About drgailbeck

I am a Child Psychiatrist in Ottawa, Ontario Canada. I am also a Board Director and the Honorary Treasurer at the Ontario Medical Association. I blog on parenting, medicine, mental health and gender issues.

Anamnesis

What do you remember from your childhood? How far back do you remember? I believe that I have memories from the second house I lived in, close to downtown Pembroke, Ontario where I was born. In my memory, I am with my older cousin who is taking me to a Lumber Kings hockey game. I was just under 4 years old and I didn’t know what a hockey game was, although I thought it might be like checkers. I was so surprised and pleased by this special outing with my favourite cousin and I have always considered this to be my first memory – and one of my happiest memories.

So many of my patients cannot remember their lives before school started. In fact, many of them say they recall very little before age 10 and their favourite memories are often quite recent. Many of them have no good memories at all. Anamnesis refers to a patient’s account of their medical history but this account takes on particular significance in psychiatry where memories and their meaning in the life of a person can be difficult and can even affect how they recover emotionally from trauma they have experienced.

An anamnesis is the patient’s story. The word anamnesis is derived from two Greek words: “against” and “forgetting”. I like to think that a part of my work is to help people not forget the memories they have that are positive and healing.

I often work with youth and their families to develop memory books of good family times. I believe these can balance the impact of traumatic memories. Some of the most effective family therapy techniques involve asking families to build devices to protect their happiest memories. For example, if I ask each member of a family to bring in the family picture they like best and to speak about it, they may remember that the youth who is now surly and sullen was a little boy, eager to help and always kind. A picture of this boy with a little sister in their lap is the reminder. That picture, and its story, worked “against” “forgetting” that important fact.

The other memory problem that patients and their families often want to discuss concerns the “need” to “work through” traumatic memories. I have always been horrified by the belief so many have that you cannot recover from trauma until you have been forced to remember what your mind wants you desperately to forget. At these times, I think anamnesis can work against a patient, which is what we observe when someone’s traumatic memories “trigger” them. I have no difficulty listening to my patient’s traumatic memories, but I have a lot of difficulty with the view that they should be “encouraged” to have those memories if they’re not sure this is a good idea, and the research is beginning to show exactly that. Having said this, the research is also demonstrating that the stories that go with our memories may contact as much fiction as fact. In other words, the way we remember things may not be accurate. Why then, I ask, “work through” them?

I have been contemplating this problem of the meaning of the patient’s story, as they remember it, since I hear so much at this time of year about patients’ “best” and “worst” Christmas. I have observed that people can be healed by hearing and telling their own stories. There is research that supports this clinical observation and so I listen to all the stories people want me to hear even as I wonder about the value of the research, and hope that I’m helping.

I believe it helps because I remember the wonderful afternoon I believe I spent with my cousin, learning that hockey was not much like checkers. If the research is accurate, then the whole thing likely never happened. But, if you don’t mind, I’ll ignore this. This is my first memory of what it means to come from a large family – the kind that looks after you when you’re twelve and your dad dies. That’s my story and I’m sticking with it.

(Watching the Pembroke Lumber Kings)

How to Manage a Suicide Pact

Recently at a Montreal high school, 62 high school students made a suicide pact. As the story broke last week, the Montreal Gazette revealed that school officials had determined the three people who started the pact, who claimed that it was a prank. The article also quoted a school official as saying that “some of the students did not know what they were signing because only the first sheet indicated that it was a suicide pact”. No doubt school personnel were trying to allay the fears of the public, and more importantly, parents of students at College d’Anjou, a private high school in Montreal’s east end.

I learned about this situation when I was asked to comment and provide advice for Global News. I found the tone of school officials, as characterized by the Montreal Gazette, to be troubling. We know too much in 2017 not to be concerned whenever news of a suicide pact emerges, especially among youth between 15 and 24 years old. During these years, suicide is the second most common cause of death.

Some of the other facts that ought to have engendered more concern are the actual statistics about suicide and suicide attempts in Canada. The Canadian Mental Health Association has found that 34% of youth between the ages of 15 and 24 have contemplated suicide – one third. Also, the actual number of suicide attempts in this population in Canada is 8%. Both the rate of contemplation and the rate of attempts increases when there is a suicide pact. The acceptance implied in a suicide pact reduces a young person’s emotional barriers to suicide and so the risk increases.

