Graduation Days

I have been attending graduation ceremonies this year. I attended my son’s graduation, some of my patients’ graduations and graduations for the College where I am a Governor. As I watch the graduates cross the stage, I find myself wanting to know more about them and their struggle. I want to know more about them and what their graduation means to them.

I cannot get this information from the black, or blue or white gowns they wear over their clothing. There is come information in faces: beaming smiles, nervous glances, eyes rolled when a parent calls their name to look to the front for a picture, tears. These same variations are repeated over and over on the faces of graduates as they pass by the podium.

The gowns of graduation tame young people into similar creatures in a way that is concealing. The gown demonstrates that each of these wonderful humans has met a standard that is important in their community – and ours. But how can I tell what it might mean for them at the most personal level? How can I learn what lies beneath that tame exterior?

I decide that I will see what I can learn from the one part of their outfit in full display. I decide that I will see what I can learn from their shoes.

Here is someone teetering across the stage in very high heeled stilettos. The stilettos are bright blue and brand new, and the wearer is clearly signaling that this event is worth some special attire that you don’t always wear.

Then comes a newly minted carpenter in steel toed boots, ready for those days when safety will be a priority, ready to head off for that first big job.

Then a stiff, young man walks across in highly polished brogues. Someone from the audience calls, ”Looking good, Joe!” The new business major looks sideways but his head doesn’t move, dignity as tight as those laced up shoes.

Ballet flats dance excitedly over, and pivot to wave and cheer, then two step their way to the grad party.

Small feet in Lace Toms glide across, courtesy of the wheel chair bringing them along. Four strong sets of arms accompany this graduate who is lifted to and from the stage. She just wanted to cross the stage like everyone else, and many hands made sure this girl could manage like every other high school graduate.

It continues: platform shoes, moccasins, flip-flops, boat shoes, golf shoes, loafers, high heels, high tops…bare feet! So many shoes, so many dreams, so much achievement in the thirty steps that end years of effort.

Shoes do not tell me much personal information about a graduate, but it is something. It is enough to make me want to ask, like Mary Oliver:

“Tell me, what is it you plan to do with your one wild and precious life?”

Book Review: The True Secret of Writing

Natalie Goldberg has been assisting her students into a writing life for forty years. She has developed her own teaching series to do this, a teaching series captured in The True Secret of Writing: Connecting Life with Language. This is a peaceful book to read, a book that reminded me of the sanctity of the simplest routines.

Goldberg speaks of the struggle to develop practices, routines for the things that we wish to do but that are not always easy. Reading Goldberg’s book, I realized some of the practices I’ve developed: my walk in the morning, my tea in the afternoon, my knitting in the car while my husband drives. Goldberg uses examples from her own life and that of her students to inspire us to overcome our personal barriers to practice. She ushers us into peacefulness with poetry and reflections.

This is a book written with writers in mind, but if you’re in a hectic or troubled time of your life, it is possible to read this book slowly, absorbing its calmness in ten to fifteen minute periods of reading. I am contemplating mindfulness at work, and especially I am contemplating the instruction of mindfulness. I read a passage from the book to one of my patient groups and, in the anonymous survey returned after the group, the reading received positive reviews from the youth attending the group.

This book also has excellent notes and reading lists to open your mind. There is no index but The True Secret of Writing does not provide information in the manner of standard creative nonfiction. An index is not as crucial.

Finally, this book has provided me with the Loving Kindness Prayer. I am always so saddened by the fact that it is necessary to remind people over and over again to be kind to themselves. I do not know why this is so hard to learn, but I know it’s taking me a long time. I am going to copy out this meditation for you. I hope it helps you.

May I be happy
May I be peaceful
May I be free
May I have the ease of well-being
May I be safe
May I be healthy

(Note: The prayer comes from page 142 of the 2013 Atria Books edition of The True Secret of Writing: Connecting Life with Language)

Two Practices That Combat Suicide

In the wake of the most recent celebrity suicides, I want to speak about two practices that we can learn that combat depression. I am convinced of the value of these practices not just from the fact that research (particularly Cognitive Behaviour Therapy Research) has confirmed their value, but because my patients have consistently told me that these tools helped them the most to survive. The tools are mindfulness practice and behavioural activation.

