Rachel Grimminck, MD, FRCPC, DABPN, CGP

Clinical Assistant Professor at the University of Calgary and the University of British Columbia

External Collaborator with University of Calgary EMBER study

Physician Associate with Well Doc Alberta and Well Doc Canada

Board Member with the British Columbia Psychiatric Association (BCPA)

About Dr. Grimminck

Dr. Rachel Grimminck, MD, FRCPC, DABPN, CGP (she/her), is a psychiatrist of mixed European ancestry living on the unceded territories of the Quw’utsun Peoples. She is a Clinical Assistant Professor at both the University of Calgary and the University of British Columbia.

Her passion for systemic change has developed through various leadership roles, including her time as the Clinical Medical Director (CMD) for Psychiatric Emergency Services (PES) at Foothills Medical Center (FMC) in Calgary. In collaboration with Dr. Jacqueline Smith and the EMBER (Exploring Mental Health Barriers in Emergency Rooms) team, her work in Emergency Psychiatry led to the genesis of a multi-year study at the University of Calgary focused on stigma reduction. Since moving to British Columbia in 2021, she has continued as an external collaborator on the project.

Dr. Grimminck is a Certified Group Psychotherapist and facilitates psychoeducational, mindfulness-based, and process-oriented groups. She serves in leadership roles with Mind Space which provides evidence-based groups across British Columbia. Additionally, she serves as Physician Associate for Peer Support with Well Doc Alberta and Well Doc Canada. Dr. Grimminck is a board member of the British Columbia Psychiatric Association. She is a graduate of Island Health’s Physician Quality Improvement (PQI) program and Vancouver Island University’s Psychedelic-Assisted Therapy Graduate Certificate program.

Dr. Grimminck received the 2020 Early Career Leadership in Medical Education Award from the Royal College of Physicians and Surgeons of Canada and the 2020 Early Career Achievement in Psychiatry Award from the Canadian Psychiatric Association. She was also named to Calgary’s Top 40 Under 40 class of 2020.

Dr. Grimminck’s Story

I didn’t initially plan to pursue psychiatry when I started medical school and had little understanding of the role of a psychiatrist. However, during my first clinical exposure to psychiatry, I became fascinated by the field’s complexity. I am tremendously grateful I attended the University of Calgary’s Cumming School of Medicine which has a strong psychiatry curriculum proven to reduce stigma (Papish 2013). I have also been fortunate to have many mentors who have a profound passion for the profession. I continue to feel privileged to work closely with individuals during some of the most vulnerable moments of their lives and cannot imagine working in any other discipline in medicine.

As the former CMD for PES at FMC, Calgary’s largest teaching hospital, I witnessed individuals presenting with mental health and substance use (MHSU) concerns waiting up to 14 days in the emergency department (ED) for inpatient care due to various systemic barriers. This experience was dehumanizing and distressing for patients, their families, and providers. Unfortunately, Calgary is not alone in this; prolonged boarding in the ED for people with MHSU concerns continues in many settings across North America due to structural stigma.

The lack of access to quality care for many people with MHSU concerns motivates much of my work. My advocacy as CMD led to a connection with Dr. Jacqueline Smith from the University of Calgary’s Faculty of Nursing, and with the support of Dr. Valerie Taylor, the Head of the Department of Psychiatry at the University of Calgary, this ultimately resulted in the EMBER study. This multi-year study aims to address stigma at the intrapersonal, interpersonal, and structural levels in the ED. Structural stigma can be defined as the “accumulated activities of organizations and systems that deliberately or inadvertently create and maintain social inequalities for people with lived and living experiences of mental health problems and illnesses and/or substance use” (Knaak 2020).

Mental health concerns affect one in four people, yet there is often significant discomfort and resistance to the topic, both within medicine and the general population. I’ve learned that addressing all forms of stigma requires accurate education to counteract misinformation, as well as the need to examine biases, assumptions, and stereotypes with courage and vulnerability. All forms of stigma influence when and how individuals access care, if they do at all, and can impact the quality of care they receive. Unfortunately, many people seek treatment later in the course of their illness, making it more difficult to treat. As with other health conditions, such as infections, mental health concerns are easier to treat earlier in their course.

My hope is that all Canadians with MHSU concerns can access high-quality, evidence-based, and compassionate care. I envision MHSU care fully integrated into all aspects of healthcare and, where applicable, other domains of society (e.g., housing, legal).

Our Conversation with Dr. Grimminck 

Can you share a bit about the work you’ve done in addressing mental health structural stigma within healthcare systems?