What should happen when a school learns of a suicide pact? There are 3 direct steps that might help. The first step consists of education through assemblies. Bring all concerned together, in this case the entire student body along with their parents and other interested family members, e.g. siblings. Have an experienced resource person speak to this group about what to do to reassure themselves that their family member will be okay. This person can direct the assembly to resources for Mental Health First Aid as well as to local crisis and emergency services. There will be lots of questions about both the general subject of suicide and suicide pacts and about the specific situation. The resource person and school personnel should be prepared to address these. The school personnel must be prepared to address concerns openly, without judgment, and compassionately. This is not a time to be defensive. It is a time to make sure you have support moving forward should there be a need for further mental health assistance.

The second step must involve meetings with mental health professionals for each person involved in the pact. The best scenario is that one third of these youth were contemplating suicide and it is important to reach out and find help for these young people.

Finally, it is an important time to remind everyone of these three circumstances that indicate an increased risk of suicide in a young person:
1. Increased use of alcohol and drugs.
2. Giving away one’s belongings.
3. Signs and symptoms of depression or a history of depression.

Doing all of this is a good start to preventing suicide, but suicide and suicide attempts are symptoms of a serious medical illness. People die of serious illnesses. In some cases, such as this, these deaths can be prevented.

If anyone reading this has questions, please ask. The best way to prevent suicide is to talk about it openly and without judgment.

Black Box

What happens when memories are triggered when you least expect them? In my current life, practicing psychiatry, I usually think of triggering as something negative and difficult, but what happens when something positive and affirming is recalled?

This week, I was in Montreal on a cold November evening for the first time in thirty years. I walked around the Lower Campus of McGill University, again something I have not done for thirty years. Through the windows of buildings that I had known too well, I saw young people pouring over their work, as I had done. McLennan Library was bustling, a sign that there is less than one month before exams and papers are due. I shuddered with the memory of all that work, wondering in the moment how I had ever gotten everything done.

I was reminded of a long-forgotten schedule and I hastily turned up McTavish Street, heading from Sherbrooke Street toward Dr. Penfield Street, toward the Students Society of McGill University Building and the Players’ Theatre. Forty years ago, I spent more time with the Players’ Theatre than I did on any of the things I was supposed to be doing, like reading Harrison’s Textbook of Internal Medicine or reviewing anatomy for my surgical clerkship. The time I’d spent there had meant that I’d barely managed to pass anatomy, but, on the other hand, the time I’d spent there had helped me to survive four years of undergraduate medicine. I could never understand how medical studies could be so much more sterile and heartless than the English and Theatre from whence I’d come, but they were.

Players’ Theatre was founded in 1921, operated completely by undergraduate students at McGill, funded completely by ticket sales. I remember selling tickets to plays, although I don’t believe I ever sold one ticket to my medical school classmates. Theatre was my shameful secret and, even now, I feel I am confessing a weakness as I write this.

Buildings such as the Students Union Building are open at 7 p.m. and I walked in to the building and into the theatre. Players’ is a Black Box Theatre, a simple performance space with plain, black walls and sets are always minimal. It is a space where actors and audience can imagine freely what the scenes might be. As I looked at the space forty years later, the scenes I recall are vivid. I am experiencing flashbacks, I realize. This plain space, so ordinary and unremarkable, had kept my mind open as everything I had to remember in medical school threatened to close off and close down my imagination. The space had not saved my life, but it had certainly saved my mind.
I watched myself running from the space, after a performance, rushing to get back home to study such things as how the Loop of Henle works or the layers of the retina. How could I remember soliloquies, but not remember the layers of the retina?

I am sitting on the steps, and a young woman approaches me, “Can I help you?”

“Oh, no, I’m just remembering. I used to act here, when I was a student, forty years ago.”

“What do you do now?”

“I’m a doctor.”

The young woman stares at me. Slowly, she says, “Do you know that we’re doing Fables now? It seems odd, you being here tonight after forty years and being a doctor, like you’re coming full circle or something.” Fables is a play by Jackie Torrens with four characters, one of whom is a doctor – a traditional, male doctor, but wasn’t that the case forty years ago?

