Removing barriers to Indigenous mental-health services

Statistics reveal that less than one per cent of Canadian doctors identify as Indigenous. In this podcast episode, physicians discuss the barriers to mental-health services Indigenous doctors face and how the OMA’s Physician Health Program is working to bridge these gaps. Through personal stories and clinical experiences, they share the importance of culturally competent care that understands and considers the unique needs and perspectives of these communities. 

Transcript

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Georgia Balogiannis: In this podcast, the Ontario Medical Association looks at current issues of interest in healthcare. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association. 

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Balogiannis: The Ontario Medical Association's Physician Health Program aims to be a culturally humble outreach for physicians and medical students who are struggling with substance abuse and mental health concerns. They are working on also being a welcoming service provider for Indigenous doctors and students who can face prejudice and stereotyping in Ontario's healthcare and education systems. In this episode, physicians discuss the pressures felt by Indigenous healthcare workers and the steps being taken to ease their journey.  

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Balogiannis: Dr. Chase Everett McMurren is the Indigenous Medical Education theme lead at the University of Toronto's MD Program and Indigenous practitioner liaison in the Office of Indigenous Health at the Temerty Faculty of Medicine.

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Dr. Chase Everett McMurren: When considering the unique needs and wants of Indigenous trainees and learners, specifically, that reality of really vast perspectives and expectations and hopes is quite mind boggling in a way. Like I think it's, it's certainly easier said than done to know how to successfully show up for, for learners, especially those who come from historically marginalised communities. It's a bit of a trap in a way to think we know what people need because we usually don't know, but to not try is also not a possibility. 

I've been thinking more and more about like the, the more immediate or short term hopes and ways of, of making spaces more welcoming and, and more capable of communicating trustworthiness. And then at the same time, really thinking about the long road and the reality being that it will be challenging for Indigenous learners to feel really welcome until they see themselves reflected in faculty in a more robust way. 

And so at the moment, less than 1% of physicians across what's currently called Canada identify as Indigenous — less than 1%. It feels especially important to do whatever we can to make more space that's welcoming to Indigenous faculty, and current medical trainees to stick around once they're done. And that requires a lot of institutional commitment and broader structural support.

The barriers to accessing care for people who identify as physicians is, most physicians feel like they have to be healthy or, like, be seen as healthy, and so that if they have any kind of health condition, that it's something to kind of keep under wraps. And physicians, I think, are notoriously good for not taking their own advice. Very easy for physicians to fall into a martyring kind of mode where they can sort of say, like, oh, there's no time or people need to be seen. So I think that if someone's facing a health issue, it goes very quickly to them being a failure or somehow not doing things right.  

For learners, they were afraid that if they disclosed, even though it's, they know that it's supposed to be confidential, that it would leak back to people in evaluative roles within medical school and would affect their ability to move forward. It's in small talk that microaggressions often flourish. There have been several reports from medical students to me that their tutors have glossed over or dismissed certain Indigenous-related content because they feel like it's not very relevant because there aren't Indigenous people in Toronto. 

So I'm speaking from a very Torontonian perspective, but I say that as a highlight that if people think they're not caring for Indigenous people, it might be because the Indigenous people aren't telling them that they're Indigenous, and that we're leaning a little heavily on stereotypes of what Indigenous people look like.

Transformation typically happens because of catastrophe so it's, either 90 or 99 times out of a hundred, it's because our life is falling apart or like something has gone horribly wrong. And from that we, we elect to change or to transform. Things have to really be just desperate before we opt to kind of make, make a shift in our lives. In order to call the PHP, people have reached a threshold. 

I think that the, the most important thing that can be done at the PHP and across the board is to be a bit more trauma-informed and to acknowledge the truth that it's not comfortable to be calling at all. This may be a really, really terrifying attempt to get support or to make a change.

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Balogiannis: Dr. Nel Wieman is Canada's first female indigenous psychiatrist and a national expert in Indigenous health issues who works as the Deputy Chief Medical Officer for the First Nations Health Authority in British Columbia.

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Dr. Nel Wieman: For Indigenous people, our experience in the health system and with institutions like justice, the law system, we have not been treated well. When thinking about a service like the Physician Health Program, you know, it's important not to be based on prior beliefs or stereotypes that a particular group is at risk. Rather, I think it's more that we know that issues affect all people. The important thing for something like the Physician Health Program to be aware of is there are specific barriers to accessing those services for different populations.

 When I got myself into difficulty with using substances, I had my own internalised stereotypes about myself as a First Nations person. So I, I literally became the horrible racist stereotype of the drunken Indian. That's how I felt inside, and I felt so much shame and internalised stigma that that in and of itself was a barrier to me seeking care. It was something that I felt so shameful about. I thought, I just have to figure out a way, myself, to deal with this and manage this on my own, because if I come forward, then everyone will know that I've become that racist stereotype. That was my thinking at the time.

