Does Ontario Have A Gun Problem?

Adolescents have been the focus of my practice in Psychiatry for more than twenty years.  Adolescent boys have a complicated relationship with violence and anger and it is not unusual to see that erupt, especially when they are struggling with symptoms of mental illness. It almost seems as though, at some point in adolescence, men must work through what their relationship with violence will be. As they do this work, the entire course of their lives can be affected by the lethality of the weapons they have at hand. A gun is never a helpful accessory for a young man struggling to understand and cope with violent urges toward himself or others.

Why am I thinking about guns? I have just returned from Boston and early in March I spent a week in New York City for the Commission on the Status of Women. As a Canadian, I am always more cautious when walking by myself, especially at night, in American cities. This is because, as a Canadian, I believe that there are many more guns in these American cities than in Canada. Public health research has shown that guns are a health risk.

Having said this, both Boston and New York are managing gun violence while Toronto, a city where I spend much more time, has seen spikes in gun violence in 2016 and increasing gun violence in 2017. Even in Ottawa, the capital city known for its general safety, had a higher than normal number of shootings in 2016 and 2017 is showing the same worrying trend.

Canadians often smugly think that gun control manages gun violence and, while all evidence supports this, these recent trends need to be considered. These increasing numbers mostly reflect violence involving the young men under 25 I mentioned at the outset. We know that young men’s brains continue to develop into their twenties and most parents of young men certainly notice this. This is true even though, by age 21, most young men have undertaken significant responsibilities related to education and work, and often families or relationships.

During the period of late adolescence and early adulthood, young men are at higher risk of being perpetrators and victims of violence. Over many years, there has been much speculation on why this is the case. Research cites adaptive advantages from our past to the economic disparity and racial tension that is believed to fuel violence around the world.

The one factor that has kept this violence from becoming lethal has been access to a weapon, usually firearms, that immediately make an attacker much more dangerous. In fact, countries that implemented gun control saw the number of multiple murders significantly decrease. This fact alone is the number one reason to implement gun control. Gun control is the perfect example of a public health measure based on the number of deaths and injuries it prevents. With this in mind, we need to ask, is there now increased access to firearms in Ontario to account for these spikes in gun violence?

There has not yet been an analysis that allows us to answer this question. In a country with gun control, a policy that has helped maintain public safety for so long, we need to be certain that we take this increase in gun violence seriously. Experience has taught us that gun control measures can make a difference in preventing injury and death.

Those of us who are the parents of young men, or who have been young men, or have been the caregivers of young men in distress know what can happen when frustration takes over from a youth’s better nature. A young man with a gun can do much more harm with a firearm than with his fists, or a knife. We know from the crime statistics that more and more guns are aimed at others, but many of these young men also aim at themselves.

The point is that there are more victims. We often decry that police are not attuned to the mental health problems of those they arrest. However, those of us who are concerned with health need to provide some support to the police and other agents of the law with respect to the increasing number of guns in Canada. The health impact is increasing along with the crime rate. Those of us who specialize in adolescent health must begin to understand the law as it relates to our patients.

Mental Illness Awareness Week 2016 – What Now?

October 2-8, 2016 is Mental Illness Awareness Week(MIAW) in Canada. This week was established in 1992 by the Canadian Psychiatric Association and is now coordinated by the Canadian Alliance on Mental Illness and Mental Health (CAMIMH). The MIAW is a week held annually to raise awareness in Canada about mental illness and its impact on those who suffer from a mental illness and on those who love and care for them.

At the time it was introduced in 1992, stigma was still firmly entrenched in Canada, with attitudes toward those with mental illness still influenced by misconception and myth and not science or fact. This history of battling stigma in Canada can be found in this review by Heather Stuart, published in 2005.

The review traces the history of anti-stigma initiatives to the work of a Saskatchewan couple in the 1950’s. The Cummings developed an extensive program based on the health education approaches of the time to address the negative attitudes of the citizens of a Saskatchewan community toward the mentally ill. The program, however, had exactly the opposite effect to what was hoped for by the Cummings. According to the report,

“As the program grew in momentum, community reactions changed from interest, to anxiety, to outright hostility. It became apparent that people held fixed ideas about the causes of mental illness, the appropriate way of dealing with those with a mental illness, and the correct amount of social responsibility to assume.”