I stand to bid farewell to the young woman and to the space. For now as then, I must rush off. There is something I must do. I had forgotten this healing place, but I must not forget again. I am not sure I will be able to return in forty years to be reminded.

(A Typical Black Box Theatre)

Holiday Coverage

This is the second year that I have been Clinical Director of the Youth Program at my hospital and, like last year, I am covering for my colleagues on the working days between December 25, 2017 and January 2, 2018. There are three work days during this period and our various programs include approximately 500 patients. That is a lot of youth and families who may need support during this time of year that can be very difficult.

While I am the only psychiatrist in my program available during this period, a few allied health staff will also be working but we are already contemplating what services to offer. My goal is that those youth and families who need it will get support, but that those of us supporting will have balanced, even enjoyable, workdays in the spirit of the season.
What will we do? Let me tell you what we’re contemplating and, if anyone feels inclined, I would be grateful for any input or ideas.

We will begin by providing all our patients with lists of local resources for families, such as the crisis lines, as well as the opening hours of the walk-in program for youth mental health. We will also provide lists of things to do that are inexpensive or free, since diversion can often take one’s mind off difficult feelings. We will especially direct families toward outdoor activities. There’s nothing like a few hours freezing together on a skating rink to get mood-improving endorphins flowing.

We’ll also provide other lists: a list of movies that can help when people are anxious or depressed and lists of TV shows that families can watch together. For those who don’t like the idea of too much screen time, there are read-aloud book lists. A visit to the library to pick up books, movies and music is an inexpensive, warm outing.

But let’s think for a moment of those who must in this season, when the emphasis for so many is on joy and miracles, visit us at the hospital because there is no joy and a miracle would be just one reasonable day.

We are thinking of having a group, for anyone who needs it: for youth, parent, sibling, aunt, grandfather. It will be more psychoeducation than psychotherapy. We will remind everyone of three important self-help activities:

1. Rest.
2. Eat.
3. Do something fun every day.

I repeat these here because these are good for all of us to remember. These few days off are a perfect time to sleep in, go for long walks and have long conversations with people. We will remind those who need support that we are not the only ones they can talk to. I am certain that every youth in our program has someone who would love to have a conversation with them. We will remind them of that and help them remember who that might be.

I have always preferred to work Christmas than New Year’s – at Christmas, everyone works hard for the day to be positive, filled with good food and the best company. New Year’s is about resolutions and regrets and doing better, as if we all forget the message of the previous week.

I like to be part of the group of doctors and health care providers working hard for everyone’s holiday to be happy and healthy. It seems like a singularly good use of my time and it is possible to make a real difference for people just by reminding them to rest, to eat well and to have fun.

I come from a family that told the stories of Chanukah and of Christmas, that could make peace with two traditions, two traditions that had faith in miracles. I will spend the holiday reminding those youth and families who are having a bad time not to give up hope.

If you have ideas how I can be successful, let me know. I rely on others to tell me what I’m forgetting, and perhaps telling me will help you to look after yourselves. We all deserve that.

(Note: I took this photo after the snow on yesterday.)

Hunger For Justice

About once every month, I buy a patient or a patient and their family a meal. This is always embarrassing for them. Parents especially struggle when I insist that they must also pick something for themselves. I understand this. No one likes to admit that they’re struggling to feed their family. I did learn, however, that when I didn’t insist that parents eat themselves that food was often saved for other children at home. At the same time as I would feed people, I would call the food bank closest to their home to arrange for the family to pick up food on the way home. Another embarrassment for them, but I insist, telling the family that they can volunteer at the food bank once they are managing themselves.

As a doctor, I find it discouraging that there is so much food insecurity in a country like Canada. Food Secure Canada estimates that 4 million Canadians are food-insecure – 1.15 million of these Canadians are children. In northern and remote communities, the situation is even worse. It is estimated that 2/3 of indigenous children are food insecure. Given how unlikely it is that families are volunteering this information, I am confident that these numbers are low. I have met teenagers who are not even aware that they are not getting enough to eat. They are told that adolescents are “always hungry” and they believe that their own hunger is a normal state. I advise residents and medical students to find out in detail what their patients are eating so that they can truly assess whether their patients are getting enough to eat. Adolescents need a lot of nourishment, especially adolescent boys. We have known this since the time of Plato who said, “A boy is an appetite with a skin pulled over it”.

