International Women's Day: A Call to Action

International Womens Day Graphic_08 March 2018.png

Sarah MacLean

Today is International Women’s Day (IWD), a global day of recognition of the social, economic, cultural and political achievements of women. IWD has been celebrated since the 1900s and emphasizes the need to accelerate gender parity globally.

The story of women's struggle for equality belongs to no single feminist nor to any one organization but to the collective efforts of all who care about human rights. (Gloria Steinem)

In January of 2017, the World Economic Forum released its annual Global Gender Gap Report, a review of gender parity in 144 countries across the globe, and the results were devastating. Specifically, they examined gender equality within the following four domains: 1) economic participation and opportunity; 2) educational attainment; 3) health and survival; and, 4) political empowerment. Much to my chagrin and surprise, they found that the gender gap is actually widening.  The report anticipated that, at the current rate of progress, it will take 217 years to achieve global gender equality.

Much in line with the progress we have seen within the last year, with the #MeToo and #TimesUp campaigns, the theme of this year’s International Women’s Day is #PressforProgress. It is a call to action, and a reminder, that now is not the time to be complacent. In order to achieve change, we must push (often, loudly) not only our political leaders but also our employers, our friends, and our family members to move gender parity forward.

 

Women’s Mental Health Canada

As we have discussed in many of our Hatching Ideas Hub blog posts, gender impacts mental health in terms of the likelihood of developing particular disorders, the burden to mental disorders and the likelihood of receiving treatment. The figure to the right provides an overview of women’s mental health in Canada.

 

Setting A Women’s Mental Health Research Agenda

In 1990, Mary Koss conducted a review of the state of women’s health and provided nine recommendations to advance women’s mental health research. These recommendations focused broadly on the need to gather national data on the scope of violence against women, including the mental health implication of violence against women; the need for empirical evidence to support treatment recommendations for women impacted by violence; the need for evidence to support victim services program development; and a deepened understanding of violence against women within the broader social context of gender inequality.

Specifically, in setting an agenda for addressing women’s mental health, Koss (1990) recommended that:

          1. Funding opportunities focus on “hidden” violence against women;

          2. National data focus on violence victimization, including its incidence, prevalence and mental health impacts.;

          3. Violence against women be understood within the context of the lifespan, which includes risk profiles, intergenerational transmission of trauma and the broader social                costs of victimization;

          4. Cognitive theories be clinically evaluated within the context of violence against women, including an examination of the storage and recall of traumatic memories,                       the impact of trauma on knowledge structures and coping strategies that minimize the mental health impacts of violence;

          5. New clinical instruments, such as history-taking forms and questionnaires, be developed in order to address the impact of violence against women within clinical                         practice;

          6. Treatments offered to address the mental health impacts of violence against women be clinically evaluated;

          7. Data collected distinguish between women who have been impacted by violence against women and other women presenting for mental health services;

          8. Treatment for the delayed and/or compounded effects of experiencing violence against women be developed and clinically evaluated;

          9. Secondary prevention efforts continue to target women at high risk of experiencing violence, while also focusing on primary prevention of violence against women.

 

 Woman Suffrage Headquarters in Cleveland, Ohio, 1912.

Woman Suffrage Headquarters in Cleveland, Ohio, 1912.

Our Successes in Addressing Women’s Mental Health

While it is beyond the scope of this blog post to breakdown each of Koss’s recommendations and assess where we stand in terms of addressing women’s mental health in Canada, it is important to highlight a number of key accomplishments made since the 1990s. Specifically, significant gains have been in the fields of: measurement of violence against women and the development of primary prevention programs to address violence against women.

 

Measurement of Violence Against Women: The Case of the Canadian Violence Against Women Survey

The proliferation of surveys specific to violence against women were developed in an attempt to address the methodological limitations of larger national surveys. For instance, the 1993 Canadian Violence Against Women Survey (CVAWS) asked a variety of detailed questions pertaining to

different aspects of violence experienced in the context of intimate relationships, including the trauma experienced by victims, their reactions to the violence, and the consequences they experienced as a result of their victimization (Johnson, 1996; Johnson & Dawson, 2011).

