Canadian Veterans Advocacy

Wednesday, October 29, 2014

New announcement: Stigma & Mental Illness: History & Our Hope by Dr Antoon A. Leenaars

Written requested testimony/submission to the Parliamentary Committee on Palliative and Compassionate Care, Ottawa, February 2, 2012.

Stigma & Mental Illness:
History & Our Hope

Antoon A. Leenaars, Ph.D.
First Past President, Canadian Association for Suicide Prevention
Windsor, Canada

Mail: Antoon A. Leenaars, Ph.D., C.Psych.
1500 Ouellette, Suite 203
Windsor, ON
Canada N8X 1K7
Tel: (1) 519-253-9377
Fax: (1) 519-253-8486

People are generally perplexed, stressed, confused, and even experience prejudicial reactions when they are confronted by mental illness. There is a tremendous stigma attached to mental illness, psychopathology, psychiatric disorder, imbalance - whatever we may wish to call it. Mental disorders have always fascinated, yet frightened people. There is a modicum of comfort in regarding the imbalanced as "different" from the rest of us "healthy" Canadians. We see mental illness as something another person is plagued with, or punished with, or jailed for. We are not responsible! We, the sane Canadians - at least those on Parliament Hill - are immune to those sicknesses. "They" are sick, sick, sick.

"No brain, no mind" is my first premise. Mental illness is multifaceted with biological, cultural, sociological, interpersonal, intrapsychic, logical, conscious, unconscious, and philosophical elements present, in various degrees, in each incident. I do not want to be viewed as being reductionistic. Some reduce psychiatric disorders to the biological roots only. Efforts aimed at identifying the potentially mentally ill individual using demographic, social developmental and psychological factors are seen as too ephemeral to have clinical utility. It is believed that the biological perspective, which has grown out of the expanding research on the biological basis of mood disorders, is the predominant approach to research. Utilizing only this view will lead us astray, however, on the topic at hand. (Stigma and mental illness are not simply biological anomalies). Imbalance is complex, more complex than most people are aware. It is not only the brain. It is not only the mind.

My point is that the last time that I looked at my anatomy book, the brain is an organ, no different from the heart, lungs, etc. - yet, despite that obvious fact, there is enormous stigma to having an emotional disturbance, but not (or at least, less so) a kidney disturbance. That is prejudice. That is stigma. This stigma, sadly, was/is/will be suicidogenic!

A definition: Stigma is a branding, as a sign of disgrace or discredit (Oxford English Dictionary [OED], n.d.) " Stigma is a term once used to refer to a mark branded into the skin of slaves and criminals, so others would know to shun them, especially in public" (Nielson, 2011, p. 8). It is a blot, brand, disgrace, slur, stain, taint, and so on (OED).

Let us look back, to allow us to understand stigma and mental illness:
Some History on Mental Illness and Stigma

During classical Greek times, Aeschylus saw mental illness as being due to demonic possession, whereas Socrates believed that it was heaven-sent, not shameful. Hippocrates believed that psychopathology was due to natural medical causes and melancholia. Mental illness was seen differently; yet, over time, it became primarily seen as a mental (intrapsychic) problem. The person was to blame; they were sinners or criminals. Evil spirits, moral weakness, personal inferiority, and so on, caused the disorder. They were outcasts, and surely different from the majority of "moral" people. At times, they were accused of witchcraft, sorcery, devil worship, and other crimes. Stigma was well established, and still is!

There are many details to the history (Foucault, 1965; Rabkin, 1972). In the 'Western world', from 1500 to 1800 the mentally ill became to be seen very differently (Foucault, 1965). From the Middle Ages when insanity was seen as part of everyday life and "fools" and "madman" were considered part of the community, to the time when these individuals were considered a threat, asylums were built for the first time, to keep a wall between the mentally ill and the rest of humanity. The "madman", by many, was seen as a sinner or a criminal. (Of course, many people with physical illness were seen no different). By the middle to late 1800's, "insanity", especially by medicine, was believed to be inherited. A core 'medical' belief was that people with mental illnesses are genetically inferior, weak, and so on. (Again, no different from the "fact" espoused of the genetic inferiority of people with physical impairments and disabilities). Suicide was believed to be "the most hereditary type of insanity" (Colt, 1991). We, not so inflicted with bad genes, are superior. Although medicine eventually espoused that suicide was not genetically transmitted, a new stigma arose. Colt (1991) writes:
"All the superstitious fear of the queer and the mad attached itself to suicide; the instinctive withdrawal of the sane from the tainted extended itself…" wrote Henry

Fedden in Suicide. Finally, these new medical ideas hardened family prejudice against suicide: a suicide in the family became tantamount to insanity in the family, a stigma not confined to one member, but attaching jointly to the whole group of its descendants." With birth of the medical approach to suicide, the act of self-destruction was no longer viewed primarily as a sin and a crime but as something abnormal and sick" (Colt, 1991, p. 188).

