Barriers To Access And Care

Research has identified several issues contributing to stigmatization in healthcare, which have direct and indirect impacts on access and quality of care for persons living with mental illnesses. These have been described as ‘‘key learning needs,’’ acknowledging that they are specific concerns that can be changed through targeted initiatives.

People with lived experience of a mental illness commonly report feeling devalued, dismissed, and dehumanized by many of the health professionals with whom they come into contact. Key themes include feeling excluded from decisions, receiving subtle or overt threats of coercive treatment, being made to wait excessively long when seeking help, being given insufficient information about one’s condition or treatment options, being treated in a paternalistic or demeaning manner, being told they would never get well, and being spoken to or about using stigmatizing language.

While research also highlights many positive patient experiences, the pervasiveness with which negative interactions are reported suggests the problem is not isolated to a few insensitive providers but is more systemic in nature—that it is a problem with how healthcare culture prioritizes and perceives persons with mental illnesses.

Research with healthcare providers is consistent with this idea, finding that stigmatizing attitudes and behaviours towards persons with mental illnesses exist across the spectrum of healthcare. Also, patients with certain disorders, such as personality disorders, tend to be particularly rejected by healthcare staff and are often felt to be difficult, manipulative, and less deserving of care. A Canadian qualitative study articulated stigmatization among health providers to be, at least in part, related to a tendency ‘‘see the illness ahead of the person,’’ which can contribute to a failure to use person-first language and/or a tendency to engage in behaviours that may be experienced as dismissive or demeaning. Burnout and compassion fatigue have been identified as exacerbating concerns.

A survey conducted by the Canadian Psychiatric Association found that 79% reported first-hand experiences of discrimination towards a patient and 53% observed other medical providers, discriminating against a patient from psychiatry.

Stigma also has consequences for patient safety. Persons with lived experience of a mental illness commonly report barriers to having their physical care needs met, including not having their symptoms taken seriously when seeking care for non-mental health concerns. Studies also demonstrate that persons with mental illness histories receive poorer quality care for their physical health problems. This is believed to occur largely through a process of diagnostic and treatment overshadowing, whereby physical symptoms are misattributed to a patient’s mental illness, creating delays in diagnoses and treatment options.

Key ingredients for effective stigma reduction in healthcare contexts have been identified. These include teaching skills that help healthcare providers know ‘‘what to say’’ and ‘‘what to do,’’ ensuring program facilitators are modelling person-first behaviours and making ample use ofsocial contact. Social contact generally refers to hearing first-voice testimonies from people with lived experience of a mental illness who are trained to speak about their experiences of illness and recovery, as well as their experiences within the healthcare system, and is a key strategy for interprofessional educational approaches to stigma reduction in healthcare. It is a qualitatively different kind of contact from typical provider-patient interactions. In social contact approaches, people with lived experience of a mental illness are seen not as patients but as educators. Social contact has been shown to disconfirm stereotypes, diminish anxiety, heighten empathy, make personal connections, and improve understanding of recovery.

Two other key ingredients have also been identified. The first is providing interventions that include myth busting or a transformative learning focus to target unconscious biases and correct false beliefs that may be negatively impacting care. The second is demonstrating/emphasizing recovery from a mental illness and showing ways in which healthcare providers play an impactful role in that process. For example, skills-based interventions focus on behaviour change by aiming to improve confidence, comfort, and understanding of mental illnesses as being inherently treatable and manageable. An evaluation of such programs in Canada and the US found that physicians reported decreased reliance on prescribing antidepressant medications, felt their patients were better able to stay or return to work, and reported improved patient care along with a significant reduction in social distance.

Another important model is that of intensive social contact, where health providers meet at multiple time points with a person with lived experience of a mental illness living in recovery in order to learn about that person’s life and experiences. Evaluations have shown this model to be effective at improving attitudes and behavioural intentions and sustaining those improvements over time, and qualitative research suggests the personal and cooperative nature of the social contact can provide a powerful and positively transformative learning experience for both providers and client educators.

Reference: Knaak, S., Mantler E., and A., Szeto. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions, Healthcare Management Forum. The Canadian College of Health Leaders, Canada. Vol. 30(2). Pages 111-116.