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Tracing the growth of an idea or social movement offers a glimpse into the way we think about health and its disorders. In Canadian society, social acceptance is emerging as a fundamental pillar of harmonious coexistence. This concept transcends cultural and linguistic boundaries, offering a common ground where individuals can feel recognized, valued, and respected. At the heart of social acceptance lies empathy. Roughly speaking, it’s putting ourselves in other people’s shoes, understanding their experiences and perspectives, even when they differ from our own. It is called into question time and again, as in Quebec with the environmental issues surrounding the construction of a battery factory or the siting of wind turbines, or as in Vancouver with drug users and the homeless. Education plays a crucial role in promoting social acceptance. For example, by integrating programs focusing on intercultural awareness and the fight against discrimination, schools can train young people to become aware and respectful citizens of the world.

In the field of mental health, social acceptance is more than just a concept; it can become a catalyst for healing and transformation. When we speak of social acceptance in psychiatry, we are referring to the recognition and respect of individuals living with mental disorders, and the promotion of an environment where they are fully integrated and supported. For decades, this has been the editorial line of our journal Santé Mentale au Québec.

One of the cornerstones of social acceptance in mental health is the fight against stigma. All too often, people with mental health problems are confronted with prejudice and discrimination that can hinder their recovery and well-being. Social acceptance aims to break down these barriers by promoting understanding, empathy and support for those struggling with mental health problems.

Social acceptance in mental health is not limited to the individuals themselves, but also extends to their families, friends, neighbors, shopkeepers, schoolchildren, and communities. By fostering strong social support and encouraging inclusion, we can create a strong support network that helps people living with mental disorders to overcome challenges and thrive. However, for this social support to become a reality, we must avoid making mistakes such as locating a care or residential facility in one place, without considering the immediate environment, the neighborhood. The consequences of such mistakes are such that stigmatization and antipathy develop, despite all the good will of those involved in mental health or addiction. To illustrate this dilemma, I have chosen a concrete case in Montreal.

I’ve been living in the South-West district for 35 years, more specifically in Saint-Henri and Little Burgundy. It’s an area that has improved in an exemplary way for a city like Montreal. In the past, the area didn’t enjoy a good reputation. There were legends of organized crime revolving around the Dubois brothers’ clan, and frequent misdemeanors and crimes to the extent that when I was still a student, it enriched the mockery of my young colleagues. I continued to live there, even though I changed addresses several times. On the other hand, the area has developed wonderful community resources, and exemplary day-care centers have sprung up alongside training, francization, and literacy centers. Jazz has made its mark on murals and cultural venues. Parks have become well maintained and friendly, and sports are possible at any time in marvellous spaces. The community has also worked hard to make Saint-Henri and Little Burgundy a sought-after tourist, cultural, inclusive, multi-ethnic and dynamic commercial destination, while preserving social housing, some of which is still being renovated. The Lachine Canal that borders the neighborhood is a vector of well-being and peace for strollers and rowers alike. Our children’s and grandchildren’s love of the area has found a soil full of parks with slides, outdoor games and water fountains where everyone seems to flourish. Even when you’re shopping at the Atwater market or leaving the Victor-Rousselot school[1] across the street from it, you’ll find children laughing all day long. So, anyone who loves children, including pediatricians, anthropologists and politicians, could rejoice at this success.

The park between Victor Rousselot elementary school and the Supervised Drug Injection and Inhalation Center (SCS) at Maison Benoit-Labre. The name of this school comes from Rousselot, Benjamin-Victor, priest, Sulpician and parish priest, born in Cholet, Anjou, France and immigrated to Montreal. In addition to his involvement in the creation of the Institute for the Blind, Rousselot contributed, in 1880, to the establishment of the Notre-Dame Hospital in Montreal. We remember him for considerable undertakings with regard to the poor and disinherited of the earth.

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And then one day, the sky darkened. The construction of the Maison Benoit Labre of a supervised drug injection and inhalation center (SCS) adjacent to a children’s playground, across from an elementary school and the Atwater Market, renowned for its fall pumpkin displays and Christmas trees, became the subject of heated debate. La Maison Benoit Labre is a non-profit organization that has been working with vulnerable people for decades. I know this organization because it offers front-line services, including a day center, meals, groceries, showers, a nursing service, and prevention workshops. And for me as a psychiatrist, this is the kind of resource that usually helps us a great deal in our day-to-day work with our clients. But what the heck: who chose such a location?