After moving to British Columbia in 2021, I participated in Island Health’s PQI initiative, supported by Doctors of BC. The project aimed to reduce the time patients experiencing behavioral emergencies spent in locked seclusion in the ED. Our team worked with Patient Partners to inform staff education and implement process changes, including tracking seclusion times, using nursing and physician checklists, and ensuring adherence to provincial guidelines. We shared our results locally and provincially through conferences, and our work was profiled in the BC Patient Safety and Quality Council (now Health Quality BC) Patient Voices Network Annual Report.

Through this process, I gained a deep appreciation for the importance of involving people with lived and living experience (PWLLE) of MHSU concerns in projects. Programs like the Patient Voices Network in BC are instrumental in bridging the gap between patients and providers.

As part of the EMBER team, I was actively involved in developing and delivering the Trauma and Resiliency Informed Practice (TRIP) training program for ED providers, originally from Fraser Health [Knaak 2021], which we adapted for the FMC ED context. TRIP training acknowledges that healthcare providers often experience high levels of distress and trauma, and it emphasizes that self-compassion and resiliency skills are essential for providers to deliver trauma-informed care effectively to patients.

Additionally, policy impacts structural stigma, and therefore policy reform is needed to improve care for people with MHSU concerns (Sukhera and Knaak 2022). I am working with members of the policy arm of the EMBER team to develop a tool to evaluate structural stigma in healthcare policy.

What have been some of the biggest challenges you’ve faced in this work, and how have you overcome them?

One of the biggest challenges has been addressing differing perspectives among providers and leaders regarding the inequities faced by individuals with MHSU concerns. These differences often stem from varying experiences, priorities, and levels of awareness about these issues.

I’ve found that building relationships and fostering open, respectful dialogue to better understand their perspectives and concerns is a productive way forward. Reminding myself that system change takes time helps me stay patient and compassionate—toward myself, others, and the system.

Connecting with others who share a vision for health equity and a commitment to addressing structural stigma has been both energizing and essential for support. Seeing small changes over time gives me hope and motivates me to continue this work.

In your view , how does mental health structural stigma manifest most prominently in healthcare settings, and what are the first steps to addressing it?

Structural stigma in mental health manifests in several ways within healthcare settings:

• Poor Access to Evidence-Based Care: Systemic barriers such as long wait times, a shortage of providers, insufficient funding, and other challenges delay diagnosis and treatment.
• Diagnostic Overshadowing: Physical health complaints are often attributed to mental illness, leading to inadequate or inappropriate care, resulting in increased morbidity and reduced life expectancy.
• Human Rights Violations: People with mental health conditions sometimes experience violations of their rights within healthcare systems.
• Lack of Resources for Psychosocial Interventions: Insufficient funding and resources hinder access to and implementation of evidence-based psychosocial treatments.

First Steps to Address It:

1. Increase Awareness and Acknowledge Harm of Structural Stigma: Raising awareness about the impact of structural stigma is the first step in addressing it.
2. Adopt a Human Rights-Based Approach: Following frameworks like WHO QualityRights can guide healthcare systems in protecting and promoting the rights of people with mental health conditions.
3. Involve People with Lived and Living Experience (PWLLE) of MHSU concerns: The voice of PWLLE is critical to reducing structural stigma. Patient partner organizations like the Patient Voices Network in BC (https://patientvoicesbc.ca/) can support providers to involve patients to improve care.

Could you share a success story where you’ve seen meaningful change in reducing mental health structural stigma in healthcare?

One promising example is Health Justice’s governance model, which actively involves PWLLE of MHSU concerns at a structural level within the organization. This model demonstrates how meaningful partnership and integration can influence systemic change. For more details and other examples, please see the Mental Health Commission of Canada (MHCC) Dismantling Structural Stigma 2023 report and the MHCC website.

Organizations need data and the Stigma Cultures in Healthcare scale (Stewart and Knaak 2023), is a tool to quantify how stigmatizing service users find the culture of care in healthcare settings. This scale is being used in the EMBER study to identify and address stigma within EDs.

Lastly, there has been an increased recognition of the role of trauma in healthcare, leading to the implementation of Trauma-Informed Care (TIC) practices. This shift supports a more compassionate and supportive approach to care, helping reduce stigma and improve patient outcomes.

How do you think healthcare professionals can play a role in challenging and changing mental health structural stigma in their daily work?