Therefore, mentally ill people were still seen as abnormal, weak, and "sick". Stoff and Mann's (1997) edited volume, The Neurobiology of Suicide, begins to outline the current understanding of the neurobiology of suicide. On a critical note, however, one could see Stoff and Mann's view as being too reductionistic. They reduce suicide to only biological roots. Ironically, these biological doctors state that the earlier medical beliefs in psychiatry and psychology, that mentally ill people were genetically inferior, were based on unscientific myths. They are evidence-based. Therefore, the stigma continues.
The main finding of our historical dig is that we see ourselves as normal; and they as being abnormal. I'm ok, they are not ok! Of course, there were mental health providers and advocates who wanted to change and tear down the walls or barriers. Many of those, who themselves were accused of crimes, witchcraft, etc., and who have made a difference include: Galen, who considered psychic factors in the brain to cause mental illness; Campbell Meyers, who in 1906 started Canada's first public general hospital unit for mental illness at the Toronto General Hospital; Dorothy Dix, who began advocating in America for benevolent care; Rev. Bruce McDougall, who started the first outreach telephone crisis line, in 1963 in Sudbury, ON; and many more advocates for justice. However, even today in Canada and the U.S. there is a great deal of stigma. Hollywood gives us a window. Most of the portrayals of mental illness in film are demonizing; for example, think of One Flew Over the Cuckoo's Nest. They foster the difference, "not ok". Who can forget the portrayal of insanity and the standard of care by Nurse Ratched? The stigma of mental illness has not been eradicated! It is alive in Canada. It is a major barrier to wellness for many in Canada today.

There are, of course, many historical case examples. Given my focus on police (see Leenaars [2010], Suicide and Homicide-Suicide among Police), I will illustrate with a classic example of mental illness among police:
'Suicide in police is at epidemic levels.' These were the headlines in the New York media, 1934-1940. Ninety-three New York police officers died by suicide. Anyone who wants to know something about police and mental illness needs to know about the classic study of the great 1930's suicide epidemic in police. It was the work of Gregory Zilboorg. It still is a unique but common window to the topic of psychopathology and suicide among police. Zilboorg's work offers an avenue for an effective study of mental illness. There was enormous stigma to having a mental disorder then, which is no different from today. On this, we read:
One manner of handling the mentally or physically ill patrolman was to take him away from regular duty. This most frequently meant placing him on the duty called "raided premises," which usually consisted of guarding raided houses or hotels used by prostitutes. The purpose appeared to be that of keeping prostitutes from again inhabiting the place. The patrolman sat quietly by himself in one spot for a full eight-hour shift. In other instances, the recipient of light duty was given a simple errand or clerical job. In the case of both assignments, the average policeman felt much contempt for the job and condescending sympathy for those assigned to it. Some of our cases avoided and feared these assignments, saying, "I'll be damned if I'll cut paper dolls all day." As one said, "It's the next step to the nut house." One patrolman who felt that he was being "discriminated" against refused an inside assignment with the words, "That's no job for a man." In his disturbed behavior he thought people were claiming that he was "not a man." (Leenaars, 2010, pp 84-85).

How many Canadians feel so? Estranged?
Basic Human Rights and Standards of Care

The United Nations Working Group on the Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (United Nations, UN, 1991) has offered some principles of basic human rights. The UN's first principle on basic rights has as its second clause: "2. All persons with mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person". Canadians need to adopt that principle. Furthermore, The United Nations describes standards of care: "1. Every patient shall have the right to receive such health and social care as appropriate to his or her health needs…" and "2. Every patient shall be protected from harm including unjustified medication, abuse by other patients, staff or others or other acts causing mental distress or physical discomfort". These are standards, I believe, we Canadians should hold. Stigma needs to be eradicated. It is harm.