The report goes on to tell us that twenty years late, in the 1970’s, when other studies were beginning to show that Canadians were becoming more knowledgeable about mental illness and more accepting of those with mental illness, replicating the study done by the Cummings in the same small community showed no change in attitudes at all.

Progress on the frontlines of the anti-stigma campaign continued to be slow – a study in Quebec in 2001 found that 54% of those surveyed believed that people with Schizophrenia were “violent and dangerous”.

In the last fifteen years, those of us who work in mental health believe that we have seen positive developments in the anti-stigma campaign. For us, the proof is that more and more people are coming forward courageously to tell their personal stories of mental illness. When athletes like Clara Hughes and public figures like Margaret Trudeau describe their mental health struggles, some of the myths and misconceptions about mental illness can be broken down.

With a change in attitude, however, comes an increased demand for treatment and support. However, our health human resources still are not ready for this change. Many of us were trained at a time when our career choices were as denigrated as our patients’ illnesses. In fact, there are many who still characterize psychiatrists as not being “real doctors” and mental health workers in various professions earn less than their counterparts in other areas of medical practice. For example, Emergency Room Nurse Practitioners earn in the $100k range while Psychiatric Nurse Practitioners earn an average of $15k per year less. Psychiatrists make less than other physician specialties. There are many reasons to consider careers in other areas of healthcare.

At this point, in 2016, having been able to change some peoples’ attitudes toward mental illness, might it be reasonable to take a long, hard look at how we support those with mental illness? If people require Cognitive Behaviour Therapy every few weeks, should they have to require a letter for their employer? I don’t believe you’d need this if you were being treated for Diabetes or Heart Disease. Might we begin to think about prevention, since it’s well-established that there are conditions and circumstances that foster improved mental health?

Is it possible yet to move from awareness to action? Or will that take over sixty years also?

Aftermath

World Suicide Prevention Day can be difficult for those who’ve lost a loved one who suffered from a mental illness. It can also be difficult for psychiatrists, as I was reminded on the day after I participated in a Facebook event to provide information to parents on how to talk with their children about suicide.

My unease began in a CTV interview and stayed with me through the evening. The following morning I was working at my desk when tears began to pour down my face and I remembered three youth whose suffering affected me too much. Two died of suicide and one died because the injuries he inflicted on himself eventually caused his death.

Catherine is sixteen years old. That is the age of medical consent. She can say what she wants; I cannot tell her parents unless she is in physical danger. But I would like to say her mind is disintegrating. She cannot string two words together, let alone a sentence. I have to speak to someone and so I have conversations with my supervisor. My supervisor is focused on privacy and separation. I am focused on someone’s thinking dissolving in front of me.

The Teenage Mother High School Program wants me to see Lisa. Lisa is thirteen (thirteen!) years old and that is not usually the age of medical consent. Her baby is two months old and Lisa doesn’t get to school much because she’s tired from the night feedings. I go to see her at her parents’ home. She has a pink frilly bedroom and what seems like hundreds of dolls. But my eyes are glued to the real live infant in her arms…Lisa tells me that she’s fine, she doesn’t need to talk. I know that the child welfare agency wants to remove Lisa’s baby from her care. She tells me this would kill her. It does.

“…Lesch-Nyhan Syndrome is a X-linked recessive disorder of purine metabolism characterized behaviourally by self-mutilation…” There is a green room with large windows and four cribs – one in each corner – curtained off from each other. In crib No. 4004, there is a little boy with large eyes (haunted) with suspicious lesions all over his body. As I watch, he bites into the flesh of his hand before I can stop him and call for help. His parents are crumbling behind me in a corner. They watch as I put mittens and booties on him and then turn to their terror.

Every doctor has patients who die. I have been deeply affected whenever one of my patients has died and, even if there is not an official review of the patient’s care, I do that examination myself. As a doctor, I cannot help but question my care when a patient dies. I may come to a determination that everything possible has been done, and then I question my care once again. When I consider how much I am affected when a patient dies, I can only imagine what it must be like when a family member dies of suicide. I can only imagine.

(Note: These three children were my patients many years ago. Enough details were kept to sustain the reality of the difficulties they faced at the same time as the need for privacy was maintained.)