Similarly, the Canadian General Social Survey (GSS) was launched in 1985 and is the primary source of victimization data in Canada. The most recent version of the GSS victimization survey took place in 2014 and collected information on the following forms of violence against women:

          ·         Sexual violence committed by non-partners;

          ·         Emotional or financial abuse committed by current and former partners;

          ·         Physical and sexual violence committed by current and former partners;

          ·         Unwanted sexual activity with current and former partners;

          ·         More detailed questions about the most recent incident of violence by current and former partners.

Specifically, the GSS collects data on experiences of victimization, help-seeking behaviours related to these experiences of violence, and whether the respondent sought help from the criminal justice system to address these experiences of victimization.

One of the biggest issues with conducting violence against women survey research is that it relies on respondents not only accurately reporting incidents of victimization, but that they also the recognize and name their experiences as violence. This is a chronic issue, especially in terms of sexual violence, which has been so normalized that survivors often have an extremely difficult time naming their experiences of violence. The continued proliferation of myths which excuse male violence against women within the context of sexual relationships has also been found to contribute to this.

One way to address this issue has been the development of questionnaires which minimize the use of jargon and avoid stigma through the use of behaviourally specific questions regarding unwanted sexual experiences (Testa et al., 2004). These measures are designed to increase the likelihood of recalling experiences of unwanted sexual activity. These questionnaires also allow for the consideration of experiences that respondents would not necessarily classify as violence, even though they frequently meet its legal definition (Testa et al., 2004).

 

Investing in Youth: The Role of Primary Prevention Programs in Preventing Dating Violence

The Fourth R: Strategies for Healthy Youth Relationships, developed by Dr. David Wolfe, is a relationship knowledge program which takes the position that healthy relationship behaviours can be taught much in the same way that reading, writing and arithmetic are taught. The program primarily targets students from grades seven to nine, and seeks to address violence/bullying, unsafe sexual behaviours, and substance use.

To evaluate the effectiveness of this program, a randomized controlled trial was conducted in 2009 which included 1,722 grade nine students aged 14-15. Results showed that students who were exposed to the 21-lesson Fourth R curriculum reported rates of physical dating violence 2.5 times lower than students who received the control condition. Similarly, participants who received the intervention were also more likely to practice safe sex, reporting always using condoms (Wolfe et al., 2009).

What is promising about this program is that it can be delivered at a very low cost, roughly $16 per student, and therefore, has the potential for a very high rate of return on investment. This becomes especially important when we consider that addressing the consequences of spousal violence alone collectively costs Canadians $7.4 billion dollars (Canadian Women’s Foundation).

 

Challenges yet to be met

Lack of Health Research Funding on Women’s Mental Health

Many organizations, including the World Health Organization (WHO), have highlighted the need to invest in research targeting women’s mental health. So what has been the response of health research funding agencies in moving the women’s mental health research agenda forward? To assess this in the Canadian context, I reviewed all grants funded under the Canadian Institutes of Health Research (CIHR) Institute for Gender and Health from 2008 (earliest available data) to present. The results of this review can be found in Figure 1.

 Figure 1. Number of Projects Funded by the Institute for Gender and Health (2008 - 2017) 

Figure 1. Number of Projects Funded by the Institute for Gender and Health (2008 - 2017) 

The data shows that, in Canada, of the $153,430,267 invested in gender and health research, a total of 56/749 grants (7.5%) have been awarded related to violence against women. In some cases, especially within the field of biomedical research, the link between the proposal and women’s mental health was tenuous; however, potential impacts could be reasonably expected. For instance, examinations of women’s responses to stress could be understood as related to their experiences of trauma and, as such, were included in this sub-analysis.

However, it is disappointing to see the extent to which a large majority of proposals funded under the Institute of Gender and Health do not meaningfully address the incorporate of gender issues in health research. While significant gains have been made by virtue of having a CIHR institute dedicated to these issues, expectations must be raised in terms of what this looks like in practice.

 

Context of Gender Equality in Which Violence against Women Occurs

Gender role attitudes have been found to be related to various forms of intimate partner violence (Jenkins & Aubé, 2002; Mahlstedt & Welsh, 2005). In their systematic review, Flood and Pease (2009) consistently found a relationship between endorsing traditional gender roles and intimate partner violence. Gender role expectations for male and female behaviour reflect male-dominated perceptions of how men and women ought to behave and frequently attribute greater status to the roles of men than to those of women (Johnson & Dawson, 2011).