The Standing Committee of Social Affairs, Science, and Technology's report Out of the Shadows (2006), agrees; stigma is the number one problem for people with mental illness. The Mental Health Commission of Canada has developed an anti-stigma initiative out of the report's recommendations. Yet, as Nielson (2011), a senior advisor to the Mental Health Commission, stated we need to do more: "Ultimately, the vision is to create a Canada where all citizens are supported in their efforts to be physically and mentally healthy, and where those in need of help are able to get it – and where those to whom they turn can provide it." (p.9)

My personal core belief: The only reason for stigma towards mental illness is our own anxieties! It is a defense (intrapsychic [within the mind], interpersonal, and social/cultural): denial and projection. It is bullying!

A definition: Bully is browbeat, coerce, domineer, frighten, harass, intimidate, oppress, persecute, threaten, torment, tyrannize (OED). Lindsey Leenaars and David Lester (2011) have found that individuals with significant mental health concerns are more likely to be victimized and bullied. They are not only more frequently subjected to physical and verbal bullying, but also more likely to be \ostracized, rejected, and humiliated (Leenaars & Rinaldi, 2010). However, Charles Dickens in Oliver Twist wrote: "Mr. Bumble… had a decided propensity for bullying… and, consequently, was (it is needless to say) a coward."

The Complexity of Anti-Stigma Initiatives

The complexity of our topic calls for diverse strategies. This is necessary to not only solve what is sometimes assumed to be primarily a "medical problem", but also to address the deep taboo and its stigma. Our history shows that silence was the goal. Secrecy was Canada's national strategy. It was effective. There was/is secrecy. Allow me, my example, on suicide: The recognition of suicide as a major health problem is relatively new. Marc Lalonde, the Minister of Health, had commissioned a study of public health problems in the 1970's. His White Paper (1974), as it became called, identified suicide as a major cause of early death, especially in the young. This was a surprise to most Canadians, including the government. It was/is a taboo. The deep taboo, and the associated stigma, continued and little, actually nothing was done. There was secrecy. There was silence. I believe more needs to be done about the siblings - suicide and mental illness - by the federal government, professionals, survivors, stakeholders, and the public alike to break the silence.

There are general characteristics of the Canadian system that lead to the existence of strong psychological and social taboos. These traits minimally include:
1. Secrecy. Mental illness has been and is all about secrecy, the importance of keeping our disabled, not only mentally disabled, in the home. Mental illness is believed to be a mark on the family – and all descendants. The secrecy creates, however, a culture of not knowing; there is masking or dissembling. There is deception, even self-deception. One is indoctrinated, not necessarily directly, to keep silent.
2. Appearance. It is important to keep up "appearances". Social-self (a mask) is you. The social/cultural appearance of stability and strength is everything. This belief needs to be reinforced in order to maintain the mask! There is, in fact, a huge prejudice in Canada towards imbalance, instability, mental illness, depression – and especially, suicidality.
3. Denial. Mental illness must be denied. Canadians must keep all the feelings, fears, or "normal" familial stresses under wraps. What it does mean for most families is that the realities of mental illness are not expressed, fears are not shared, and the need to ask for help or request assistance goes unnoticed. A core belief: To get help is weakness!
Therefore: Secrecy, "appearance", and denial are walls! These characteristics often determine whether Canadian citizens seek treatment. To the extent that seeking mental health treatment is defined as "weakness", people in need may be slow to obtain and pursue services. (The road to wellness takes perseverance). Often this reluctance to seek help delays treatment, which ends up pushing many beyond tolerable stress levels, and some to suicide – also a few to homicide. Addressing these characteristics may decrease the chance of citizens denying or minimizing symptoms, and thereby help them benefit from a professional's ability to normalize their beliefs about fears, stigma, and future treatment. Mental illness and suicide risk can be effectively helped (Leenaars, 2004).

My belief: Not talking about mental illness will cause more imbalances. The "insane" were kept secrets. They were a societal shame! The problem was kept invisible. The main reason was stigma. One would hear, "Oh, Joe is a basket case." Or, "Sally is crazy". It was not acceptable to be mentally ill - all too often suicidal - or to get help; somehow it was more acceptable in Canada to lie in a coffin. I hope that we can count on this parliament's intention to change this iatrogenic attitude (belief).

A final thought to ponder: People with mental illness have often been described as being manipulative. "It is just to get attention" is a common belief. The mental health patient is seen as just weak and is often described as a person who is actually just dissatisfied with life. He or she is a coward. People with psychopathology are often described as "immature, inadequate, and sociopathic". In Canada, there is stigma and very high Canadian walls. (Would you reveal your "cowardly weakness" in such a cultural milieu?)

