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Featured guest: Nicole Figueroa, RN, MSN

This episode will focus on stigma in mental health including access to care, bias, and a focus on vulnerable populations. Discussion will focus on strategies to normalize engagement in mental health and reducing stigma.

Objectives:

• Define the impact of stigma on mental health treatment
• Identify how bias toward individuals with mental illness impacts medical treatment
• Demonstrate strategies to reduce mental health stigma in medical settings

Resources:

• What is stigma? Why is it a problem? (NAMI)
• Mental wellness in the black community (NAMI)
• Mental Wellness in the Latinx Community (NAMI)
• Stigma, prejudice and discrimination against people with mental illness (American Psychiatric Association)

CME:

Credits available: 0.50

Visit our CME course overview page for CME credit, or complete this survey for social work CEUs.

Transcript:

Dr. Christina Cwynar:

Hello, and welcome to our podcast Breaking Down Mental Health with myself, nurse practitioner, Dr. Christina Cwynar, child and adolescent psychiatrist, Dr. Heidi Burns, and social worker Syma Khan. This week we are joined by Nicole Figueroa to discuss stigma in mental health.

Syma Khan:

Nicole Figueroa, MSN, RN, AHN-BC, HWNC-BC is a nurse leader for wellbeing at Michigan Medicine Health System. Nicole received her BSN from the University of Detroit Mercy and received her Master in Science of nursing with a concentration in advanced holistic nursing from Florida Atlantic University. Previous to her starting her role as nurse leader for all being, her career was spent as a child and psychiatric nurse and the clinical director of the child and adolescent psychiatric unit at C.S Mott Children's Hospital. Her work has included education nurses around clinical presence and reflective practice, particularly with patients and families who are struggling emotionally during their hospitalizations.

She is passionate about creating system-wide approaches that support bold inclusive work environments where people from all backgrounds feel welcome along with prioritizing and reducing stigma around mental health needs for nurses. Nicole believes through educating nurses on how to support themselves around emotional parts of their work. We can create a health system where healthcare providers can flourish and subsequently our patients and families can truly heal. None of the speakers here today have any conflicts of interest or financial disclosures. Thank you for joining us here today.

Nicole Figueroa:

Thank you so much for having me today.

Dr. Heidi Burns:

Nicole, this is a very broad and general topic, but what is stigma in mental health?

Nicole Figueroa:

I think that's a very complicated question, but one that I think is so important to talk about. I think when we think about stigma and mental health, I really go back to how we culturally see people who struggle emotionally in general. And I think our dominant culture in America is one that everyone feels like they have to be perfect. Everyone feels like they cannot maybe show emotion. And at times, that leads people to think that if they are struggling, that they have to hide that.

And I think that feeds then mental health stigma that people don't feel safe being honest with how they're feeling. They may not even feel safe sharing things that may feel strange. And I think particularly our folks who struggle with thought disorders or other things that maybe be portrayed in our media and in our social contexts in which maybe get demonized or looked at in a fantastical way. And I think there's so many drivers to stigma, and I think that one of the things that's really important for us to talk about is that stigma. Where does it come from? But it comes so from so many multifaceted places and probably came from many generations of ways that we think people understand their mental capacities and understandings.

Syma Khan:

Thanks so much for starting us off with that really broad reflection on how a stigma and where maybe it came from. I think that it's important to recognize that there's stigma within communities about mental health, seeking mental health treatment. There's stigma for people who have mental illness and how they can seek care and how they're perceived within their communities. It's a really deep topic. One question that we thought was important to ask is how are individuals with mental illness a vulnerable population?

Nicole Figueroa:

I think, probably, that's one of the most powerful questions to ask is how are patients populations or any population with mental health needs vulnerable? And I always reflect back that there are multiple things that may make the mental health needs or mental health, mental illness, a vulnerable population. For me, I think about the fact that we don't have really fair and equitable treatments for people who have mental health needs or mental illness. And I think through that process we create more vulnerability. And one thing I think about is my background is child adolescent psych and finding a child adolescent psych practitioner is really hard. If you don't live in maybe more urban areas, you may have to drive hundreds of miles to get treatment. And then putting people who are already at risk and already vulnerable at even higher risk because we just don't have the equitable treatment care or care in general.