Food Secure Canada works to advance food security and food sovereignty through 3 goals: zero hunger; safe, healthy food; a sustainable food system. To help the youth that I see, I encourage schools to support breakfast and lunch programs. Snacks and meals are available in many of our Outpatient and Day programs. In my neighbourhood, the Parkdale Food Centre works with restaurants, schools and even the local theatre to grow food all year long and to help young people learn to cook. Community meals are a part of the social support network across Canada, often run by faith groups but also by food banks and restaurants and other agencies. Despite all these efforts, people still go hungry. The Ottawa Mission serves 1300 meals per day and food banks estimate that over 40,000 people in Ottawa are food insecure. Last year in Toronto, 136,000 children needed school lunches.

There are just over one hundred youth seen in our outpatient program at my hospital every week. These youth and their families are already managing at least one family member’s chronic health condition. Given how many of these are from marginalized groups, it’s likely that as many as 40% are not getting enough to eat, leading to even more health problems. We have not been able to figure out who most of them are. I don’t know if food banks and social agencies could manage to help everyone if we did.

The lesson from my experience is that every doctor in Canada, no matter where we practice, no matter how prosperous our community, needs to ask their patients if they are getting enough to eat. Once we have asked, we then need to accept that many, many people will not be truthful about this. They are too ashamed.

Our patients are hungry, and we must be hungry also…for justice.

(Note: This is a picture of one of the Parkdale Food Centre’s growing towers.)

Get the Flu Shot – Promote World Peace

Tomorrow, nursing staff in the Youth Program at the Royal will offer the flu vaccine to inpatients. This is the kind of public health work that nurses often do, education and prevention, and they are very good at this work. But, inevitably, from time to time, they will have to present the science that vaccines work and I have pulled together my approach to flu vaccine advocacy.

I prefer the World Health Organization website information which includes an article that lists the proven benefits of vaccines, including all the scientific references. Let me present the abbreviated version I’m going to use if anyone asks me tomorrow why I think they should use vaccines.

I remind my patients (and anyone who’ll listen, really) that there are four different categories of vaccine-related benefits: diseases are controlled; the unvaccinated population is protected; related diseases, even cancer, can be prevented; and there are other societal benefits as well, such as economic growth, promoting equity and even peace. These benefits are all proven in studies and the WHO website lists those studies for the skeptical.

To present a compelling argument regarding disease control, I am going to keep handy the picture below of the statue erected at World Health Organization Headquarters when smallpox was eradicated. Smallpox was declared eradicated in 1979, almost forty years ago. This took an international effort and even countries that couldn’t get along for other reasons got along to eradicate small pox. They are now working to eradicate polio, with a timeline to complete this by 2018 – next year. This will be a historical event of great importance, again the result of a level of international cooperation that is now rare.

I am going to emphasize that vaccination against certain infections can prevent other diseases, including cancer. Prevention of chronic liver infection with the Hepatitis B vaccine can prevent liver cancer and even now, barely 10 years after the introduction of the HPV vaccine, scientists are measuring the decrease in incidence of cervical cancers caused by serotypes 16 and 18.

Finally, I am going to speak about all the societal benefits. I am going to begin by summarizing the savings. It is well-established that public health measures save $7 for every $1 spent, but vaccines are sometimes even more economical. Some studies are now available that show that $10 can be saved for every $1 spent fully vaccinating very young children.

As for equity, the burden of the diseases that vaccines can prevent is borne mostly by the disadvantaged. When this burden is lifted through vaccination, these groups are more likely to flourish.

As for peace, the United Nations Children’s Emergency Fund (UNICEF) has medicated at least 7 cease fires during civil conflict that were related to vaccines. Even people in conflict can resolve some differences so that disease can be prevented.
Being vaccinated is one of the few things a person can do for the greater good and know that they are being effective.

I hope that my young patients will be convinced with this science of the value of vaccines, but I will still thank them just for listening to my public health service announcement. I have also made cookies that look like viruses (sort of) for the vaccination celebration. Vaccines deserve celebrating, I’ll tell them.

Get the flu shot. Have a cookie. Promote peace.