Mental Illness, Stigma, and Culture

Understanding mental illness is not enough. Helping professionals, such as institutional administrators, medical personnel, and mental health professionals, must also understand the unique culture in which mental agony is experienced and endured. The set of beliefs and attitudes shared by people in Canada forms the context of community care. These cultural beliefs sometimes make it difficult for citizens to acknowledge their own stress, or to fully engage in a partnership with helping professionals to reduce their 'howling tempest' of the mind (Styron, 1990). There is enormous fear and anxiety in Canada!

Culture is diverse - and allow me just to scratch the surface: When investigating cultural differences, a distinction is often made between Western or individualistic cultures and non-Western or collectivistic cultures. Individualism is "a social theory favouring freedom of action for individuals over collective or state control", whereas collectivism is the "practice or principle of giving a group priority over each individual in it" (Oxford English Dictionary, n.d.). Stigma is known to be greater in most collective cultures (Leenaars, Sayin, Candansayar, et al., 2010). There is greater silence, dissembling, and shame. For example, one of the major social obstacles in getting help for psychopathology or suicidal behaviour is stigmatization (Grad, Clark, Dyregrov, & Andriessen, 2004). Grad et al. argued that stigma surrounding suicide may occur for different cultural reasons including religious sanctions and judicial laws, and may be expressed differently through discrimination from religious, or social communities (There are, of course, other discriminations or barriers; for example, age. Ask the elderly). It is not only the person with a mental disorder, but also the larger community. The stigma surrounding mental illness has a profound effect on family and community members and can bring with it shame, guilt, disgrace, and alienation. Canada is a diverse country; immigrants come from individualistic and collectivistic cultures. Greater stigma exists in collective cultures. The immigrants of those countries not only bring their culture with them, but also how it impacts on mental illness and suicide, and even their rates of suicide. Some countries have high rates, some low. Allow me to illustrate the marriage of culture and stigma with mental illnesses' sibling, suicide:
Religion plays a large role in how mental illness and suicide are viewed. In Canada, which is predominantly Christian, suicide is still condemned. Traditionally, and in most cases today, suicide is seen as a serious sin in Judaism, Christianity, and Abrahamic religions (e.g., Islam). Beliefs about suicide in India's religions are diverse; for example, it is considered a sin in Hinduism, the predominant religion, with some exceptions; it is allowed in Jainism; and is seen as a negative action, but not condemned in Buddhism. Religion plays a role in our taboo. Furthermore, there are wide cultural differences in the stigmatization of suicide around the world, which affects individuals' responses to a suicide trauma (Grad et al., 2004). Some do not see nor help those in need. This is true in Canada.

The stigma associated with suicide has a long legal history as well (Stanford Encyclopedia of Philosophy [SEP], 2008). In ancient Greece, a person who committed suicide was denied the honours of a traditional burial. In 1670, Louis XIV ordered persons who had committed suicide to be dragged face down through the streets, hung, or thrown on top of garbage, and all property confiscated (Durkheim, 1897/1997). In more current history, suicide has only recently been decriminalized or continues to be punishable by law (SEP, 2008). For example, in Australia, although suicide is no longer a crime, a survivor of a suicide pact can be charged with manslaughter. In Western countries such as the U.S. and England, suicide has only recently been decriminalized. Specifically, suicide was made lawful in 1961 in England with the Suicide Act of 1961. Yet, in Ireland, decriminalization only occurred a few years ago. There are many countries around the world where attempted suicide is still a crime. In Canada, legislation in 1972 removed section 213 in the criminal code; attempted suicide was then no longer considered a crime. Imagine, only 40 years ago, not 100! That is not only stigma, but also a crime. Our culture needs to change; we need to change what we can. Our efforts must be culturally and community/socially sensitive, however. Canadians need courage to change what they can!

Public Health and Anti-Stigma Efforts

Public health approaches target the factors beyond the individual. They are primarily focused on the community and societal levels, but may also be at the relationship level (e.g., with family members, with health providers). (See WHO [2002] ecological model). Community or public health aims to maximize benefits for the largest number of people. It is interdisciplinary and evidence-based. It draws upon knowledge from many disciplines, including biology, medicine, psychology, psychiatry, sociology, anthropology, philosophy, politics, ethics, political justice, and so on. It emphasizes collective action. Furthermore, most importantly, it has been proven to be effective. The public health approach is an innovative, rational, and organized way to marshal prevention efforts (Leenaars, 2005; Jenkins, McCulloch, Friedli, & Parker, 2002). This is not to say the approaches with an individual, such as psychotherapy and/or pharmacotherapy are not effective, only that public health approaches attempt to address the problem in a different way. This is necessary when dealing with stigmatization, by definition.