Pool Shark

If you have a look at the picture above, I’m sure you’ll agree that I am an unlikely pool shark but some pool skills are a good tool for any psychiatrist who looks after adolescents. A game of pool is an excellent opportunity to have a conversation with a young person or a group of young people and it really helps if you play well enough that they’d like to have you on their team. It is also always an excellent topic of conversation for a patient to have with new people in a group when you cannot figure out how to break the ice: “Have you played pool with Dr. Beck? It’s a lot of fun.” It seems that it’s worth a laugh for everyone to see the look on the newbee’s face when you ask that question.

My patients are always interested to know how I learned to play. I have to confess that I would love to play well enough to be able to say, “I put myself through medical school playing pool.” I am very proud that I did learn to play from my patients and from one young woman in particular who explained to me that it was better if we were “doing something and not just staring at each other.”

It is from this statement that you learn the most basic interviewing skill when dealing with adolescents (maybe anybody). Don’t stare, keep your expression neutral and nonjudgmental and don’t say a word unless you have to. It’s better to know how much cannabis someone is using daily than it is to know, “Do you ever worry that that’s too much?” You want to understand what is really happening in someone’s family and they are more likely to speak about this when you’re shooting some pool than if you’re both sitting in stiff little chairs while one of you is asking “empathic” questions.

Another reason to do something enjoyable with a group of teens at times is to model that pleasant, healthy activities can improve one’s mood. Laughing at the psychiatrist who’s old enough to be your mother as she tries out a new technique is also good for everyone’s mood. First of all, laughing is just good for you and pool, like any game, is a great teacher. You learn how to be a good loser, a gracious winner and a kind teacher from a game.

Why am I thinking about pool today? I was going through my notes today, remembering how I learned to play pool originally. It was 10 years ago and a young girl joined the group who was very hardened, with a lot of bravado. She came to group after group without saying a word. She had come from a chaotic family situation and had lost her only positive contact, a sibling, to suicide. She was barely hanging on herself.

Those who know best insisted that she come to a group program and for months we could not figure out why this could possibly be a good idea since she said absolutely nothing. Adolescents are often kinder than we imagine – they offered this girl seats in the circle, snacks, conversation – even though she was surly and bitter.

One day, a pool table arrived – a gift from hospital volunteers – and we gathered around to try it out. I couldn’t play at all then and hit the 8 ball. “Oh, God,” she cried out and dumbfounded we watched as she broke and ran. (Broke and ran like in pool, not as in ran away.)

After all these years, when I consider my years of education, and continuing education, and ever increasing years of experience, my perspective on my fancy title and credentials remains realistic. The reason lies in the humbling realization that one of my best interventions is, “C’mon, it’s your break.”

My Expertise in Bad News

Most writers love to have a piece that people read over and over and, in general, I am the same way. Having said this, my second most popular blog, which is published on The Scientific Parent website http://thescientificparent.org/, has been reposted and read more often that I ever wanted or would like.

The particular blog is a piece that I wrote for The Scientific Parent at the time of the Lafayette Theatre shooting in July 2015. Almost a year has past and this post has been republished and read so often that it is becoming disconcerting. To me, it emphasizes how often the news is so terrible that we have to worry about its impact on children. We also have to wonder how much to tell children and how much we should try to protect them from seeing or hearing.

I will let you read the piece and use what is useful to you within it, but I want to reflect on some of the times in just this past year when you might have been able to use this little guide on talking to children about terrible events.

Here’s a short list off the top of my head, in no particular order of some of the issues that distressed the youth in my practice, before today’s shootings in Orlando:

  1. Mass Shootings: There are an average of 1 per day in the United States, all of them get coverage and so young people can always find one where the circumstances relate to their situation.
  2. The Paris Attacks in November 2015.
  3. The Refugee Crisis, in Europe especially but also around the world.
  4. The abduction of girls and women by Boko Haram.
  5. The Brussels Attack.
  6. The Attawapiskat Suicide Crisis.
  7. The Fort McMurray Fires and Evacuation.
  8. The attacks in Tel Aviv.