As a psychiatrist, I specialized in psychosis. As a researcher, I studied co-morbidities with drug use disorders. When I was Chair of the University Department of Psychiatry at the Université de Montréal, I renamed it the Department of Psychiatry and Addictology. Every day, I meet patients who use drugs such as speed, crack or fentanyl, even when they are hospitalized in our rehabilitation units, because even within hospitals they are no longer spared by the market of illegal dealers. I’ve come to understand the small benefits of models like harm reduction versus coercive, abstinence-based methods. I know what it’s like when an intoxicated patient becomes catatonic, twists his trunk, or crosses his locked arms completely and screams in response to his voices, or defecates on the sidewalk, or falls asleep to the point where he’ll never wake up. I also know that there’s a stigma attached to drug users, mental health patients or people experiencing homelessness. And it’s precisely for all these reasons that I’m campaigning to ensure that we don’t make a mockery of the relationship between society and the care resources we offer and want to use, by preaching harmony and coherence. We should be sensitive to the fears and questions of citizens living in this deserving and resilient sector of Saint-Henri and Little Burgundy. In this situation, which we use as an example, I understand that a request has been sent to the national director of public health and that the Ministry and federal approval stages for this SCS have been completed. I also saw a petition from almost 5,000 citizens of Saint-Henri and Little Burgundy expressing reluctance and a different location. This building, which I passed on my way out of the Greenspot restaurant, famous for its smoked meat sandwich, is supposed to house 36 units intended to accommodate vulnerable people for at least a year. The organization claims to be able to offer its services 24 hours a day. In theory, the project focuses on empowering people to take control of their living conditions and offers an environment where everyone is treated with dignity and respect. I’ve heard this before, having worked as a psychiatrist in Vancouver, where I rubbed shoulders with the emergency department of St Paul’s hospital and supervised psychiatric residents on the Downtown Eastside, which has become a showcase for hell. On this subject, I invite everyone to watch the film Love in the time of fentanyl. This film is an intimate look beyond the stigma of injection drug users, revealing the courage of those facing tragedy in a neighborhood often considered the focal point of the overdose crisis.[2] When the number of overdose deaths in Vancouver reached an all-time high, the Overdose Prevention Society (OPS) opened its doors: a safe, “renegade” injection site employing mainly current and former drug users, and where its staff and volunteers today save lives and give hope to a deeply marginalized community as the overdose crisis rages on. I know the psychiatrist who works there, too, and he warned me against opening this kind of resource anywhere but in this very type of neighborhood, and to do it away from the schools. There had indeed been an attempt in a more residential area of Vancouver, and it had failed. It reinforced rejection and contempt for drug users. What’s more, in Quebec, unlike on the West Coast, it seems that overdoses are more related to speed than to opioids, although this will no doubt be transitory. Stimulants such as crack, cocaine and crystal meth are the most popular and deadliest psychoactive substances in Quebec, according to an excellent analysis of coroner’s files by Le Devoir.[3] The distribution of pipes for inhaling crack and crystal meth has grown exponentially in recent years in Montreal. We can also expect users to start consuming mixtures of speed, benzodiazepines (anxiolytic drugs) and fentanyl, and unfortunately, they are not always aware of what they are about to ingest. Behaviors are then even more difficult to predict. A SCS in Ontario, for example, was placed under guardianship in the Leslieville District because of disturbances, crimes and misdemeanors committed at its bedside. The center had come under scrutiny when a bystander was shot and killed nearby.[4] Evidence on the locations of 39 SCS in Canada is also available thanks to the interesting work of criminology professor Côté-Lussier (2023).[5] Her finding is that, for the other sites, there is a distance of at least 600 m separating them from a school. There would be a risk that setting up a SCS near an elementary school would have a deleterious impact on children’s health, well-being, and academic success.

Based on an ecological approach to public health, our universities teach that the characteristics of an individual’s social and physical environment can have major consequences on health. For example, the characteristics of the local environment and parents’ perception of neighborhood safety help to explain the health-related behaviors of young people.

In theory, social acceptance in mental health also involves creating inclusive environments where individuals feel safe to express their emotions and needs. This can take the form of policies and practices that promote accessibility to mental health services, as well as awareness campaigns aimed at educating the public about mental disorders and promoting caring. Today, it’s questionable whether the school’s adjacency to a neighborhood school is a good place to generate such campaigns.

Finally, it’s crucial to recognize that social acceptance in psychiatry is an ongoing, evolving process. Although progress has been made, there is still an enormous amount to be done to create truly inclusive and caring societies. However, by working together to combat stigma, promote inclusion and support recovery, we can make social acceptance a reality for all those living with mental health problems. And in the process, we build stronger, more supportive, and resilient communities for all. This is what we are achieving, for example, with Les Impatients in Montreal, now networked across the province.[6] Nevertheless, it’s crucial to take into account precisely those ingredients that make social acceptance easier. I’m not sure that installing an inhalation or injection site adjacent to a children’s playground and an elementary school is the best ingredient for this acceptance.[7],[8],[9]

Despite confirmations that it will be a 24-hour monitored site, one could almost argue that it is an ingredient for social unacceptance.[10]