Feminists argue that the link between male violence and gender roles is one where violence against women is not the result of a violent impulse of an individual man against an individual woman, but rather is the result of over-conforming to traditional gender roles (Johnson & Dawson, 2011). In a society in which masculinity is associated with dominance and femininity is associated with passivity and compliance, anything that comes to be defined as feminine is a threat to this masculine ideal (Adams-Curtis & Forbes, 2004). This conception of masculinity and its instability can create a fragile gender identity for men who, in turn, may seek to protect it at all costs (Adams-Curtis & Forbes, 2004). This can lead to hostile and negative attitudes toward women, a need to dominate women, and displays of violence towards women (Adams-Curtis & Forbes, 2004). As such, men are more likely to accept or excuse violence against women if they believe men should be dominant in their intimate relationship and have the right to protect that through physical aggression (Flood, 2010).

Studies have shown that men who endorse sexist attitudes towards women are also more likely to use violence against women (Anderson & Umberson, 2001; Archer & Graham-Kevan, 2003; Brownridge, 2002; DeKeseredy & Kelly, 1993; Nabors & Jasinski, 2009; Reitzel-Jaffe & Wolfe, 2001). These violence-supportive attitudes may serve to “justify, excuse, minimize, or hide physical or sexual violence against women” (Flood, 2010, p. 15). For instance, Brownridge (2002) found that men who endorse traditional gender roles, as demonstrated by acts such as limiting a partner’s access to income and controlling or socially isolating a partner, were found to be more likely to physically victimize their intimate partners than their more egalitarian counterparts. This is consistent with previous cross-cultural research which has linked female physical victimization to lower levels of gender equality at the societal level (Archer, 2000).

While the majority of this research focuses on the link between gender role expectations and male violence against women, there is also evidence that women who are hostile toward or generally distrustful of other women are also more likely to endorse traditional, and therefore rigid, gender role expectations for women (Forbes, Adams-Curtis & White, 2004). It is therefore possible that these gendered expectations serve different purposes for men and women. For instance, Bohner, Siebler and Schmelcher (2009) found that while these attitudes may serve to justify men’s sexually violent behaviour, for women these attitudes may allow them to distance themselves from the threat of sexual violence. This, in turn, may increase the likelihood that these women will also endorse other attitudes that are harmful to women and contribute to a culture that legitimizes violence against women. Moreover, in their longitudinal study of 1,291 adolescents from North Carolina, Foshee, Benefield, Ennett, Bauman and Suchindran (2004) found that girls’ endorsement of traditional gender role expectations was associated with past sexual victimization.

 

Moving forward

The Canadian Federal Budget was released on February 27, 2018 and, on paper, took leaps forward in addressing issues of gender inequality. The highlights include:

          ·         $1.4 billion over the next three fiscal years to be invested in the Business Development Bank of Canada specifically for women entrepreneurs;

          ·         $70 million commitment over the next five years to the BDC Women’s Technology Fund for women-led tech firms;

          ·         Funding and loans available for women-led business through Export Development Canada and Farm Credit Canada;

          ·         $100 million over the next five years to Status of Women Canada, which will move from a federal agency to a federal department for the first time in its history;

          ·         $1.2 billion over five years to provide five extra weeks of parental leave for two-parent families, to be implemented in June 2019;

          ·         $7.5 billion over 11 years for early learning and childcare through the creation of subsidized childcare spaces;

          ·         $2 billion over five years invested in additional foreign aid under the Feminist International Assistance Policy;

          ·         $10 million over five years to the RCMP to review 25,000 “unfounded” sexual assault cases;

          ·         $30 million over three years to promote women and girls’ participation in sports;

          ·         $6.7 million over five years to create a Gender, Diversity and Inclusion branch of Statistics Canada; and,

          ·         $8 million for legal-aid funding to support charges of sexual harassment in the workplace.

I am cautiously optimistic that these investments will lead to shifts in addressing gender equality; however, I also understand how much work there is to be done and am aware of the numerous issues not yet addressed by federal spending. I look forward to checking back on the progress of these investments over the next five years.

 

References

1.  Adams-Curtis, L. E., & Forbes, G. B. (2004). College women's experiences of sexual coercion: A review of cultural, perpetrator, victim, and situational variables. Trauma, Violence, & Abuse, 5(2), 91-122.

2.  Anderson , K. L., & Umberson, D. (n.d.). Gender violence: Masculinity and power in men's accounts of domestic violence. Gender & Society, 15(3), 358-380.