I will start by describing behavioural activation, because this is the easier of the two to describe. I also think that, of the two practices, it can be more fun for people to develop. Behavioural activation is based on the knowledge that our behavior can affect our emotions. We can all think of situations where this has been true. For example, we avoid visiting Aunt Jane because we’re worried that she is angry with us. However, the longer we avoid her, the more likely it is that Aunt Jane will become angry at us.

Often when people are depressed, they isolate themselves, finding it too difficult to participate in activities they value, like visiting Aunt Jane. Behavioural activation helps us to figure out how to work toward positive, mood enhancing activities even when they’re difficult and our anxiety or depression interferes with our efforts. There are three ways that behavioural activation can help improve mood:
1. By helping us to increase our participation in activities that improve our mood or validate our self-worth.
2. By helping us to decrease the times when we engage in activities that cause us to feel more depressed.
3. By helping us to find solutions to issues that keep us from participating in validating activities or circumstances that keep us entrenched in negative activities.

What is great about behavioural activation is that there are many books and online tools that can help us to begin this practice. I like this online tool for my work with patients in Behavioural Activation. If you’re looking for books, anything written by or with Christopher Martell would be a good bet.

Now let’s consider mindfulness. Once people learn the practice of mindfulness, they find it valuable. Time and time again, however, we hear back from patients that they “don’t get it”. In each of our programs, at least once per day in the daily programs, we provide a mindfulness exercise and encourage patients to develop this practice. We are always providing different exercises because one mindfulness practice will not suit everyone. I have found that we each have to find the exercises that suit us best. I do secretly think that the reason I struggle so much to assist patients with this practice is that I struggle personally with daily mindfulness practice. I am certain lots of people can identify with this. Don’t you have days when it seems that the last thing you have time for is fifteen minutes for a mindfulness exercise? The problem is that it is exactly on these days that we need to STOP and reset, bringing our minds back to the most important things: peace of mind, health, safety…peace. The key is to make time and to find a mindfulness exercise that you like and find helpful. Then you will work it into your day and the long term evidence is that this will alleviate anxiety and help improve mood.

As with behavioural activation, the research, and particularly some meta-analyses, show that mindfulness has a positive impact on both anxiety and depression. Of all the definitions of mindfulness, I like Jon Kabit Zinn’s best. Zinn says that mindfulness is “the ongoing moment to moment awareness that arises when observing the present non-judgmentally.” This definition gently captures the notion of awareness in the moment and reminds us that to be “nonjudgmental” is essential to good mindfulness practice.

Of all the people in the world who suffer from depression, Anthony Bourdain and Kate Spade could have had access to the best treatments in the world, and it still was not enough. In considering this, rather than feeling hopeless, I suggest finding out about the tools of behavioural activation and mindfulness. You can do this inexpensively and both only become more helpful with practice.

I am not saying that developing these tools is the antidote to suicide, but they will give you practices that are proven to combat depression.

Let me close with some pictures of one of the places that I often go to for mindfulness practice: my garden. This month, there are flowers that bloom for only a week or two, like peonies or irises. Enjoying them when they are at their best is one way to practice awareness in a moment, one way to be mindful. Knowing that they will not be blooming one week from now, I enjoy the moment of their beauty.

Book Review: The Death of Expertise

Tom Nichols’ The Death of Expertise: The Campaign Against Established Knowledge and Why it Matters is one of those perfectly written nonfiction books in which a review of the Introduction will tell the reader the premise the author will examine, and in this manuscript, prove over the course of two hundred or so pages. Nichols tells us that he will examine “the relationship between experts and citizens in a democracy” (Page 6). It is Nichols’ view that this relationship is in difficulty and so, he says, we are witnessing in our time the breakdown in the dialogue that is necessary for a democracy to thrive. Then Nichols goes on to examine the reasons for this breakdown in dialogue.