And one thing that I think particularly around vulnerability is if we think about perhaps cardiovascular health, people oftentimes can find access to that. And we may have somebody who has a cardiovascular risk and therefore they're able to get the treatment that they need. When you have a mental health need or mental health mental illness, you may not be able to find a practitioner who you can care for you. Therefore, putting you into more vulnerable states. And then also there's the stigma in which people who may have mental health needs may then further be vulnerable at getting a job or in school and getting the needs that they have. And it just layers on itself over and over again.

Dr. Christina Cwynar:

Nicole, you reflected a little bit on this in your previous response, but how does mental health stigma impact different communities and access to that care?

Nicole Figueroa:

I think our health systems in general have equity issues. Then when you get to mental health care, there is also equity issues in general. And I think different communities based on their mental frame of how do they see and perceive mental illness. You may have a cultural context in which people may have an understanding of mental illness around maybe still believing that people may be bad and that's the reason why they have depression or anxiety. And you have that piece that plays into it so people may not be able to get access. And then secondarily, if we look at communities that don't have the practitioners that they need, we have heightened access issues.

Again, thinking about particularly in our child adolescent areas, we may have a kid who... I remember on the unit, we would've kids who would come from 200, 300 miles away to get access to treatment, and some of the children maybe would've really done well with early intervention, but they're now 15, 16 years old and they never had any sort of intervention. And you think about subpopulations of people and where they live and just knowing that sometimes, particularly with mental health, their zip code really determines their health outcomes, which is sad, but also why I think all of us are in this room and talking about why it's so important to think about mental health first and foremost.

Dr. Heidi Burns:

And I think probably something worth mentioning in a bigger picture look at stigma is that it can be really culturally bound and culture can mean lots of different things. It can literally mean different places in the world have different belief systems about mental health, but also even within a local community, there are different subgroups of people who all may think differently about mental health and access to mental health, whether that's a religion or a certain ethnic group. And going along with how does that stigma impact a community if you're in a particular community or culture that does have a very strong stigma against the treatment or even just even belief, perhaps they believe that psychosis is actually related to witchcraft or something like that. There are all of these culturally bound issues with stigma where people are even less likely to seek care and have access to care.

It really can be globally a problem related to access, but even within smaller and smaller and smaller subgroups, you're having lots of issues with just sometimes even the basic things of speaking about a mental health problem is not allowed in a certain context. There's just a lot of complexity to stigma.

How about bias? There are different subgroups that have certain feelings about mental illness. And then if you think about the people who are trying to come in and get treatment or care for mental health problems, what bias might they encounter? How does that impact their ability to get care?

Nicole Figueroa:

I think as somebody who's worked in this academic health center for a long time, I think that's one of the things that we have to be really mindful in building cultures that are open to seeing, I would say, healthcare as a mind body spirit intervention. And one thing that I see often is that it takes so much for somebody to want to engage in treatment. It takes so much for somebody to say, "My child needs help, I'm going to bring them to, let's say even to the hospital and they need help." And what they hope for is that when they enter into our health system that they have people who are very knowledgeable about mental health needs or what their child may need. And what often happens is that our healthcare providers don't have the education they need, or they themselves have their own biases.

And to me, it's one of the things that we need to work on the hardest in our healthcare industry is getting people who work outside of behavioral health, the understanding of the impacts of what mental illness or mental wellbeing is around chronically ill kids and adults. And that's what we usually see in the health system. And for me, I think being aware of your own biases, like you just said, we all come from cultures who have understandings of mental illness and we all have our stuff that we think about it. We may have grown up in a family that did not believe that mental illness existed, and if we didn't do our own work and then we become a healthcare provider, we may put that bias on the patient that we see. And a lot of times it's because we don't understand what's happening in front of us.

And I think that what I see in the bias in the healthcare industry is that we see things that don't make sense and then we make judgements. And then what happens is the patients and families don't get what they need. We may have a child who's struggling with psychosis, we don't understand psychosis, so we may think that somebody is embellishing what they're experiencing versus sitting with somebody who is having an experience and honoring what their truth is. And for me, biases everywhere and we all have our own biases, but really doing our own work around what do I know about mental illness? What are my own thought processes about it? So that we don't harm the people who have worked so hard to get to our health system because it takes so much to get to the point where you might say, "I need help."