3.  Archer, J., & Graham-Kevan, N. (2003). Do beliefs about aggression predict physical aggression to partners? Aggressive Behavior, 29, 41-54.

4.  Bohner, G., Siebler, F., & Schmelcher, J. (2006). Social norms and the likelihood of Raping: Perceived rape myth acceptance of others affects men's rape procilvitiy. Personality and Social Psychology Bulletin, 32, 286-297

5.  Brownridge, D. A. (2002). Cultural variation in male partner violence against women: A comparison of Quebec with the rest of Canada. Violence Against Women, 8, 87-115.

6.  Canadian Women’s Foundation - https://www.canadianwomen.org/the-facts/gender-based-violence/

7.  DeKeseredy, W. S., & Kelly, K. (1993). The incidence and prevalence of abuse in Canadian university and college dating relationships. Canadian Journal of Sociology, 18(2), 137-159.

8.  Flood, M. (2010). Where men stand: Men's roles in ending violence against women. Sydney: White Ribbon Prevention Series, No 2.

9.  Flood, M., & Pease, B. (2009). Factors influencing attitudes to violence against women. Trauma, Violence & Abuse, 10(2), 125-142.

10.  Forbes, G., & Adams-Curtis, L. (2001). Experiences with sexual coercion in college males and females: Role of family conflict, sexist attitudes, acceptance of rape muths, self-esteem, and the big-five personality factors. Journal of Interpersonal Violence, 16(9), 865-889.

11.  Foshee, V., Benefield, T., Ennett, S., Bauman, K., & Suchindran, C. (2004). Longitudinal predictors of serious physical and sexual dating violence victimization during adolescence. Preventative Medicine, 39, 1007-1016.

12.  Koss, M. P. (1990). The women's mental health research agenda: Violence against women. American Psychologist, 45(3), 374.

13.  Jenkins, S., & Aubé, J. (2002). Gender differences and gender-related constructs in dating aggression. Personality and Social Psychology Bulletin, 28(8), 1106-1118.

14.  Johnson, H. (1996). Dangerous domains: Violence against women in Canada. Toronto: Nelson Canada.

15.  Johnson, H., & Dawson, M. (2011). Violence against women in Canada: Research and policy perspectives. Don Mills: Oxford University Press.

16.  Mahlstedt, D., & Welsh, L. (2005). Perceived causesof physical assault in heterosexual dating relationships. Violence Against Women, 11(4), 447-472.

17.  Nabors, E. L., & Jasinski, J. L. (2009). Intimate partner violence perpetration among college students. Feminist Criminology, 4(1), 57-82.

18.  Reitzel-Jaffe, D., & Wolfe, D. A. (2001). Predictors of relationship abuse among young men. Journal of Interpersonal Violence, 16, 99-115.

19.  Testa, M., Vanzile-Tamsen, C., Livingston, J.A. & Koss, M.P. (2004). Assessing women’s experiences of sexual aggression using the Sexual Experiences Survey: Evidence for validity and implications for research. Psychology of Women Quarterly, 28(3), 256-265.

20.  Wolfe, D.A., Crooks, C.V., Jaffe, P.G., Chiodo, D., Hughes, R., Ellis, W., Stitt, L., & Donner, A. (2009). A universal school-based program to prevent adolescent dating violence: A cluster randomized trial. Archives of Pediatric and Adolescent Medicine, 163, 693-699.

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).

Strength in Voices, as Light Once Again Takes Over Darkness

Guest Blogger: Syeda Shanza Hashimi (University of Ottawa, Faculty of Medicine)

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Tracing back a number of years, medical students have chosen a plethora of topics to dedicate advocacy and research efforts. Whether it be in targeting clinical issues affecting society, social climates needing exposure and reform, or healthcare in Canada generally, these topics seep into all aspects of the determinants of health.

The Canadian Federation of Medical students (CFMS) is a body that represents over 6000 medical students in Canada. Annually, CFMS holds their Day of Action (formally known as Lobby Day), where medical students travel to Ottawa to participate in advocacy training and meetings with Parliamentarians for a nationally chosen topic [1]. This year, the topic was Indigenous Mental Wellness, inspired by the position paper released in 2017, “Mental Health & Suicide in Indigenous Communities.” This paper, created by medical students across the country, highlighted a number of issues that are still prevalent, namely the significantly higher mental illness and suicide rates [2].