Stigmatization is a preventable public health problem. The factors isolated to date that can help include: decreasing stigma; building social networks and help-seeking behaviours; and enhancing understanding of mental health in the community. A truly Canadian public health effort is paramount – to stop the fear of mental illness. As in the past, so too today a Canadian citizen with a mental illness, who feels Canada's stigmatization, will thus feel sick, sick, sick. This in turn may heighten his or her risk for suicide, and even homicide – which has obvious implications for what we do in Canada. Shame and disgrace would be predicted – the Canadian culture makes it so.

Does this live up to the UN principle?
Standard of Care and Stigma

Care for people with a mental disorder(s) should be reasonable and prudent. Yet, what is "reasonable" and "prudent"? The community typically defines the yardstick (Leenaars, Cantor, Connolly, et al., 2002). We can all agree, however, that stigmatization is not reasonable and prudent care. Although this is relevant in all treatment, such as psychotherapy and medication, I need to make a special comment on hospitalization. Hospitalization is complex; all treatment of people with a brain illness is complex. Many issues are involved, but stigma is one. The topic is so vast that it would call for a report of this honourable Committee on the topic itself. The main point: Hospitalization should never be eschewed, if needed. It probably works best, however, if stigma is eradicated. Hospitalization will save lives. Of course, treatment must be not only a multi-method, multidisciplinary approach, but also it has to be not iatrogenic! Otherwise, it should be eschewed! To quote a father of suicide prevention, Edwin Shneidman (1980), "the quality of care from doctors, nurses and attendants is crucial."

Most alarming is Rosemary Barnes' (1986) study of care in Toronto hospitals. She found strong evidence of stigma and prejudice among health providers. Among health providers, there were negative beliefs towards mental health patients - some suicidogenic. A main finding was that the negative attitude was especially evident towards patients who repeat suicide attempts. She found: The greater the number of attempts, the greater the negative attitudes. This is not a strong basis for quality care. This is tantamount to failure in care! Our attitudes can be life-enhancing, but also death-promoting. Case studies converge on this topic. As a forensic expert, I have provided opinion in cases of wrongful death, including in hospitals; quality of care is paramount. Stigmatization was often a factor. The question: Was stigma the "last straw"? Barnes' Canadian research says it can be. Shneidman and I agree! At times, in forensic cases of institutionalization, I noted even deliberate indifference!

What constitutes wrongdoing? What is malpractice? What is "stigmatization"? When are mental health workers liable? Gutheil (1992) suggested that there are fundamentals of malpractice, related to the following: the existing clinician-patient relationship; negligence or the breach of duty (although negligence itself does not necessarily equate with liability); the negligence results in specific danger or harm; and the fact that the clinician was negligent resulting in the patient committing suicide, if the element of causation is determinable. Demonstrating causation is often difficult; this would be true in the case of prejudice, and even more so deliberate indifference, which stigma may imply. Gutheil offers a metaphoric example that best illustrates the issue. He writes:
Consider a camel with serious osteoporosis of the spine, whose back is laden with straw. A final piece of straw (the proverbial "last straw") is placed on the back, and the camel's back breaks. In utilising a clinical analysis of the situation, the clinician would consider the pre-existing condition of the camel and its back, the burden posed by the pre-existing straw, and the final straw leading to the condition of clinical compensation. (Gutheil, 1992, p. 150)

The legal viewpoint, at least in Canada and the U.S., focuses on the last straw, which is called the "proximate cause". The question is a "but for", and we quote Gutheil again, "But for this last straw, the camel's back would not have been broken" (p. 150). In suicide, the relation is more perplexing; yet, the metaphor applies. The question is, did the failure in care/stigmatization cause the suicide? The answer lies in the statement "Dereliction of a duty directly causing dangers" (Gutheil, 1992, p. 150). Prejudicial and negative attitudes, such as identified by Barnes, can be dereliction. Anti-stigma efforts have application to in-hospital suicide, outpatient suicide, and so on.