 Stereotypes about Indigenous people and substances play into why Indigenous medical students, residents, and physicians may be reluctant to seek help. I think healthcare professionals in general have a hard time being patients of any sort. Because there are relatively few Indigenous physicians still in this country, uh, because of systemic barriers to education, we are still, to a certain extent, held up as role models and examples for our community. If you get yourself into difficulty with using substances, you've had this tremendous fall from grace. We have to be twice as good to be recognized as being on par with our colleagues. 

My clinical case coordinator came and visited me when I was in treatment, and I remember being really struck by that. She just wanted to say hello and let me know what the program was about. It was a warm kind of introduction to the Physician Health Program and the services that they offered. Next April, I'll be coming up on eight years of continuous sobriety. This is a deadly disease, and if we don't take care of it and we don't take care of ourselves, we die. So I feel grateful every day of my life that I'm living. I'm a warrior.

 I think my ideal scenario for culturally safe care at the PHP for Indigenous medical students, residents and physicians would probably, you know, consist of a number of different offerings. One could seek out spending time talking with an elder, participating in certain ceremonies, or being able to access traditional forms of healing and traditional medicines. Having either an Indigenous clinical case coordinator or an Indigenous navigator, especially at that point of initial contact to familiarise the person with the services that are available and lead them through that process, I think would be helpful. 

Having Indigenous staff working for the PHP. One of the things is working on cultural safety and humility as an organization. I would like to see those, the availability of options be expanded to include traditional forms of healing in ceremony and medicine and culture. I think I've always been an empathic person, but you know, when you, when you are on a recovery journey yourself, it just, it brings that dimension to your work. And in many respects, cultural humility is almost for, for some of us, it's intuitive.

You meet someone for the first time and rather than launching into a series of questions on your agenda, you take that time and space to find out where that client is as an individual and what, what has their journey been up until this point, getting to know that person and having them develop that trust. It's just having that empathy and that experience, it gives you so much credibility with patients that, I found this myself when I worked with First Nations patients, I didn't have to disclose very much at all about myself, except that people could sense that I had in some way suffered too. And that made it easier for them to tell me what was going on with them.

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Balogiannis: Dr. Jon Novick is a psychiatrist and medical director for the Physician Health Program.

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Dr. Jon Novick: I think we've learned a lot about how we can improve the ways in which we support Indigenous learners and physicians who make contact with the Physician Health Program. A big part of that is how much more learning we have to do to become more culturally competent with respect to the services that we provide, the ways that we engage with Indigenous learners and physicians, and the resources that we reach out to and that we connect Indigenous learners and physicians with. 

So a truly client-centred way of supporting people that we can't assume, for example, that because they're calling the Physician Health Program that they're looking for a Western or colonial approach. If we want to think in terms of generational or intergenerational trauma and the history of having essentially experienced genocide, attempted genocide, by being sent somewhere and made to conform, we have to realize that somebody being sent to us because they're experiencing, for example, problems in their learning environment or problems related to an illness, there is this potential to unintentionally and unconsciously repeat those traumas.

 We have changed programmatic elements, the ways in which we gather information. We ask a lot more questions to try to get a better picture of the people who are connecting with us. We can best connect them with and match them to the resources that they're looking for and not assume that they're looking for one particular type or another. And there may be Indigenous learners and physicians who call us, who want to connect with more people from their community who provide an Indigenous-infused approach, anti-oppressive approach, elders, people in their community. There may be people who want something far removed from their community of origin or the community that they're working with or living in. 

Not only previously did we not know, you know, what we were not providing to Indigenous learners and physicians who were calling us. Some of them wouldn't even know what else is out there. You cannot assume that one approach for connecting with and helping group X is going to help you with group Y or group Z. You need to be open, practise with a lot of humility. Sometimes that will work and sometimes it doesn't work. Also, learning from mistakes and being able to accept sometimes not the most gently delivered criticism. 

Cultural humility — we can't ever assume that we know everything we need to know even about our own culture. Even within cultures, there's great diversity. You really can't generalise about one group because there's such diversity even within a group. So I just learned to try not to assume anything, but to remain perpetually open to learning. People might think, well what does this white guy with privilege, uh, what is he doing talking about that? But there are lots of things in my background, and you can borrow from that to understand, but you don't want to assume that that gives you a lot of information about what the other person is experiencing. 

It's really important to remain curious, to provide more culturally appropriate services. When we are talking about our efforts to reach out to Indigenous learners and Indigenous physicians and to provide whatever services they are looking for, we're really talking about our problem. We're not talking about the problems or the challenges that Indigenous learners and physicians are facing, like this is our work to do. This is our journey. We're very fortunate and very thankful that we have people like Nel and Chase, other people from the Indigenous community, who are helping us do this work.

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Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.