In order to guide the federal response to the Indigenous suicide crisis, and direct Health Canada and Indigenous Services to increase funding for preventative and land-based wellness programs [1], students across Canada were selected as delegates. Acting as CFMS representatives, these delegates worked extensively with Indigenous community leaders to make preparations, research, and hold consultations with the aim of advancing these policies.

Speaking as a second-year medical student and current National Officer of Health Policy, I can say that there has not been much educational exposure to this issue.  It appears as an elephant in the room, one that many seem to acknowledge briefly, but then forego.

Nevertheless, for more than 70 passionate delegates from across the country, a decision was made to actively advocate for the rights of aboriginal peoples, and to urge specific changes to the funding currently supporting Indigenous programs. In order to enter into these difficult conversations and discussions, these students had to dive into the troubling history of aboriginal peoples (First Nations, Inuit, and Métis), for only then were we able to begin to translate our knowledge into action.

Following 25 years of negotiations, the UN General Assembly on September 13th, 2007, 143 countries voted to adopt the United Nations Declaration on the Rights of Indigenous Peoples. In Canada, the Federal government formally endorsed the UN Declaration on November 12th 2010, through its commitments to the Truth and Reconciliation Commission (TRC). Accordingly, this commission published a “Call to Action” report, consisting of 94 recommendations the government took on as their mission [3]. Much of the content in the Declaration involves commitments to Indigenous rights, by securing strength in self-government, maintaining distinct political or cultural institutions, ensuring informed consent, approval, and fair compensation for any approval of projects for traditionally owned lands/resources -as well as land that has already been taken or damaged prior to such right-, determining identity, recognizing treaties, and relinquishing populations from discrimination [4]. To achieve these goals, the Canadian government has allocated resources to interpret and act on the report’s recommendations.

Despite this commitment, there remains a significant amount of mental health issues in Indigenous populations. This stems from trauma and cultural losses as a consequence of colonization, creating a ripple effect that has seeped into younger generations. For example, memories of Residential Schools, operating from late 1800s to the 1960s, whereby children were separated from families and their roots, created rifts in cultural identity, resulting from an inability to in participate in traditional activities.  Many children within these schools also experienced emotional, sexual and physical abuse, and often internalized these traumas upon returning to their homes [6]. This history is now an ingrained part of the story of Indigenous people in Canada, it looms over and colours the ancestral lands they continue to call home, and years of bearing its weight tells a story of great resiliency and courage. Today, members of these communities continue to fight for their land, their identity, and their future.

However, even with the abolishment of Residential Schools and Canada’s commitment to the TRC’s recommendations [6], a lack of access to adequate resources, professional and educational opportunities, and political autonomy has acted as a catalyst contributing to the ongoing deterioration and disconnection of Indigenous communities. Despite federal reconciliation efforts, there remain significant issues mental health concerns in First Nations and Inuit communities [6]. The community of Neskantaga in Northern Ontario declared a state of emergency on April 17th, 2013 “…following two suicides in less than a week and 20 suicide attempts over the previous year” [6]; Inuit communities experience suicide rates estimated to be 11 times higher than the general Canadian population [7]; and the national rate of suicide among First Nations communities is approximately double that of the general public [8].

With the passing of Bill C-262 (April 2016) [3] and public endorsement of the United Declaration on the Rights of Indigenous Act, there is now a nation-wide call in Canada for alignment of Canadian laws with that of the UN Declaration on the Rights of Indigenous Peoples. With this, as well as other federal initiatives aimed at forming a legislative framework in keeping with such provisions, medical students looked at adopting the First Nations Mental Wellness Continuum Framework and the National Inuit Suicide Prevention Strategy to address these two populations’ mental health and suicide rates. Students were also to undertake a comprehensive review of current distribution of funding through the National Aboriginal Youth Suicide Prevention Strategy (NAYSPS) [1].

In addition to learning about the nature of funding for these programming initiatives, as well as logistical and legal considerations, students engaged in extensive consultation with community leaders for an appropriate account of personal experience. A proportion of delegates were also Indigenous students, who contributed their own personal and professional efforts toward the Day of Action. Students met with Parliamentarians and posed questions, received feedback, and established a follow-up process to ensure something was being done. Students were also assigned to meet in pairs or alone, and were provided a day of training beforehand to review all relevant documentation and participate in group discussions.

