Dr Joanna Cheek: Stigma is scaring people away from talking about mental health

By Dr Joanna Cheek
As originally posted in The Province

My colleagues and I responded to the mental-health crisis by building a publicly funded mental-health program to offer supports to the growing majority of people in the province who can’t access services.

But despite the program’s effectiveness, many seats remain empty. We thought if we built it, they would come. But many still didn’t.

It’s not only the lack of mental-health services that prevent those in need of supports from accessing them. Stigma often scares people away from talking about mental health and seeking out help. The Centre for Addiction and Mental Health (CAMH) reports that stigma stops 40 per cent of Canadians experiencing anxiety and depression from reaching out for medical support.

As a psychiatrist, I understand the causes of mental-health conditions to be complex and varied, illustrated by our “bio-psycho-social-cultural-spiritual” paradigm of mental health. Treatments for mental-health conditions are equally multi-faceted.

Yet our universal health care usually only covers the biological arm of treatment, such as physician visits, hospital stays and medications, leaving Canadians to pay privately for most of the rest. As a result, the Canadian Mental Health Association reported that Canadians named counselling as their highest mental-health-care need, though it was the least likely to be met.

When biological treatments are funded, but psychotherapy often isn’t, we risk misrepresenting mental-health conditions with oversimplified — and inaccurate — biological explanations (e.g. “depression is a chemical imbalance in your brain.”) Medications can be a miraculous part of managing a mental-health condition, but they’re still only one piece of the treatment plan. As psychologist Abraham Maslow famously said: “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.”

Having studied mental-health stigma myself, I previously assumed that the medical model of framing mental-health conditions as a biological “disease like any other” would reduce stigma. But numerous studies show that these biological explanations alone actually worsen stigma as they instill an “us-versus-them” attitude, defining people who experience mental-health conditions as fundamentally different or broken.

Instead, research supports understanding mental-health conditions in the context of our psychological and social stressors — which psychotherapy and other social interventions do — to normalize symptoms and reduce stigma.

This is the exact approach of Derek Thompson-Thlaapkiituup, the director of Indigenous Engagement at the University of B.C., as he gave the opening speech at our annual Pacific Psychopharmacology Conference, the day before this year’s National Day for Truth and Reconciliation. He warned us of the practice of removing the social context of mental-health conditions by diagnosing symptoms in our Indigenous people as a dizzying array of labels from the Diagnostic and Statistical Manual of Mental Disorders rather than as arising from an “affliction of the Residential School Syndrome.”

Yet with the cost of mental-health services a major barrier outside of the public health system, 80 per cent of people are left trying to manage their mental-health-care needs within the publicly funded primary care system. But they often need more support than the primary care provider can provide in a 15-minute visit, if they’re lucky enough to have access to a provider at all. With the primary care crisis, a 2022 Angus Reid poll showed that nearly 60 per cent of British Columbians found it difficult to access care or had no access at all.

While we’ve been advocating for the government to publicly fund more non-physician mental health workers, we couldn’t wait for the slow process of systemic change. We needed to adapt how we offered our own services.

In 2015, my colleagues and I came together to create the Cognitive Behavioural Therapy Skills group program to offer equitable, accessible and timely evidence-based mental health treatments for early intervention on a large scale. With startup funding from the Shared Care Committee (a partnership with the Doctors of B.C. and Health Ministry) and the Victoria Division of Family Practice, we launched a project to offer patients supportive physician-led groups to learn skills to effectively manage the psychological and social stresses that impact their mental health.

The purpose of the group format isn’t simply to improve accessibility (although the numbers speak proudly: each person gets 12 hours of physician time in a group at the same cost to the system as four, 20-minute visits with their family doctor). Rather, the group itself is therapeutic.

The antidote to internalized stigma and shame is in sharing our stories with those who have earned the right to hear them, teaches shame researcher and University of Houston professor Brené Brown. This is also the premise of “contact-based education” — where people with lived experiences of mental-health conditions share their stories of illness and recovery — one of the most promising practices researchers have found for reducing stigma in the public.

“There’s so much stigma surrounding mental illness,” said a past participant. “I still find it nerve-racking to tell someone I have mental-health issues because it’s a gamble: Are they going to ‘get it’ or not? At CBT Skills, we all ‘get it’ because we’re all there for the same reasons.”

These groups empower patients with an eight-week curriculum of the best evidence-based strategies, drawing from CBT, dialectical behavioural therapy (DBT), acceptance-based therapy (ACT) and mindfulness to self-manage mental-health symptoms.

Because of its local success, the Shared Care Committee funded the provincial spread of the project in 2020 to train over 100 doctors across the province, offering these groups both in-person and virtually. This expansion allowed us to offer affinity groups for participants who feel more comfortable or safe in groups with shared experiences, such as those specific to age or gender, Indigenous and 2SLGBTQIA+ identities, people of colour, cancer survivors, pregnant people and new parents.

The program offers a range of additional groups, all available to participants through one referral by a primary care provider. Once a participant completes the foundational CBT course, they’re then offered “Level 2” groups such as CBT for insomnia, mindfulness and boosters (including self-compassion, values, cognitive change and skills for avoidance, perfectionism and procrastination).

There’s also a Raising Resilient Kids’ group that teaches parents and caregivers skills from child development, mindfulness, attachment and reflective parenting, and an ADHD Skills for Success group offering adults strategies to help manage their symptoms of ADHD.

With 397 different groups offered by physicians across the province this year, new participants can start attending with little or no waiting time.

While stigma pushes us to hide from help, the shared experiences of these groups not only support us in managing our mental-health symptoms, but also in healing the associated stigma itself.

Dr. Joanna Cheek is a psychiatrist and clinical associate professor at the University of B.C.’s Faculty of Medicine, and cofounder and co-lead of the CBT Skills Group (cbtskills.ca)

Note: None of the past participants interviewed for this oped were the author’s own patients. Each volunteered to share their experiences for the purposes of this story.