Hallowe’en and Stigma

In the last two weeks, several of my young patients have mentioned to me that they were being mocked by acquaintances about a seasonal attraction near Ottawa and their personal connection to a psychiatric hospital. With their families they have been asking me what they could do about this attraction, which has so negatively affected them. I have directed them toward this essay by a remarkable mental health advocate, Jean-François Claude.

Mr. Claude launched his website The Men’s D.E.N. in 2013 and was the driving force behind the City of Ottawa’s declaration of the Men’s Mental Health Day. He has been a tireless advocate for Mental Health and against stigma. Recognizing his tremendous contribution, the Royal Ottawa Foundation for Mental Health presented him with an Inspiration Award in 2016. His work was further recognized on June 23, 2017 with the Governor General’s Meritorius Service Decoration, presented by then Governor General David Johnston. Mr. Claude is ranked #5 in the Top 100 Mental Health Influencers on Twitter – please follow him @JFClaude. Mr. Claude has lived experience of mental illness, a circumstance that, instead of making him bitter or cynical, has strengthened his resolve. The world needs more people with his courage.

He has allowed me to copy his essay here, so that my readers have a chance to see it. Please also follow Mr. Claude on twitter and visit The Men’s D.E.N. website.

Here is the essay:

Why My Local Kiwanis Club Has Me sKreaming Against Halloween Stigma

Every Halloween season, the stigma against mental illness rears its ugly head, usually in the form of distasteful “dangerous crazies” costumes and asylum-themed decor. This year’s no exception.
But I’ve been so busy raising awareness and fighting stigma of mental illness on social media, that I was blindsided by what’s been happening in my own backyard of Orléans, a suburban community in the City of Ottawa’s east end.
sKreamers is the “demented and awkward child of the Kiwanis Club of Orléans.”
Their words, not mine. It says so right in the About section of the sKreamers website.
sKreamers is a so-called Halloween ‘attraction’ held annually at Proulx Farm in rural Cumberland, with the fictional Orléans Asylum for the Insane serving as its fictional backdrop.
It boggles the mind how a community service club like Orléans Kiwanis could find it acceptable to be teaching our youth that people with mental illness are to be feared.That denigrating people with mental illness as “bitchy, whiny inmates with very bad attitudes” is somehow all in good fun, in the spirit of the season.
Try telling that to the parent who’s lost a child to suicide, the #1 cause of non-accidental death among Canadian youth. Or to any of the 1.2 million Canadian children and youth who will struggle with mental illness this year.
This $20-admission ‘attraction’ features, among other activities, “The Escapee’s [sic] Insane Wagon Ride”, where you get to witness the “live-capture” and “beheadings” of in-patients from our local (fictional) mental health institution. As if that weren’t bad enough, you can also partake in “Shoot to Thrill” where, for a mere $5 more, Kiwanis volunteers will “train” you to take part in the “interactive inmate shooting gallery.”
Yes, you read that right. Because apparently open season on the mentally ill is what we want to be teaching our kids?
To call people with mental illness “uncontrollable” “assassins” is irresponsible at best, perpetuating the myth that those with mental ill health are dangerous killers, when they are much more likely to be victims of violence. So say the stats.
Labeling people with mental illness as “insane” or calling them “crazies” further fuels stigma. It shames into silence those who struggle with their mental health. Stigma is the single biggest barrier to people getting treated for mental illness.
And by the way, every single word in quotation marks above comes straight from the sKreamers website. It’s in their promotional material. Seems no one has taught Kiwanis members how the language we use matters… a lot.
One would think a service club whose motto is “Serving the Children of the World” would discourage name-calling and fear-mongering. And want to encourage our children to seek out mental health help and support when they need it.
Although too late in the season now, Orléans Kiwanis and their partners need to abandon the concept of a Halloween “asylum attraction” for 2018. It’s horrendous, hurtful and harmful to the 6.7 million of our fellow citizens diagnosed with mental illness. And its damaging to the Kiwanis brand.
But you can still do something about it for this year. Send Orléans Kiwanis an e-mail. Get your pumpkins from somewhere other than Proulx Farm. Spread the word by sharing this blog post.
And instead of heading out to sKreamers this weekend, donate the equivalent admission amount to The Royal Ottawa Foundation for Mental Health…and do so in the name of the Kiwanis Club of Orléans.