The social media outreach of Day of Action was tremendous. Along with the “Thunderclap” campaign and incredible Twitter coverage, 91, 455 people were reached. Delegates were encouraged to spread the word the word and encourage discussion.  

In the collected reflections of delegates, many comments described the opportunity to meet with MPs, professionals and students across the country as inspiring. Similar interests and a drive for activism motivated students to unite on a single day, where all their work and preparation served them well in advocating for Indigenous mental well-being. Time and energy was spent to ensure that students were well-prepared and equipped to support their claims and pose their difficult questions, and to propose alternative strategies to address this nationwide issue.

Students established professional relationships to ensure there was a follow-up process after the meetings. While some students were exposed to difficult realities in having these discussions, for the most part, students received a positive response from their questions, and perceived an overarching desire to support ongoing efforts for Indigenous mental wellness. Some students hit hard obstacles, where they found their points were not being considered, or were confronted with a lack  of knowledge from the specific Parliamentarians , making higher level advocacy a harder target to achieve. In such cases, these students left the room with a belief that they tried their best. “And I think we planted a seed” (Day of Action Delegate), a good analogy in the efforts that took place Monday, February 12th on Parliament Hill. By voicing pertinent issues, strategizing action plans for improvement, posing difficult questions and conversing through months of research and consultation, students started something they will continue to push forward. As a united nation, we stand forward for what is right and true.

References:

[1] CFMS (2018) CFMS Day of Action on Indigenous Mental Wellness. Retrieved February 16, 2018 from: https://www.cfms.org/news/2018/02/03/the-cfms-national-medical-student-day-of-action-on-inidigenous-mental-wellness.html

[2] (2017) Mental Health & Suicide in Indigenous Communities. Retrieved February 16, 2018 from: https://www.cfms.org/files/position-papers/sgm_2017_indigenous_mental_health.pdf

[3] (May 2016). The United Nations Declaration on the Rights of Indigenous Peoples- Moving Forward. Retrieved February 16, 2018  from: https://hillnotes.ca/2016/05/25/the-united-nations-declaration-on-the-rights-of-indigenous-peoples-moving-forward/ 

[4] Truth and Reconciliation Commission of Canada (2012). Calls to Action. Retrieved February 16, 2018  from: http://www.trc.ca/websites/trcinstitution/File/2015/Findings/Calls_to_Action_English2.pdf

[5] Bill C-262. House of Commons of Canada. Retrieved February 16, 2018 from: http://www.parl.ca/DocumentViewer/en/42-1/bill/C-262/first-reading

[6] Kielland, N and Simeone, T. (2014). Current Issues in Mental Health in Canada: The Mental Health of First Nations and Inuit Communities. Retrieved February 16, 2018 from: https://lop.parl.ca/Content/LOP/ResearchPublications/2014-02-e.pdf

[7] Oliver, L., Peters, P., and Kohen, D. (2012) Mortality rates among children and teenagers living in Inuit Nunangat, 1994 to 2008. Retrieved February 16, 2018 from:http://www.statcan.gc.ca/pub/82-003-x/2012003/article/11695-eng.pdf

[8] Public Health Agency of Canada. The Mental Health and Well-Being of Aboriginal Peoples in Canada. Retrieved February 16, 2018 from: https://www.canada.ca/en/public-health/services/reports-publications/human-face-mental-health-mental-illness-canada-2006/mental-health-2006.html

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).

Making Space to Speak the Unspeakable: Talking About Suicide

Nicole Dunn

Suicide can feel unspeakable because for many of us, being in a place where living no longer feels like an option is unimaginable. In conversation, you may have noticed that it is not uncommon for the word “suicide” to be whispered or mouthed as an acknowledgment that something here is taboo. It is an emotionally charged word, loaded with feelings of blame, anger, guilt, sadness, and shame. No matter your lived experiences, speaking about suicide in some way forces us to confront the existence of these complicated and often deeply uncomfortable emotions. And yet, we know that having conversations about suicide is important – in fact, lifesaving. In the interest of making the unspeakable speakable, the following discussion will unpack some common terminology used to talk about suicide and offer some alternative language.