Healthcare professionals and leaders, though not responsible for creating the current system, hold power within it that they can use to effect change. Here are some ways to reduce structural stigma:

1. Increase Awareness of Implicit Bias: It’s essential for providers and leaders to learn about implicit bias, especially biases they may have towards PWLLE of MHSU concerns. Acknowledging and building awareness of these biases is a crucial step in reducing stigma.
2. Implement Trauma-Informed Care (TIC): Organizations are encouraged to adopt TIC as a universal precaution, similar to hand washing (Racine 2020). TIC encourages providers to shift from asking, “What’s wrong with this person?” to a more compassionate approach: “What happened in the past leading to this situation, and how can I help?” This change fosters trust, respect, and collaboration, enhances safety in healthcare settings and supports recovery.
3. Develop Structural Competency: Structural competency is the ability to recognize and address inequities in medicine and lead structural change (CAMH 2024). This involves understanding the policies, social hierarchies, and economic systems that perpetuate inequality and structural violence (Metzl 2014; CAMH 2024). Structural competency enhances awareness of the frameworks that reinforce inequality and highlights system-level changes needed to advance health equity.

Looking forward, what changes or innovations would you like to see in mental healthcare?

To improve access, enhance quality, and reduce harm, structural stigma must be addressed not only within MHSU services but across all areas of healthcare and society. Recognizing this is a complex issue, I would like to highlight a few considerations for leaders and providers:

1. Adopt a Health Equity and Human Rights-Based Approach: A human rights-based approach is based on human rights standards and promotes and protects human rights at the organizational level (Porsdam Mann 2016). The WHO QualityRights initiative offers a framework and strategies to promote mental health systems, services, and practices that prioritize respect for human rights (Funk 2020). Another example is the CAMH Bill of Patient Rights.
2. Reduce Fragmentation: Mental health is intricately connected to all areas of health, yet there is often an artificial separation between mental health and other aspects of healthcare. For example, some provincial governments silo MHSU care at the ministerial level. Integrating mental health services into general health services is crucial, since conditions like depression are prevalent in patients who have had heart attacks and are linked to poorer outcomes. Medical education curriculums and training often reinforces this separation which further perpetuates stigma.
3. Establish Wait Time Standards and Benchmarks: Set clear standards for wait times and access to quality MHSU care, accompanied by a transparent monitoring process. This has been implemented in the NHS in the UK and could serve as a model for improving accountability and access.

What do you think needs to happen on a systemic level to reduce mental health structural stigma and improve access to mental health care?

To effectively reduce structural stigma and improve access, it is essential to meaningfully engage and partner with PWLLE from the outset of any initiative. This goes beyond traditional advisory or consultative models, by integrating their perspectives into organizational processes and decision-making. It also includes fair compensation for their time and contributions. This partnership-based, equity-focused, and co-design approach ensures that initiatives are more relevant and effective for those most impacted by MHSU-related stigma. The MHCC Dismantling Structural Stigma in Health Care guide provides more details and links to additional resources.

If you could implement one major change in the healthcare system tomorrow, what would it be?

I can’t pick just one, so here are my top three:

1. Structural Competency Training: Training providers to recognize and address the implicit frameworks that perpetuate structural inequality and violence is essential (Metzl 2014, CAMH 2024).   Implement training for all healthcare providers, administrators, and leaders on structural competency including structural stigma, equity (not just equality), human rights-based approach, implicit bias, and intersectionality.  This article by Neff outlines a structural competency curriculum that can be offered at an organizational level.
2. Engagement of People with Lived and Living Experience (PWLLE) of MHSU concerns: Actively involve PWLLE in system co-design to ensure services are more effective, inclusive, and compassionate.
3. Measurement and Evaluation: Establish metrics to measure structural stigma, and the quality of care for people presenting with MHSU concerns. These metrics can be used to improve access and hold leaders accountable for the quality of care and patient outcomes.

What advice would you give to others who are passionate about addressing mental health structural stigma in their healthcare organizations?

Start by learning more about Structural Stigma and Structural Competency to promote health equity. Here are a few resources to get you started:

• The Mental Health Commission of Canada (MHCC) published an implementation guide in 2023 titled Dismantling Structural Stigma in Health Care. This is an excellent resource for healthcare providers and leaders to understand structural stigma, with practical steps and examples on how to address it. It also includes a wealth of additional resources.
• The MHCC’s Mental Health Structural Stigma in Healthcare e-learning course, offered by CHA Learning, is another valuable tool. This free online training covers the impact of structural stigma and offers guidance on how to dismantle it.
• The Center for Addictions and Mental Health (CAMH) recently published “A Framework for Integrating Structural Competency into Physician Leadership Curricula”.
• There is a growing body of literature on structural competency in health professions education (Gholar 2023).  Learn more by visiting the following websites: Structural Competency Working Group and structural competency.

Dismantling Structural Stigma in Healthcare in Conversation with Dr. Javeed Sukhera