I see only adolescents in my practice. Even though they have mental health problems, like all adolescents they want to change the world. In fact, when they begin to feel better, many of my patients have a new found optimism that they will be able to make a difference. When I wrote this piece for The Scientific Parent, I thought about the advice I have given that people told me was most effective. I am pleased that this advice is useful since I want children and youth to be able to see past these tragic events to a better time.

With that in mind, I left out one piece of advice in that article: the advice to share with them the positive aftermaths of people and communities coming together to heal and care for those affected. Fortunately, these are as certain as the tragedies themselves so watch for them and celebrate them with children. Research tells us that to be hopeful and optimistic begets resilience. In this difficult world, we need to help build resilience.

 

 

More on Safe Injection Sites

Every day I see patients who need a safe injection site in Ottawa. This would not only help ensure their physical health but the health promotion geared to help them stop misusing injectable drugs would be more available to them.

It is important for this issue to be debated widely so I was pleased that my letter to the Editor on this subject was the lead letter in Saturday’s edition. Have a look at it and at the other letters as well. This is the link.

Also, if you are wondering how Safe Injection Sites actually function, TVO produced this great documentary on the subject.

People do ask me how people as young as my patients, who are mostly between 16 and 18 years old get hooked on injectable drugs. Often these people are worried that Safe Injection Sites actually promote more drug-related crime. This is actually the concern of Ottawa’s Police Chief.

It’s not difficult, unfortunately, for children and youth to get hooked on drugs because they have access to them at school. I do not know whether Ottawa is unique but I ask most of the youth that I see – and not just the ones who are have a dependency or abuse disorder – where they got access to the drugs they tried and all of them say that they could get them at school. Even elementary school. It’s not unusual for children to try drugs when they are in Grade 7 or 8 – 12 or 13 years old. As a society, we need to protect our children more effectively. Better mental health prevention is needed in schools.

Thank you to everyone who is working to improve youth mental help and especially to everyone who has emailed me or communicated about my last blog. I hope this additional material is helpful and look forward to your comments.

The Power of Purple

This week I want to raise awareness for D.I.F.D.:Do It For Daron. This is a youth-driven program run out of my hospital to raise awareness and funds for youth mental health education at The Royal. D.I.F.D. was created by the friends and family of Daron Richardson who sadly took her own life in November 2010. Daron’s life truly changed our world in Ottawa, however, for since that time, awareness of mental illness in youth has dramatically improved and the number of young people seeking help has increased by 30%.

This year’s campaign runs from February 1 – 10, 2013 and it is expected that many schools and organizations will register to wear purple, which was Daron’s favourite colour.

For advocates like Darren’s family and friends, advocacy pushes beyond personal pain to a realization that they could be a catalyst for change in improving health care. Many people, if a child, or sister, or good friend dies, need solitude and reflection to fully recover. Media attention with unexpected questions and sometimes painful exposure only reopens old wounds. Knowing this, it takes considerable courage to decide that, no matter the personal cost, you will do exactly this in  the hope that others will not have to endure what you have.

As a psychiatrist,I want to highlight the advocacy efforts of those who have worked for change and progress in Canada’s direction in Mental Illness and Mental Health. Many of these advocates are young. These youth inspire me. I know some of them personally and know that, even as they worked to overcome their own mental health problems, their hearts went out to others who were suffering as they had suffered. Their efforts go beyond the statistics: they let their own personal stories drive change and, again, that takes great courage. (By the way, I know you’re reading this and you know I mean YOU!)

Other than hospitals like my own that promote mental health and treatment for mental illness, a group that inspires me is the Mental Health Commission of Canada. The Commission, now under the leadership of Dr. David Goldbloom, has gotten the attention of all Canadians and is, in my view, the reason for an important beginning in what must be a long conversation about Mental Illness and Mental Health in Canada. Patients, patients’ families, mental health care providers and legislators – we had all worked for many years to have mental health become a priority in Canada. It was only once all of our collective energies were directed into the Mental Health Commission of Canada that we began to see change.

The Mental Health Commission of Canada was built from the hope and tenacity of many, but especially of those Canadians with mental illness and their families, families like the Richardson’s. Their courage to use their experience as the impetus for change even when they might have been isolated or shunned is inspiring. As Canada moves forward in a journey to improved mental health and health care, I hope all Canadians can find the same courage.