What do we need for a change in care? From a public health perspective, this is a question for all levels of government, including the federal one, as well as for our communities. On January 14, 2011, my city's newspaper, The Windsor Star (Scaheli, 2011) presented a front-page story of the needless suicides of Steven Kokotec and Margaret Draskovich. They were suicidal and sought care, but they were turned away and/or escaped from a hospital. Within minutes of the estrangement, they were dead. Having courage, the survivors have shared their stories and, understandably, have pleaded for action. They do not want this to happen to other Canadians and their families! Was there dereliction of care? Was there stigma? The survivors reported that they felt the stigmatization! I was interviewed for the article, and called for focus, not on what was done wrong, but on what we can do to stop such needless deaths! What will help? What can be done at a federal level?

A Few Observations on the Cognitive-Dynamics of Stigma on Mental Illness

As you have learned, within Canada, the common existence of a person with mental illness is estrangement. The person is disenfranchised! All too often the wish to live is replaced with the wish to die. The root psychological cause of suicide is trauma, the traumatic experience of loss and/or rejection of a significant highly cathected person, such as a loved one, or a doctor, or a therapist, and all too often society (Freud, 1917/1974, 1920/1974), or some other ideal (e.g., youth, health, citizen hood) (Leenaars, 1996). This "overpowering affect of aloneness which makes life unendurable for a large number of suicidal individuals can be understood within a general class of primary (automatic) anxiety. The eerie devastation of adult aloneness (not loneliness) probably repeats the empty hours of an infancy where no empathic soothing was available to relieve imperative needs and fearful tensions." (Maltsberger, 1986, p. 7)

Suicide is an intrapsychic drama on an interpersonal stage (Leenaars, 1996, 2004). The common state of mind of an estranged person with psychopathology is pain. The common stimulus in suicide is unbearable psychological pain (Shneidman, 1985). The suicidal Canadian is in a (automatic) heightened state of perturbation, an intense mental anguish. It is the pain of pain. The person may feel any number of emotions such as feeling alone, rejected, deprived, bullied, distressed, and especially hopeless and helpless (Leenaars, 1996). Aaron T. Beck (1963, 1976) has shown that a critical link between mental illness and suicidal intent is hopelessness (Beck, Kovacs, & Weissman, 1975). The hopelessness is something like " Canadians will always be this way, stigmatizing". The helplessness is something like, "No one can do anything about it. The Ministers of Parliament can do nothing about it". The suicidal person perceives suicide as the only possible and best solution to his/her desperate and hopeless, unsolvable problem (trauma) (Beck, 1963). The suicidal person views him/herself as deprived, forlorn, abandoned, estranged, and so on. There is/was/will be a narcissistic injury! (Leenaars, 1996). The suicide is functional because it stops, among many other things, the stigma (the mark), and the pain.

All this occurs in a common cognitive state of mental constriction; i.e., rigidity in thinking, tunnel vision, stinking thinking, etc. The imbalanced, suicidal person is figuratively "drugged" or "numbed" by the constriction; the intoxication can be seen in emotions, logic, and beliefs (Shneidman, 1985). The suicidal person's thoughts, which are often automatic and involuntary (unconscious), are characterized by a number of possible errors, some so gross as to constitute distortion; e.g., jumping to conclusions, magnification (making a big deal), all or nothing thinking, putting things in a nutshell (Beck, 1963, 1976; Beck, Kovacs, & Weissman, 1975). This mental constriction is the most lethal (dangerous) aspect of the suicidal mind (Leenaars, 1996; Shneidman, 1985). The bullied, suicidal, mentally ill person, being alone, hopeless, and not wanting to tolerate the pain (angst, depression, anxiety, feeling alone, and so on), desires, if not needs, to escape. Suicide is escape (egression) (Leenaars, 1996).

It is, however, more than aloneness, feeling estranged, and hopelessly in pain. Maltsberger (1986) offers a deeper interpretation. He writes:
There is a second intolerable affect, suicidal worthlessness, closely related to the first, aloneness, as a subjective experience and as a pathological development. The subjective experience of utter worthlessness is related to the experience of aloneness and cannot be entirely separated from it because both threaten, or even announce, irrevocable abandonment. In the grips of aloneness the patient is convinced he will be forever cut off from the possibility of human connectedness; in suicidal worthlessness, the patient is convinced he can never merit the caring notice of anyone, including himself again. The subjective result is very much the same; to be beyond love is to be hopelessly alone." (Maltsberger, 1965, p. 9).

The beliefs of the suicidal person are, however, faulty. The best known faulty syllogism may well be:
All men are immortal
Socrates is a man

Therefore Socrates is immortal.
The above syllogism is valid, but it is also faulty because it begins with a first premise that is false. All men are not immortal. It is a false universal inductive generalization. It is basic to realize that a valid syllogism can have a false conclusion. This can happen if one or more of the premises are false. In the suicidal person, the first premise (sometimes called core beliefs) is not only false, but also lethal.

