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Stigma Expert Says Policies, Perceptions of the Mentally Ill from All Sides Must Change

World-renown psychiatrist, Dr. Julio Arboleda-Flórez, wears many hats: forensic psychiatrist, professor, epidemiological researcher, international consultant, administrator, ethicist and, most recently, public education expert.

In 1995, when the World Psychiatric Association (WPA) met to address stigma toward mental illnesses, WPA President Dr. Norman Sartorious asked Dr. Arboleda-Flórez, as chairman of the WPA forensic section, to help focus the debate. “Nobody knew much about stigma,” he recalls. “It was like three blind men describing an elephant, each one describing what he touches but none able to describe the animal.”

At that point they agreed to pilot an antistigma program and Calgary, where Dr. Arboleda-Flórez headed the Department of Psychiatry at the Calgary General Hospital, at the time a WHO Collaborating Centre, took the lead. Many of the materials produced for the Calgary pilot are used today in a network of centers in 27 countries. Although the program is modified to suit local circumstances, all countries use the same evaluation tools, which yield internationally comparative data says Dr. Arboleda- Flórez. This October’s WPA Together Against Stigma conference in Kingston, organized by Dr. Arboleda-Flórez and his wife, Dr. Heather Stuart (also a stigma expert), permitted the heads of sites to share data.

The 1996 Calgary pilot revealed that all population groups hold similar negative attitudes toward mental illness and that stigma is often systemic, says Dr. Arboleda- Flórez. The pilot also found those most informed about mental illness, psychiatrists and clinicians, also stigmatized the mentally ill—calling into question the effectiveness of mental illness literacy campaigns that aim to change attitudes through knowledge.

Dr. Arboleda-Flórez also says that the increasingly depersonalized health system means that many clinicians no longer connect adequately to the individual. He blames a system where psychiatric patients are treated in hospital for two weeks and then released. Treating acute symptoms is not enough, says Dr. Arboleda-Flórez, “We have to help with that patient’s recovery and their reintegration into their community.”

What Works

The Calgary pilot demonstrated that public education activities targeted at specific groups such as students and clinicians work but they must be continuous, focused and have a personal element. In Calgary, students were glued to presentations by persons suffering from schizophrenia, remembers Dr. Arboleda- Flórez, “They learned to see these persons, not as crazy mental hospital patients, but as human beings.”

The WPA program, called Opening the Doors, develops permanent programs in the centers it supports, using targeted intervention strategies and evaluates efficacy. Although the stigma research team that supported the Calgary pilot dissolved with the closing of the WHO Centre and the Calgary General Hospital in 1998, the Alberta Mental Health Board continued to run many aspects of the program for five years, and the Calgary Branch of the Schizophrenia Society of Alberta is still involved as the Canadian site for the WPA Program.

The problem with many stigma campaigns like Mental Illness Awareness Week is that they are “flashes in the pan” that temporarily pump up enthusiasm and awareness but have no lasting effect. Also, they typically lack an evaluation component, making it difficult to measure efficacy. Big campaigns such as ParticipACTION are also limited in their effectiveness says Dr. Arboleda-Flórez. To be effective, these programs require large ongoing interventions over extended periods and big budgets, something mental health doesn’t have.

What does he propose for a Canada-wide strategy? “The federal government has clearly shirked its responsibility in this area,” says Dr. Arboleda-Flórez. He points out that health promotion and prevention is a federal responsibility, yet Canada is one of the few western countries without a central administration, or division, for mental health. “Their role should not be to dictate to the provinces how to handle their sick people but to inform the policy choices and debate through leadership.” Such a division should take the advice and ongoing input of stakeholders, including researchers, academics and clinicians in the field, “Without dialogue and expert advice, a federal unit would be a sterile bureaucratic exercise,” says Dr. Arboleda-Flórez. Through a Mental Health Division, the federal government could mount needed national-level public education intervention studies on disability, how people suffering from mental illness function in the community and what works with children. Federal research agencies such as the Institute of Neurosciences, Mental Health and Addiction of the Canadian Institutes of Health Research should also make matters of mental health policy a legitimate research area.

He also thinks provinces should be made accountable for the mental health of its citizens. “The provincial government has an obligation to provide a mental health system that encompasses a continuum of care across the life span. In the past, hospitals advocated for patient treatment rights but deinstitutionalization has left the fragmented community system to take up the fight. The result has been under funded community systems and symptomatic people on the streets and in jail. This is stigmatization,” says Dr. Arboleda-Flórez.

Medical schools also play a role in fighting stigma says Dr. Arboleda-Flórez based on 30 years of academic and teaching experience and as current Head of the Psychiatry Department at Queen’s University, “Many students and faculty in other departments still think of psychiatry as ‘feely, touchy, talky’ because they don’t know how scientific psychiatry has evolved, and they look down their noses at psychiatry.” Psychiatric education in Canada faces a massive public relations task to change this perception and recruit medical students.

Despite the problems he faces as a psychiatric educator, Dr. Arboleda-Flórez considers his teaching activities to be the most significant accomplishment of his career. “I have a large number of Fellows in forensic psychiatry that have gone to many places in the world and now they carry the growth of my specialty in forensic psychiatry.” An expert witness to the courts since the 1970s, Dr. Arboleda-Flórez enjoys the adrenalin rush of a counsel who comes at him with heavy scientific and legal arguments, “It’s that moment of confrontation with your knowledge: how in depth you can go and what you know,” he explains. The need to stay abreast also makes forensic psychiatry a demanding profession. “The moment you’re not up-to-date in forensic psychiatry, you are dead meat in court.”

A few well-placed nudges brought Dr. Arboleda-Flórez to psychiatry. Although tossed between law and medicine, it was natural that he should enter into medicine and hospital administration. Both parents were medical; his father was a doctor and hospital administrator in Colombia. During his residency in internal medicine in a Colombian general hospital, his supervisor suggested that, given his knack for talking with patients, he might consider psychiatry. During his psychiatric residency at the University of Ottawa, the department head, noting his aptitude for grasping legal issues, suggested he specialize in forensic psychiatry.

Indeed, chuckles Dr. Arboleda-Flórez, the sabbatical year he used to complete a PhD in epidemiology in 1994 was one of his few self-driven career moves. His forensic research work involved setting up studies using large databases and had an epidemiological component. “I found myself in a trap,” he says. With little knowledge of research methodology and statistics, he was reliant on others.

Dr. Arboleda-Flórez’ accomplishments are many. Through the WHO and the Pan American Health Organization he has helped set up national mental health and forensic systems in many countries. He also established the University of Ottawa’s forensic services early in his career as well as the regional services for southern Alberta. He has written on forensic psychiatry, ethics and stigma. He drafted the WPA Madrid Declaration (a world code of ethics). He wrote the background document for the WHO on stigma and mental illness that was used at the health ministers’ conference at the World Health Assembly in Geneva in 2001. A contributor to The Canadian Journal of Psychiatry (CJP), Dr. Arboleda-Flórez is the Guest Editor of next month’s CJP special issue on stigma and discrimination.

Besides a yearning to renew his poetry and essay writing, Dr. Arboleda-Flórez has few regrets. Although his first marriage ended in divorce, his two children are now grown: one a lawyer and the other a small business owner. He and his present wife, Dr. Stuart, both work in psychiatric epidemiology and often collaborate on projects. Arboleda-Flórez claims he’s found the key to happiness, “Fully enjoy whatever it is you do, whether it’s hard work or entertainment, pour all your life into it.” HC