To understand language and its relationship to suicide, it’s helpful to acknowledge that for 80 years in Canada, suicide was codified as a criminal offence. Then, in 1972, suicide was decriminalized. But the language commonly used to talk about this issue still tends to include criminal overtones. For example, it is common to hear someone say that “X committed suicide”. The consequences of using the term “commit” when referring to suicide lies in its ability to generate feelings of shame. According to Brené Brown, shame is “the intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging [because of] something we’ve experienced, done, or failed to do...” [1]. Using the term “commit” thus likens a person’s unimaginable experience of pain to a crime. Acts we “commit” tend to be reprehensible and so you can imagine that this association might generate feelings of shame. Furthermore, the word “commit” conveys literally nothing about the fact that a suicide is the tragic outcome of someone’s personal struggle [2]. Nonetheless, we know that experiencing deep physical and/or emotional pain does not make someone a criminal. We don’t say things like “X committed depression” or “X committed post-traumatic-stress-disorder”. We recognize that these conditions are not chosen, but are instead, serious mental health concerns that deserve compassion and empathy. As an alternative, instead of saying “X committed suicide” a neutral approach might be to say, “X died by suicide”.  This strategy has two advantages. On the one hand, it is very matter of fact, and does not diminish or try to hide the gravity of the act. On the other hand, this approach eliminates shame from the conversation.

Other shameful terminology that exists relating to suicide includes phrases like “successful attempt” and “failed attempt”. Here, a “successful attempt” refers to someone who died by suicide and a “failed attempt” refers to someone who survived suicide. If you read that and felt something rubbed you the wrong way, you’re not alone. Indeed, it’s puzzling to associate success with death and failure with life. Using language that couples the notion of achievement with suicide is very far removed from the nature of the issue and does not do this public health concern the compassionate justice it deserves. In place of “successful attempt”, neutral language opts to use “died by suicide” and in place of “failed attempt”, “suicide survivor” can be used.

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Shame is seriously dangerous. It is an emotion that is highly correlated with addiction, depression, violence, aggression, eating disorders, and suicide [3]. Shame does have an antidote, however, and it is found in the empathic reception of this emotion. By defusing the shame that discussions of suicide provoke, empathic communication helps makes space for us to speak about suicide, and is thus an important way to support survivors. In one study, researchers found that parents of young adult children who died by suicide found joy in talking about their lost loved ones as a means to keep their memory alive and process their grief. But they also felt that before they could open up about their child, they had to test their listeners to avoid unsupportive reactions. For parents, this process had the potential to isolate them in the moments they most wanted support [4]. Overcoming this barrier means conveying empathy to survivors and a simple and survivor-centric way to do this is through our language use. In fact, demonstrating this kind of care is proven to have a meaningful impact as research has shown that reducing stigma can improve access to care for mental health [5,6,7]. In other terms, communicating from a place of empathy can be life-saving.

At the Hatching Ideas Hub, we recognize that using neutral language when talking about suicide requires both knowledge of the weight of words and a willingness to be conscientious about their selection – a task that is not always easy! In fact, when it comes to talking about emotionally charged content, there are no perfect ways to have these conversations. But do have them. Language use might appear to be a minor issue in the grand scheme of suicide prevention efforts. After all, “a change in the words we use will not immediately dispel deep-seated prejudices” [2] but it can help lay the foundation for addressing this topic from a place of empathy, and the power of this should never be overlooked.

References

[1] Brown, B. (2017, September 10). Shame v. guilt. Retrieved January 15, 2018, from https://brenebrown.com/blog/2013/01/14/shame-v-guilt/

[2] Sommer-Rotenberg, D. (1998). Suicide and Language. Canadian Medical Association Journal, 159, 239-40.

[3] Brown, B. (2012, March 16). Listening to shame. Retrieved January 20, 2018, from https://www.youtube.com/watch?v=psN1DORYYV0

[4] Maple, M., Edwards, H., Plummer, D. & Minichiello, V. (2010). Silenced Voices: Hearing the stories of parents bereaved through the suicide death of a young adult child. Health and Social Care in the Community, 18, 241-248.

[5] Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614–625.

[6] Scocco, P., Preti, A., Totaro, S., Ferrari, A., & Toffol, E. (2017). Stigma and psychosocial distress in suicide survivors. Journal of Psychosomatic Research, 94, 39-46.

[7] Perlick, D. A. (2001). Special section on stigma as a barrier to recovery: Introduction. Psychiatric Services 52, 1613–1614.