And what they need is somebody to really not reinforce any bias and make them feel like we're not here to help. And I think that's so much what people experience when they come outside of behavioral health. And we're really lucky here to have really great practitioners and really great services for mental health. People come to us expecting us to not have those biases. To me, I think it's doing our own internal work and assuring that we're not placing that on our patients and families who are coming to us who have already faced so much stigma and so much bias to even be courageous enough to reach out for help because we know that the vast majority of people don't get into treatment. And then the people who hit our doors actually want to be in treatment.

Dr. Christina Cwynar:

And Nicole, just to bounce off of that, I think you said something really important is that these patients and families are courageous. And I don't know how many times I've been in with families who brought their kid in and they're like, "I don't know if this is the right thing." And me just turning around saying, "Thank you, this is what they needed and we're here to support you." And just honoring that bravery that they have presented with to seek out that treatment, even though treatment may be scary for them.

Nicole Figueroa:

And so many times treatment is restrictive and it's scary to think about what may be the next step. And our role as healthcare providers is to ease that anxiety and again, honor really the bravery of coming in and getting help, which is really, really quite hard sometimes.

Syma Khan:

I think we know that even in medical settings, there's a lot of stigma and bias for marginalized communities. And in particular, I think when we talk about mental health, we also want to acknowledge the experience of black, indigenous, people of color when they are seeking mental health care that oftentimes there's stigma within their communities. There's stigma and biased to the experience when they come into the hospital related to their mental health needs. They may be miscategorize. As healthcare providers, we really need to be aware of that experience and mindful about it. And I really appreciate the reflection of doing our own work and recognizing maybe the community that we grow up in, the culture that we grow up in and how we conceptualize mental health and how can we take a step back and ensure that we are looking at the patient from a holistic perspective and really honoring both their medical and their psychiatric needs when we develop a care plan.

Dr. Heidi Burns:

And I think one of the goals of this podcast is really to talk about that issue that you raised about getting a more broad education and exposure to behavioral health in order to be able to be that welcoming place for people to land. Like you said, it's difficult to get through all of the barriers that you have to get through to get mental health care. And a lot of us took oaths and other things to work in this setting where we try to have compassion and nonjudgmental approaches. And that's the thing that sometimes when you walk into a room and there's somebody who's acting in a very surprising way or very confusing way, it takes a lot to keep that oath and think about approaching that person in a nonjudgmental manner. Particularly because as we have seen by working in behavioral health, there is a lot of variations of normal and normality and abnormality and no two patients are alike. And it takes a lot of work on yourself in order to be able to truly be an accepting human when it comes to being a provider.

Nicole Figueroa:

I think that one of the best skills that we can grow as healthcare providers is being curious versus being judgmental. And I think where I notice a bias comes in is we create a snap judgment, which is bias. We all have our own implicit bias, but the moment we can catch ourselves creating a storyline or creating a judgment, can we be curious about what's happening for that person? Even if we think, even we have a judgment, if we can just put our curiosity, first and foremost, being compassionate and being curious. Can we just offer that to everyone who enters in our doors? Particularly people who maybe cope in ways that we don't find normative, but normative is so subjective, and just be curious and compassionate.

Syma Khan:

Thanks for that reflection, Nicole. You've already touched on this a little bit, but any other thoughts on how medical professionals can normalize and support individuals with mental health needs and medical settings?

Nicole Figueroa:

I think that the more we have open discussions. I think that just with bias, when we're talking about bias, it's really important to have safe spaces. And listening to podcasts like this, but also having discussions with maybe behavioral health providers around what you're seeing, "I just don't understand what's happening here. Can you help me understand this?" And also, I always say getting involved with maybe community engagement, like NAMI or any peer support groups in which you can see people who are in a different state, maybe they're not in a crisis state, and you can see people living their life flourishing in a different standpoint.

I think if, I could say, one of our most powerful things that we should do as healthcare providers is ensure that all of us kind of do our due diligence in understanding behavioral health because one thing we can't detach is our brain and we all cope with things differently. And for me, as we look at more integration from behavioral health into medical care, it bleeds over. And for me, it's one of the most powerful things we need to do. And sometimes it's just sitting down and trying to get some to know somebody on a different level outside of the hospital and maybe getting involved in the community a little bit more.

Dr. Christina Cwynar:

Nicole, you alluded to this about this almost marriage of physical and mental health that has been occurring over the last several years, decade or so. Can you speak a little bit to how mental health and stigma, how that discussion has changed over time?