He first considers who is an expert and who is a citizen, recognizing that, in fields outside their own, experts are also citizens. This point is important for it is evident to many of us that we live in an era when many believe that expertise has no value. Nichols examines the factors that serve as barriers to dialogue, such factors as the Dunning Kruger Effect and confirmation bias. After considering these natural barriers, Nichols considers barriers that have developed in recent history.

The first institutions Nichols posits are contributing to the demise of expertise are universities, the very institutions meant to foster expertise. Students are now treated as valued clients more than as learners, he tells us. He goes on to dissect the impact this has had on citizen’s knowledge. Because of the need to keep students “happy”, some professors and institutions have fostered an atmosphere where education can be incomplete. For example, we know that it is educated parents who don’t vaccinate their children. That this is the case is a powerful indictment of education.

From the universities, Nichols moves to Google and the internet and the confusion of facts with knowledge. As well as considering the information and misinformation that can cloud knowledge, Nichols also examines how the internet, and its minions such as Twitter, have reduced the civility in our discourse.

Next, Nichols examines how the movement from journalism to news entertainment has affected our understanding of current events. Consider, he tells us, that we once had news shows that attempted to present what was happening in a neutral, unbiased fashion. Now we have news channels that cater to our preferences and beliefs, such as MSNBC or Fox.

A final factor in the disintegration of knowledge occurs when experts are wrong. These are the circumstances that confirm the bias against expertise in a world where all the previously mentioned factors are at play.

Nichols does conclude with some solutions and these merit our reflection. His entire, well-developed thesis, however, with its notes and references, is another antidote. It is impossible to study his argument and not become determined to do better.

(Note: I read the Oxford University Press 2017 Hardcover edition of this book.)

Do You Want to be a Consumer or a Patient?

Last week, I was annoyed by a few newspaper articles in which those persons using health care services were called “consumers”.

I’ve had enough of that.

I want the people using health care services to be called “patients” again.
What is a “consumer”?

My Canadian Oxford Dictionary defines “consumer” as “a person who purchases goods or services for personal use”.

Many of the people who see doctors or go to hospitals are not there by choice. They are there because they have no choice but to have access to the “goods or services” of medical treatment. The word “consumer” does not describe their role.

More importantly, I want patients to know that, in so far as “consumer” implies a relationship, I am not someone “selling” or even offering “goods or services”.

The treatment of a medical condition unfortunately implies that a person’s health is compromised. The remedy is not usually straightforward, not usually just an exchange between someone offering a service and a “consumer” of a “good” or “service”. This kind of transaction implies that there is a choice about the “good” or “service”. To the extent that this is the case, it’s never a good choice.

So I’d like to have the language we use about health care, the language that we use about the person entering my office, to remind them and me that the “goods or services” I am offering are provided with a concern for their welfare that goes far beyond the goals of any shopkeeper or tradesperson. I want language to remind them and me that they are in my office, in a hospital to “receive care”.

I want everyone to recognize that I strive to go beyond a business transaction in what I do.

I want those people who enter my office, distressed and unwell, to be called “patients”.

Photo Credit

Book Review: A Vancouver Guide

I was in Vancouver this past week and, while I was visiting, I found an unusual guidebook. The Citi60 guide, Vancouver: 60 local creatives bring you the best of the city will introduce you to parts of the city that are not on the usual tourist routes. The landscape section took me to the Cornelia Oberlander’s urban garden – a lovely, unexpected green space. Even the usual tourist sites, such as the Totem Polis in Stanley Park, are presented uniquely.

The best part of this book was the Section considering Markets and Shops. The Paper Hound bookstore and Chinatown crept into my brain, giving me a new consciousness of Vancouver. The way the shop and part of town were presented allowed me to see differently, and my experience was richer for this different view.

What does limit this book is that, even though it does have accommodation and restaurant information, you could likely not use it as your only guidebook. It is a small book, however, measuring 110 x 160 cm and 1 cm thick. You could easily bring it along with a more conventional guide.

A final aspect of this book that you can enjoy is the dust jacket. Take it off, open it up and you will find a colourful, city map, illustrated by Vancouver artist Janice Wu.
This book was published in 2017 by viction:ary, in Hong Kong. They have also produced similar guides to a number of other cities, and I might get one or two of them…just to think of travelling.

