know best can be even more harmful than doing nothing?
What Easier Access to Services Can Mean
Today, when I think about my own experiences as that young girl in Newfoundland, which seems so long ago (but also like yesterday), I remember the kindness of the first psychiatrist I ever encountered. He saved my life – of that there is no dispute.
After my 3-week stay in hospital, I was discharged without supports. I imagine how my journey of recovery may have hastened had I had access to the Stepped Care 2.0 model. Had I been able to access a peer supporter, a single session walk-in clinic or – more like something out of a sci-fi movie at the time – an app or internet support that doubles as a mirror, reflecting moods and signaling when to get help.
I imagine how my best friend's life might have been different had she lived in a community where Roots of Hope was flourishing. She waited and waited to see a psychiatrist. She waited months, and she was medicated while she waited. It's ironic, and so very tragic, that she died by suicide after her first appointment. The pills carefully meted out by her GP were prescribed in a dose big enough to be lethal.
When it happened I again felt that psychiatry had failed me. I felt Mar-Cha's loss so keenly that I was looking to lay the blame at someone's feet. The truth is that deaths by suicide, as we all know, are complex mysteries of biology, social determinants, and timing. Roots of Hope is banking on its five pillars, including education, means restriction, and public awareness, to knit a safety net that will catch people before it's too late.
Doing Things Differently
I'm here to tell you that mental health commissions are an important ingredient in any successful plan to address mental health crises globally. Commissions like ours in Canada can shine a light on populations who may be otherwise overlooked. We tackle issues that could be politically unpopular, sway hearts and minds with hard evidence, inspire fresh policy built on best practices, and put people with lived experience at the heart of our decision making.
I don't think I need to recite the statistics that reinforce the mental health crisis we face around the world. I'll take it as a given that we all agree something needs to be done. My message is that we need to do things differently. We need to learn from one another and freely share our successes – as our own commission did with the world's first workplace psychological safety standard (which has been downloaded more than 40,000 times). The workplace standard is reshaping corporate culture and is freely available to any organization that wants it.
We need to innovate. We need to identify those bright spots where wait-lists are shrinking or suicide rates are decreasing and replicate them quickly. That's what we are doing with Stepped Care 2.0, which was bold enough to reimagine a system of care where oversubscribed, highly trained professionals are only called on when an online tool, peer supporter, or social worker are unsuccessful.
We need to bring the voices of lived experience to the table, invite them to tell us what we're doing wrong, and be prepared to listen without judgment or defensiveness. The commission has a special advisory body called the Hallway Group, whose members are our experts of lived experience. They are both our toughest critics and our greatest supporters.
We need to own our humanity. As care providers, psychiatrists are not impervious to mental health problems. Money, race, class, education level – nothing can inoculate you. Be willing to be open about your experience and be a listening ear for colleagues.
We need to be honest. The same old patchwork of services isn't going to cut it once we've mounted a campaign against stigma. The dam has already burst. There's no turning back. People across the globe are educated about what they need to improve their wellness, and a hue and cry is imminent as they continue to be disappointed and underserved.
There is no easy solution. But what we're seeing at the commission, with projects like At Home/Chez Soi, Stepped Care 2.0, and Roots of Hope, is that, through partnership, humility, a growth mindset, and a willingness to take responsible risk, we can see a light at the end of what's been a very, very long tunnel.
For every negative experience I've had – as both a provider of mental health care and a patient – I've had an equally positive counterbalance. And for that I consider myself lucky – given the time and place where I grew up. But that can't possibly be the bar we want to set for ourselves.
We need to add some equity to a balance sheet that's squarely at zero. We've got to invest now or we'll pay later – with compound interest to boot. By investing, I don't just mean dollars and cents, though that's part of it. I mean really investing, in finding new ideas, in mentoring emerging leaders, and in building roundtables of lived experience.
I hope you'll join me on this journey.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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|2||Language Matters. Available from: https://www.mhfa.ca/sites/default/files/safer_language_reference_guide.pdf. [Last accessed on 2020 Jan 31].|
|3||Faces of Mental Illness. Available from: https://www.camimh.ca/mental-illness-awareness-week/faces-of-mental-illness/. [Last accessed on 2020 Jan 31].|
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