Edwin Shneidman (1985) has been keenly interested in making explicit the latent logical (cognitive) components of everyday thought. He realized how useful it is to examine the cognitive styles exhibited in each suicidal person. For example, in a terse but insightful paper, "On 'Therefore I must kill myself'" (Shneidman, 1999), he shows how vitally important it is for a clinician to understand the mentally ill patient's idiosyncratic logical style – and then not agree with that patient's major premise when the premise is the keystone to the patient's lethal (suicidal) syllogistic conclusion. For example, "People who have a mental illness are worthless and ought to be dead; I am a person who has a mental illness; therefore, I am worthless and ought to be dead". For another example, "Soldiers who are disgraced by the commander ought to be dead; I am a soldier who has been incarcerated (disgraced); therefore, I ought to be dead." For another example of a deadly belief, "People who are "sick, sick, sick" ought to be dead". This is stinking thinking; the first premises are false. These are distortions (Beck, 1963, 1976). The suicidal person is, however, convinced! The indoctrination (denial and introjection) has been successful; he/she believes that she/he is inferior, weak, and "loveless". The mentally ill person believes the stigma. He/she is worthless!

Stigma gives the gun to a mentally ill person!

A Call To Action
The challenge - "We have to know how we are helping." Stigmatization is not helping. These are great challenges. Yet, the Canadian government knows how, but only if the MPs have the will do to so. People with mental illness do not need to feel estranged. They do not need to die. I hope that I have brought the audience, whether a MP, stakeholder, health provider, and many more, a little closer to a plan. Regardless of what the policies and procedures will be, they have to be grounded in evidence-based study. (I hold to a broad definition of the term, evidence-based, and not only randomized control trials as some espouse.) We need to get past the stigma of PTSD, Bipolar Disorder, Schizophrenia, suicide attempter, depression, ADHD, emotional disturbance, and so on, an endless list. Yet, we, each of us, have to own the problem, otherwise nothing will get done. We cannot wait for a Prime Minister to do something. We, people with a psychiatric disorder, and those of us who are not so suffering, but working with them on multi-disciplinary teams; providing mental health services to patients and their families; administrating to such Canadians; surviving a suicide; providing survivor/bereavement services, after the death by suicide; and many more, need to own the problem, nothing will get done otherwise. We are the anti-stigma!

The stigma, as discussed earlier, is one of the greatest barriers to wellness in our Canadians with mental illness, or any disability, for that matter. To tear down the walls, it begins at the top – and that means with the Prime Minister. The stigma associated with receiving help for mental illness and suicide risk continues to be substantial. For many reasons, it is vital for the Committee to convince the federal (and provincial/territorial, and First Nation/Inuit) government to set a supportive tone for those who are suffering. They are good Canadians, not cowards or manipulative. They are suffering, and you and I can suffer so too, experiencing 'the howling tempest' of the brain. There are Canadian barriers or walls. The question raised is, "What can be done to remove these barriers? Canadians need action!

A Case Illustration: A Traumatized Police Officer

To illustrate, on March 3, 2005, in Mayer Thorpe, James Roszko killed four RCMP officers, Constables Anthony Gordon, Leo Johnston, Brock Myrol, and Peter Shiemann. Not only were those murders traumatic, there were aftershocks. This traumatic event would "horrify, repulse, disgust, and infuriate any sane person" (Rudofossi, 2006). Rudofossi, a psychologist-police officer, being well aware of this, asked the now obvious question, "Why shouldn't that be true for police officers?" Regrettably, after traumatic experiences, a common response in the police (collective) culture is, "Snap out of it," or "Don't talk about it," or "Just get over it" or "Go on with your duties." Many officers hold to these "honourable" beliefs; however, this avoidance only exacerbates the problem. Many do so; denial, secrecy, "appearances", forgetting, avoidance, phobias, and inhibition are the norm, but they are deadly. There is such stigma in Canadian police culture (Leenaars, 2010).