Nicole Figueroa:

I reflect back, I started here at the university in 2008, and I think at that point in time, psych was very separate. It was seen as its own actually psych hospital. And as time has evolved, we have had more and more conversations around patients with behavioral needs are everywhere and it's responsibility. And I've seen this evolving trend. My experience is going from the that's a behavioral health patient, that is still true, at times we hear people say that, to more or less curiosity. And I think that's how I've seen things evolve is that people outside of behavioral health are starting to see that, "I need to understand the full picture of the patient. I need to understand maybe what is complicating the picture for them getting better on the physical side of things." How are they coping with this?

And I think just in general, as we've started talking more about mind, body, spirit care just nationally and complimentary care, and I think that people just are more open to it. And I think also there's been a lot of great work from organizations like NAMI and a lot of advocacy even in our health system to start looking at that it can't be separate, that we have to see things together and that it's responsibility to get some education around this. And also look at how we collaborate much better, which at times, honestly, we were two separate worlds, behavioral health, we did our stuff, medicine did their stuff. And I think now we are trying to be much more collaborative.

Syma Khan:

I think on a national level too, recognizing, I think that so much in the past, our focus and our research on mental illness really focused on non-diverse populations, oftentimes just white men. And I think there's been a significant change too within the healthcare discourse nationally and within the NIMH, the National Institutes of Mental Health, around including special populations within research to recognize that the medications, the therapies that we provide may not be meeting the needs. And I think in particular, recognizing that we've seen a rise in suicides among black youth tells us that we really need to be more in integrative and collaborative when it comes to identifying solutions for these communities.

Nicole Figueroa:

I think that's so true. And one thing I don't think we touched on as well is the intersectionality when we have BIPOC youth and then BIPOC youth who also identify as LGBTQ and the increased risk of suicidality and also not engagement and any sort of healthcare, particularly in mental health care. And I think that's been also beautiful as well, to see that looking at intersectionality, looking at how, like you said, Syma, a lot of our interventions really looked at upper middle class white men and what worked for them. And kids, don't even worry about kids. And I think that it's been beautiful to see those identification of how we need to do better, and particularly with our diverse populations and our minoritized populations.

Dr. Heidi Burns:

You mentioned the resource NAMI a couple of times, and I'm wondering if you could explain that or where more information could be found.

Nicole Figueroa:

Yes, the National Alliance for Mental Illness, they have both national and local chapters. The thing I love about NAMI is that they have a lot of peer support specialists, which I found so amazing. As somebody who worked in acute care hospitals for my entire career, oftentimes I would only see people at their acute phase of their illness. And being around peer support specialists and seeing people who have struggled with mental illness and maybe really severely impacted, and then seeing them in their lives as professors, as business owners, as a nurse, as a physician is really cool and something to get involved in. And also they help with advocacy both at the local, state and national level, and it's a great community to get involved in. I think if you're interested in learning more, they have a lot of parent to parent groups where they have parents running groups for each other. A lot of great resources just to start looking at and exploring if you're interested in knowing more information.

Dr. Heidi Burns:

Sounds like a great spot to start for that journey of curiosity.

Nicole Figueroa:

Yes, curiosity.

Syma Khan:

I think it's a great tool for mental health providers, for medical providers, for families, for patients themselves. They really try and provide education support and resources to those with mental illness, those who want to help support. And I agree that I think in this acute care setting, we often see individuals who are really on that high end of needing support, that are likely needing hospitalization. And it can be really challenging, but recognizing that people with mental illness live full lives, they can thrive, they can grow, they can give to the community. And I think NAMI really provides that space to see that reflection versus feeling really limited in our scope and understanding of mental health.

Nicole Figueroa:

On the journey of education of yourself and others is also, there are great memoirs of people who have struggled with their own mental illness. I think of there's a great memoir called Brain on Fire. I think that that is one of the most powerful things to decrease stigma is to understand that what we see oftentimes portrayed in movies and in media is not reality. And that people who have mental illness flourish. And many of us have had our own struggles and strategies that we've all dealt with.

Syma Khan:

I think the other well known memoir from a professor is Kay Jamison, and she wrote An Unquiet Mind, A Memoir of Mood and Madness.

Nicole Figueroa:

Yes, that's a great book.

