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Spring 2010 | Vol 13 No 3

Focus

An experiment in discomfort

Resident/consumer group challenges barriers to recovery

By Anne Ptasznik

The women I meet in the recreation room of a supportive housing apartment complex in downtown Toronto have an obvious camaraderie. They take gentle verbal pokes at one another, fuss appreciatively over one woman’s latest knitting project, and share birthday cake.

What strikes me most are the frequent insider jokes and edgy laughter, which stem, perhaps, from their shared experience of dealing with the challenges wrought by the mental health system – some as psychiatric consumer/survivors and others as psychiatrists-in-training. The group, known as RACI, or the Residents and Consumers Initiative, meets monthly in each other’s homes over dinner in an effort to get to know one another informally.

This sort of contact and context can go a long way in challenging the stigma and discrimination consumers sometimes experience from the very people who are supposed to help them. Dr. Patrick Corrigan, lead researcher with the National Consortium on Stigma and Empowerment based at the Illinois Institute of Psychology, has found that frequent contact with people with mental illness can actually intensify stigma among mental health professionals – a seeming irony that in fact makes sense when one considers that context matters. Clinicians tend to see people at their worst, in clinical settings, where the narrow focus on diagnosis doesn’t afford a view into people’s lives when they are not in crisis, where recovery is possible.

What does open a window into those lives is spending more time in normalized settings with people who have recovered or are well on their way. It’s a particularly valuable approach for students-in-training, says Corrigan, so they “learn early that psychopathology is only one side of the illness coin; recovery is the other.”

“We tend to see people when they’re feeling at their worst and those who don’t get better quickly. That leads to a sample bias in our overall perceptions of the impact of mental illness. Because the people who get well don’t need us anymore, we tend not to see them.”

Dr. Priya Raju, a third-year psychiatry resident at the Centre for Addiction and Mental Health (CAMH) who co-founded the group, says that RACI’s informality breaks through the barrier between professionals and consumers, altering the “subtle stigma and power dynamics” involved in psychiatry training. RACI emerged from a chance encounter between another psychiatry resident and a speaker from Voices from the Street, a leadership program for people who have experienced poverty and homelessness. Raju and the other resident, Dr. Rachel Kronick, who has since moved on to a residency in Montreal, met with Pat Capponi, a mental health and anti-poverty activist, and several other consumer/survivors over lunch, and RACI was born. Attendance varies, but at the group’s core are seven consumer/survivors and five residents from the University of Toronto’s Department of Psychiatry. Other health professionals are also welcome.

The group’s founders thought it would be novel to meet with people with histories of mental illness outside of a clinical setting. When someone mentions their illness in the group, it’s a tangential part of the conversation, not the central feature of their lives. It’s a different perspective from formal training, where the focus when consumers are invited to speak to residents is the person’s illness. RACI lets residents see “the other side of the illness coin.” “We gossip about movies, make jokes, hang out,” says Raju. When group participants learn about an aspect of someone’s mental health experience, she explains, it is “in a way that does not make us see people only through that lens.”

It is a lens that is bringing stigma into focus across the country. Dr. David Goldbloom is senior medical advisor at CAMH and vice-chair of the Mental Health Commission of Canada, which is developing a national campaign against stigma and discrimination called Opening Minds. Health care professionals are one of its first targets. “We tend to see people when they’re feeling at their worst and those who don’t get better quickly,” says Goldbloom. “That leads to a sample bias in our overall perceptions of the impact of mental illness. Because the people who get well don’t need us anymore, we tend not to see them.” Goldbloom sees RACI as one way of addressing stigma by getting at medical residents’ attitudes while they are still young and “pre-cynical.” They’ll see “a person with a whole set of strengths and weaknesses, quirks and foibles, talents and promise, who happens to have a mental illness that they’re going to try to help.”

Capponi, too, sees RACI as a step in the right direction: “The worst thing is to be asked to recommend a good psychiatrist to someone in need and you can’t come up with a name,” she says. “I’m glad we have this chance of influencing and getting to know and to trust these new psychiatrists.” Before RACI, Capponi was more accustomed to older psychiatrists, some of whom she says were “set in their ways and surrounded by privilege and attitude.” RACI has changed that perspective. “I never would have thought of psychiatrists as young and vulnerable and questioning,” she says. Capponi believes RACI has been a healthy learning experience for residents and consumers, one that requires participants to be “reasonable, open-minded and prepared to engage. If you want to change people’s hearts and minds you have to be able to listen, and you don’t listen to people by shutting them down,” she says.

The group’s capacity to listen showed itself over dinner one evening when Raju admitted to having delivered electroconvulsive shock therapy (ECT). She was met with a short silence and a gasp. But then the first questions were about how the experience was for her. “It was the most lovely response I could have gotten,” says Raju. Capponi says about that particular evening, “It helped that we already like each other and are aware of each other.” The group talked about how they would never have real agreement on this subject. Capponi knows ECT is part of psychiatric training and believes that the reactions of consumers in the group weren’t “done with a cudgel.” Rather, their reaction was, “Listen, I understand why you did that, but you have to look from our side; it is barbaric and damaging and frightening.” Raju says that discussion has influenced how she would raise ECT as a treatment option with patients.

Dr. Andrew Howlett, a third-year psychiatry resident who has been attending the group for two years, appreciates seeing the strengths and resilience of consumers. “It sheds light on what’s possible, why it’s good to have an imagination and to focus on a person’s strengths, even in vulnerable times or when they’re not well,” he says. The group has helped Howlett to understand other issues that people with mental health problems face, including poverty, unemployment and homelessness.

Violet*, a survivor of childhood trauma who has been attending RACI for about one year, also appreciates this broader perspective: “Understanding that having certain things, like a home, a job, a sense of value and worth, can heal you a lot faster than any medication,” she says. “If we have understanding and supportive professionals that don’t allow their training to make assumptions, they will find that their work is actually more productive and effective in the long run.”

But Raju sometimes wonders whether three hours a month with the group can rival the realities she faces through long hours spent with people in the emergency room or on inpatient units. Although she knows intellectually that mental illness exists on a continuum, “it’s really hard to combat experience,” she admits. Often the people who return to the emergency room over and over again have had schizophrenia for 20 or 30 years and are still quite ill. Still, Raju believes RACI is having a positive impact. Compared to her colleagues, she says, “I’ve had more exposure to dynamic, passionate, articulate people with psychiatric histories. Maybe even three hours a month is a fair bit more than most people get.”

*not her real name