Officer Jeff Whipple, along with Officer Jim Martin narrowly escaped being killed by Roszko. Only because of a call from an investigator into the Roszko case, were they delayed. They were first to arrive at the murder scene. Officer Jeff Whipple has stated that the scene was traumatizing; he reported that he suffered "significant nervous shock and emotional suffering." Whipple continued to be traumatized, he reports (Loye, 2009), as he provided services to relatives of the slain officers. Interviews and discussions with investigators resulted in Officer Whipple re-experiencing the trauma over and over. He reported that he suffered shock, but that nothing was done. Officer Whipple did not receive professional help nor, he claimed, was offered such. His mental health, as one would predict from a PTSD diagnosis, deteriorated. Officer Jeff Whipple recurrently re-experienced the event that involved horrific actual deaths, and a threat to his physical integrity. He responded with intense fear, helplessness, and horror. This is normal, not crazy. By September 2008, he was permanently disabled and was no longer employed as an RCMP officer. Nothing had been done. Officer Whipple was not alone; Officer Allen Starman has also claimed that the aftermath traumatized him and, despite suffering overwhelming shock, he was forced to continue being involved in the investigation (The Canadian Press, 2009). He asked for help and a transfer, but he was denied. Understandably, he suffered mental health problems, likely PTSD, and was medically discharged in 2007. Whipple and Starman were not alone! They suffered a normal health response to common police trauma, but the blue Canadian walls in all probability caused pain and an emotional disorder, PTSD, or some other adjustment disorder. Regrettably, this occurs all too often among police, including after suicide among police. Is there hope for Officer Jeff Whipple? This is your question.

A Traumatic Conclusion

Mental illness has a shadowy presence. Allow me to close with one more case example: On July 14, 2011, the headline in my city's newspaper, The Windsor Star, read: Family Blames Military After Ex-Soldier's Death (Wilhelm, 2011). Canadian Army Trooper Stefan Jankowski died by suicide on Sunday, July 10, 2011. Stefan Jankowski, a 25-year-old veteran, had served bravely in Afghanistan. Corporal Hunter Kersey, who had served with Stefan, described him as a hero. He stated that, Trooper Jankowski "often volunteered for the most dangerous position." They served in southern Kandahar with the Royal Canadian Dragoon, doing reconnaissance and looking for improvised explosive devices.

Stefan Jankowski was a warrior. Yet, according to his mother, Gina Duguay, he was traumatized; for example, "At one point he told me about a boy, half a face missing." He had said, "God, mom you cannot believe the stuff you'd see over here." He witnessed, confronted, and experienced horror, deaths, and events unimaginable to most of us – but, not to a soldier. His friend died. He was injured. He was haunted by having to shoot at children. It was horror, fear, and helplessness. Again, this is normal, not crazy! Understandably, Trooper Jankowski developed PTSD. He was treated for his wounds, and like many, became addicted to pain medication (Oxycontin). According to the family, the aftershocks escalated. He went AWOL. He was arrested. He was incarcerated. (More walls!) The military knew that he was troubled, had PTSD, and was at risk. He needed help! He knew it. He felt the stigma. The Canadian Armed Forces' solution: They discharged him. The family stated:
The military was good to him, as a trooper. But when it came to giving him professional help because of the things he saw and the things that happened, the military made mistakes. Their program is improper. The people that need help are not getting it fast enough.

This sounds like the very findings in Out of the Shadows (2006), and highly consistent with my beliefs. There are Canadian system problems. The military (collective) culture and secrecy were a problem.

Stefan came home to Windsor; there too he sought help. His family and friends knew that he was in serious trouble, and begged for help. He obtained help from a lawyer. Little, if anything, was done. The walls increased. The drug abuse increased. According to the family, "The military ignored him. They just said you're discharged." He felt useless. His father reported, "They don't need him anymore." Yet, sadly, professionals in our city did the same; Stefan was taken to psychiatrists, professionals and hospitals, but little help was provided.
Wilhelm (2011) reported:
Jankowski went to local hospitals in the days leading up to his death. Esco (his lawyer) took him to triage at … Hospital Thursday night. "He told them he was suicidal," said Esco. "…Apparently, they would not take him."

He died on Sunday.
Officials at the hospital would not comment. The military did not comment. And, one more Canadian died needlessly. How many Canadians will suffer, and even die from stigma? What can the government do?

A Recommendation

A recommendation: The Standing Committee on Justice and Human Rights (2002), called for federal government action on stigma. That Committee concluded in the 37th Parliament, 1st Session, Wednesday, April 10, 2002, that without efforts of parliament, the stigma of mental illness will continue. It is now time for the government to do more!

I wish to acknowledge the sterling help to my testimony to Parliament, from: my patients, as well as George Dienesch, Lindsey Leenaars, Terry Maltsberger, and Susanne Wenckstern.


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