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).

Calling People What They Want to be Called

Craig MacKie

During our lab’s last Twitter live-chat, one of the topics that generated lively debate was that of language. Specifically, we asked what kind of language was appropriate to use when describing people who use mental health services. Opinions were varied, but I did like one response in particular: @MarkOneinFour suggested that, in terms of word-choice for a mental health service-user, “I think it might be more ‘call people what they want to be.’” A simple and elegant solution.

I like this approach. It’s a friendly principle, and one that I try to pursue in my private life. It makes respectful consideration the basis of the choice, and ensures that the power to define is vested with the person being defined. To use the language of psychiatry, it is a “person-centered” approach to naming. This said, the limit of this solution emerges when you try to apply it to a group, as when publishing a paper, blog, pamphlet, or other summary. When moving from the level of individual choice to that of the collective, the imperative suddenly becomes one of selecting the most widely accepted, or at minimum, the least offensive term.

This is the road that health bureaucracies must travel, and it has created a spectrum of terms that vary from country to country, from health system to health system, and, often, within research/health teams; with the preferred terminology generated often showing preference for the kind of bland language corporate structures gravitate towards. As we mentioned in our December 4, 2017 blog post, a systematic review of the literature shows that terms like ‘client,’ ‘service user,’ ‘customer,’ and ‘consumer,’ have gained currency in English-speaking countries[i], with a range of other terms also showing some prominence.

As I’ve already suggested, these are terms that have been largely chosen because they are (relatively) inoffensive. They also mirror the language of the marketplace, especially in cases such as that of the U.S., where the desire to distance healthcare language from that of business is less of a priority due to the nature of the privatized healthcare system. The Australian healthcare system appears to have opted for a middle-road with the term of choice being “consumer,” while Canada and the U.K. seem to have made room for a range of different, though similarly generic, terms, including “person affected by mental illness” and “person with lived experience.”

I’d also like to point out that there is still some support for the term “patient,” even while it is often poorly received and remains a contentious choice. As it was explained to me, a cancer patient is never described as a “person with lived experience of cancer,” and if someone afflicted with this disease were to be described as such, they would probably find the euphemism more than a bit inappropriate, if not reprehensible. From this perspective, it is worth asking ourselves if the decision to avoid describing people suffering with mental illness as patients is not itself a form of polite stigmatization, with the imperative to select a respectful term of address covering up the practical functioning of a system that nevertheless treats people affected by mental distress as patients. While the campaigns to combat stigma through language deserve our respect and support, if they are not accompanied by real changes to the functioning of the healthcare system, then we can probably point to all of these debates as the definition of “lip-service.”

As far as the Hatching Ideas Hub is concerned, our phrase of choice remains “people with lived experience.” This is influenced by our position within the Canadian healthcare system, our role as a research institution, and our commitment to patient-oriented research. When working with research partners who have struggled with their minds as with the Canadian healthcare system, we seek knowledge of this ‘lived experience’ to inform the work that we do. It is simultaneously a pragmatic choice and a euphemism, and though it remains more than a bit sanitized, it seems like the best option among a host of inadequate choices.  When working in less of a partnered capacity, and when speaking from more of a clinical perspective, the lab’s language favours the term “service-user.” Again, this choice, while imperfect, seems like an ideally generic option. It does not escape the language of the market, but I find it preferable to the alternatives. To be able to describe and advocate for the people who use mental health services, “service-user” works, though it may not be the term I would select for myself. If I were to choose what I want to be called, it would probably be “person,” but I realize that this is not exactly the most descriptive of terms. I also like “fellow traveler,” but I don’t exactly anticipate that medical journals will flock to this choice. In the end, we have to use the words that are expected by and accepted by the listener. Blandness and inadequacy may be the flip-side of incoherence, but it also may be the price that we have to pay in order to be heard.

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[i] Dickens, Geoff and Marco Picchioni. (2011). A Systematic Review of the Terms Used to Refer to People Who Use Mental Health Services: User Perspectives. International Journal of Social Psychiatry, 58(2), 115-122.

The Hatching Ideas blog contains discussions of mental health, suicide, social vulnerability and other, similar topics. The topics discussed may prompt unwelcome reminders, and we ask our readers to exercise discretion when reading. In case of an emergency, please contact your local health provider or dial emergency medical services (9-1-1).