Compassionate Care Curriculum

Finding Compassion in Dark Places

Things are finally coming together.

Things are really starting to fall apart.

Almost exactly two years ago, the headlines in our local newspaper were jarring. On March 25, 2014 the paper read: “With the emergency ward overcrowded, six mentally ill patients were left for 20 hours and resorted to sleeping on the floor while the physically ill got beds.” The bed crisis prompted considerable reflection and in many ways catalyzed my research interests to explore deeper phenomena related to mental illness stigma and the attitudes and behaviours that result in differential treatment for my patients.

After the bed crisis in early 2014, I received support to pursue a two year grant to research and develop interventions related to stigma reduction in my hospital organization. My perspective was simple – we all carry stigma, especially at the unconscious or implicit level. An emerging area of research on implicit bias and healthcare highlights that whether biases are related to race, culture, ethnicity, mental illness, gender or other areas, there is a strong destructive impact of both negative and positive biases on patient care.

Think of this example, if two patients present to triage and one is in emotional distress and the other in physical distress, who does the nurse go to first? Part of understanding the problem is taking a step back and remembering that all providers and staff are nothing but well intentioned. Unfortunately, with time and experience, hospital culture fosters biases that lead us to discriminate against patients with mental illness by avoiding and distancing ourselves from them. This is unacceptable. We all know we can do better.

My initial research reveals that stigma is a result of a complex interaction between processes that take place at individual and societal levels. Systemically, resources are scarce, leading patients to present to the emergency department on a recurring basis. This leads to providers feeling that patients with mental illness are time consuming or seen as a “problem you cannot fix.”

One of the physicians I interviewed stated,

“I will do my best to send someone else into that room, because I know that if I go in, I’m going to be there for an hour…and, at the end of that hour, I’m going to have no answer for this family. It’s the most depressing, horrible thing to deal with because you…like a broken arm, I can fix it. Whatever else, I can deal with it, I can refer them on. With mental illness there’s no sense of satisfaction whatsoever because you emerge from that feeling despondent and feeling like you’re making the family worse because we have nothing really good to offer them in the emergency department.”

Fortunately, there was considerable insight among multiple and disparate stakeholders about the problem and a collective desire to take action and improve the emergency experience for patients/families.

On March 8th, I conducted my first stigma reduction training with emergency department staff including physicians and nurses. The training was designed to highlight biases at the unconscious level that lead to stigmatizing attitudes and behaviours. Significant effort went into providing a safe, non-threatening learning environment for participants. We emphasized that the removal of all stigma is impossible and that rather than foster guilt for our own stigmatizing attitudes or behaviours, we are there to take responsibility for our actions and work to become more empathic and compassionate with the patients and families we work with. The training went on to discuss the psychology of bias and its relationship with mental illness stigma. We discussed internalized stigma, which happens when patients with mental illness feel blamed and shamed for their own illness. We discussed the destructive impact of stigma, which can be significant enough to lead to suicide and lower adherence to treatment. Participants engaged in participatory theatre, role plays and tackled core skills to reduce stigma and take a more empathic and non-judgmental stance. Feedback was almost entirely positive.

After the training I felt hopeful and energized. Spring was all around us. The weather was warmer. It finally seemed like there was some light at the end of the tunnel.

Unfortunately, the darkness found its way back. Over the past several days, a bed crisis at my hospital has led to similar headlines as two years ago. Exactly two years after the original headlines, it almost seems like nothing has changed. The articles read, “Alzheimer’s patient spent 8 nights in ER,” and “Dementia patients creating logjam.” When resources are scarce and the system is in crisis, the clinical environment becomes fuel to the fire of bias and stigma.

When I set out on my journey, I was not sure of whether or not my efforts will succeed. Mentors and supporters reminded me that my goals were “ambitious.” Indeed I would argue they were bold and almost audacious. I set aspirational goals but took the initial humbled and default stance that my efforts would make little to no difference.

My work seeks to trigger transformative change in physicians, nurses, administrators and even policy-makers on how we approach and tackle the treatment of mental illness in Ontario. My educational interventions are designed to foster insight that deeper attitudes and social processes are at play in determining and shaping the care we provide, even before our patients are in the room. Only by recognizing these unconscious forces can we take over our brain from emotional hijacking and work to consciously process information and mitigate the adverse impact of our biases.

One of my favourite Ted Talks by Dave Meslin highlights the problem with apathy and how forces often coalesce to perpetuate disengagement. He states,

“If we can redefine apathy, not as some kind of internal syndrome, but as a complex web of cultural barriers that reinforces disengagement, and if we can clearly define, we can clearly identify, what those obstacles are, and then if we can work together collectively to dismantle those obstacles, then anything is possible.”

Despite the unacceptable lack of treatment options for patients with mental illness, the candle of compassion still burns. Sometimes it flickers, but I know it will never go out.

– Javeed Sukhera, March 2016

About the author

Dr. Javeed Sukhera

Dr. Javeed Sukhera is an Assistant Professor in the Department of Psychiatry at the Schulich School of Medicine and Dentistry at Western University and practices Psychiatry at London Health Sciences Centre. He is a 2015 AMS Phoenix Fellow.

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