Dr. Christina Cwynar:

I think what I really like about this discussion is that these people and people in general all have mental health struggles no matter what walk of life, what profession, what gender, what identity, none of that really matters. They can all suffer in one way or the other and seek, need help in different ways and just being open and curious.

Dr. Heidi Burns:

Before we wrap up today, are there any other reflections that anyone would like to add?

Syma Khan:

I think I'm definitely walking away from this discussion in terms of being curious because I think it's really important for us to be aware of our own bias and the way that we approach situations. There's so much data that tells us there is bias within medical care, within mental health care. In particular, we know that black patients are more likely to be restrained in emergency rooms than white patients. We know that they're more likely to be prescribed antipsychotics for their symptoms versus being diagnosed with depression. We know that black preschoolers are more likely to be suspended, to be given diagnoses of oppositional defiant disorder without acknowledgement of trauma, without acknowledgement of other maybe psychosocial things that are going on than their white peers.

We know there's a lot of stigma and bias. And when people come to healthcare, I think it's really important for us to be able to acknowledge that they've had those experiences before they walked in our doors, and what can we do to help them feel supported and welcomed and that we're acknowledging those experiences that we're doing our best to unpack whatever experiences we've had to help them feel cared for, and to hopefully be able to help them on this journey of recovery.

Dr. Heidi Burns:

And there are actually a lot of implicit bias trainings available now. This is something that is becoming more and more widespread. Checking out even within the university that you're affiliated with or your licensing regulator or any provider or any institutions that provide continuing medical education credits of any kind. There are a lot of trainings that are out there right now, and even there's some online quizzes of taking a look and seeing if you can identify some implicit bias that you might hold. It's a good journey, like I said before, to help with your own knowledge of what your biases might be. And then what that might mean if you are coming into contact with people in a healthcare setting.

Syma Khan:

We know this is a really important conversation too, just as Dr. Burn shared, that there's a lot of online tests to be able to take, but we also know that the state has required it for all healthcare professionals to take implicit bias training. And part of that, I think, is recognizing that the health disparities that we see are really driven by bias and stigma, and that we need to be more mindful about them in healthcare settings. There's resources through the University of Michigan that people can access. The Harvard IAT implicit bias tests is available, I think continuing on that journey and learning.

Dr. Christina Cwynar:

And I think remembering that you need to be curious, but we all walk into situations and don't realize that we hold a certain bias and we learn every time we see patients. And just being able to recognize in those moments that, "Hold on. I need to rewind. I need to look at this. Why am I treating a patient this way? What can I do to rectify this situation?"

Dr. Heidi Burns:

And sometimes it can be shocking and hard work, and it's good to remember just from a neurobiological standpoint, our minds are really conditioned to see patterns and to put patterns in place so that it can expect what's coming and prepare for that. And sometimes, you can get into that rhythm of just constantly placing your own patterns on other people. And this is something that can happen unconsciously almost. And it can be quite shocking sometimes to go through that process of learning about your own implicit biases. But I think there's definitely a strong and growing belief that doing so will provide better care for your patients.

Nicole Figueroa:

One thing I reflect on, particularly when we think about pattern responses, and when we think about particularly maybe behavioral responses, we know that when we're scared that we lean on our biases even more. And at times when people are struggling with being hospitalized or struggling with being in the ED, they may behave in ways that look escalated. And I think about leaning on training around deescalation, training around things that help us understand how do we meet people who are agitated. Because the more we can lean on some training that we know what is the best practices to approach people who are dysregulated, that helps us override, am I afraid of this person because of the way they look or the language they're using?

And if we lean on some of our implicit bias helps us with understanding our own biases, and then can we lean on other trainings that teach us when I see someone who's dysregulated, this is a skill I use and I use a skill with anybody and it works with everyone. And if I'm feeling afraid of somebody by the way they look, and this is just something I'm working on, that we can use those skills to override it so that everyone gets equitable care. And I think that's something that's really powerful. Also, thinking about how do we meet dysregulation with training as well.

Dr. Heidi Burns:

And there are some other episodes of our podcast that do focus in on coping skills that you might be able to use as well as aggression and agitation and how to approach that.

Dr. Christina Cwynar:

Thank you for joining us today. We truly appreciate your time and expertise. Thank you to everybody who tuned in this week. Nurses, social workers and physicians can claim CME's and CE's at uofmhealth.org/breakingdownmentalhealth. You are able to do this anytime within three years of the initial air date. We hope that you will join us next time.