Here are my photos of the book and dust jacket:

Managing Bullying and Cyberbullying

Last week, I had the opportunity to speak at my hospital’s annual Child Psychiatry Education Day. My topic was Social Media and Your Child’s Mental Health. I was surprised at the number of questions there were. Apart from the public questions, many people came up after the talk to speak with me privately.

Among this group of people, the most common problem was cyberbullying. Bullying includes all actions and statements used to hurt another person or persons. Bullying can also be more social when small or large groups of people collude to pick on someone else.Whenever an online tool is used to hurt or tease another person, this is cyberbullying. It is often worse than bullying by other means since the echo chamber that can result on social media can intensify the hurt that is caused. It also allows others to participate, sometimes anonymously, if their identities are concealed by false names or obscuring titles or handles. Finally, it can be impossible to get a break from cyberbullying since it can continue at any time or in any place.

Both being bullied and being a bully have serious impacts on mental health. Those who are bullied often suffer from depression and anxiety, even Posttraumatic Stress Disorder, as one might expect. Being bullied can affect self-esteem. Frustrated, victims of bullying may lash out and become aggressive themselves.

Bullying behavior can be a sign that greater problems of aggression are developing. These are individuals who can move on to greater antisocial behavior. Those who persecute others may have deeper relationship problems, as well as serious problems with aggression.

For those seeking a resource for youth who are bullied, Rachelle Cassada Lohmann has written The Bullying Workbook for Teens with Julia V. Taylor. This is a Cognitive Behaviour Therapy based book that helps teens deal with bullying and its impact. She is also a blogger for Psychology Today.

There are other things that can be done to address bullying. When I was speaking with audience members after my talk, I was struck by people’s reluctance to report bullying and cyberbullying. “Traditional” bullying can be more difficult to prove, even when “everyone” knows it’s happening. Cyberbullying, on the other hand, can easily be proven with a screen shot. I urge everyone to take screenshots and report online bullying to the website where it is happening.

As adults, we know that youth may come to us when they are afraid or distressed by bullying, and then later change their mind about reporting. I suggest that, when a teen is with you worried about bullying, get them to send you the screen shot. Then follow up with them to ensure that they have reported the problem, both to school authorities and their parents, or even the police when necessary. Bullying and cyberbullying may be illegal, or may lead to more serious aggression against a young person and both school authorities and the police need to be involved. The RCMP has resources for those uncertain about the legal aspects of bullying. Schools and school boards around the world have standard policies regarding bullying. This is the website for the resources and policies regarding bullying at the largest school board in my region.

All the websites I’ve outlined can help you to find the guidelines and resources you will need in specific circumstances. I have focused on bullying and cyberbullying in youth, but we know that these behaviours can occur at any age. Those of us on social media have witnessed bullying. If you’ve ever been trolled on Twitter, even by only one especially vile person, you know it’s unsettling and distressing.

The one thing we can all do to stop this is to ensure that anyone being bullied is not isolated. Support those being bullied, even if you disagree with their opinion. We are better than our opinions.

This is a poem that I find helps at those times when the world is too critical:

“REMEMBER THE LOTUS FLOWER

Great people will always be mocked by those
Who feel smaller than them.
A lion does not flinch at laughter coming from a hyena.
A gorilla does not budge from a banana thrown at it by a monkey.
A nightingale does not stop singing its beautiful song
At the intrusion of an annoying woodpecker.
Whenever you should doubt your self-worth, remember the lotus flower.
Even though it plunges to life from beneath the mud,
It does not allow the dirt that surrounds it
To affect its growth or beauty.
Be that lotus flower always.
Do not allow any negativity or ugliness
In your surroundings,
Destroy your confidence,
Affect your growth,
Or make you question your self-worth.
It is very normal for one ugly weed
To not want to stand alone.
Remember this always.
If you were ugly,
Or just as small as they feel they are,
Then they would not feel so bitter and envious
Each and every time they are forced
To glance up at magnificently
Divine YOU.

REMEMBER THE LOTUS FLOWER by Suzy Kassem