Recovering from Child Abuse

The prevalence of child abuse in Canada is approximately 1%. This may seem not to be very high but the impact child abuse has on those affected has far reaching consequences. This is best illustrated by more statistics, so I am going to summarize these over the next few paragraphs. While you review them, I suspect that, like me, you will find yourself asking how any of these children ever recover and, when they do, you will wonder how they managed.

Thirty percent of children who are abused do not finish high school (Lansford, Miller-Johnson, Berlin, Dodge, Bates, & Petit – 2007). They are 26 times more likely to be homeless (Herman et al, 1997), 4 times more likely to be arrested as a young offender and twice as likely to be arrested as an adult (Lansford et al, ibid.). They are 3 times more likely to have an unplanned pregnancy (Irish, Kobayashi, & Delahunty, 2009). All these circumstances interfere tremendously with becoming a productive adult and so the gifts these children might have brought to the world may be lost forever.

The impact of the trauma they have suffered does result in serious mental illness in these children and youth. They are 4 times more likely to experience suicidal ideation and self-harm (Irish et al, ibid.) Not surprisingly, some studies show that as many as 100% of these children suffer from some symptoms of Posttraumatic Stress Disorder and 37-50% develop Posttraumatic Stress Disorder (Trask, Walsh, & Dilillo, 2011). They have 4 times as many contacts with mental health services as adults than the rest of the population (Spataro, Mullen, Burgess, Wells & Moss, 2004).

When I contemplate the histories of the young people that I see in the tertiary care psychiatric hospital where I work, these numbers – other than the 100% – seem low. I suspect, however, that this is because the youth we see have usually had significant mental health services even before they were seen in our programs and so those who are eventually seen in tertiary care likely have a higher prevalence of child abuse.
The young people who have been victims of child abuse also have more contact with the general medical system as 90% of them have worse health than the general population (Springer, Sheridan, Kuo & Karnes, 2007).

I am looking up these statistics for the purposes of determining to what degree mental health programs must consider their impact as they design programming for conditions beyond trauma. For example, to what degree must a program for youth with psychotic disorders allow for a history of childhood trauma? In fact, this is likely the wrong question.

The question that must be asked is: how do mental health programs ensure that the specific needs of those children and youth who are victims of child abuse get services that will also address their psychological trauma, as well as the other programs they require?

The traits that ensure that a young person can recover from the impact of child abuse, based on numerous studies examining longer term outcomes, focus on the development of resilience. You don’t have to do more than scrape the surface of the resilience literature to determine that remaining positive about one’s talents, about one’s ability to recover and about the future are the keys that unlock the development of resilience. As mental health care providers, it is our task to ensure that everyone can feel positive about themselves and their future., no matter which mental health condition they suffer from.

What I like best about this is that it is a simple lens through which to examine programming. You examine each facet of a mental health program asking: Does this foster the development of a positive attitude toward the patient, their recovery and their future? If the answer to the question in any circumstance is “no”, then changes are needed until the answers and the approach is positive.

I do find it personally helpful to be mindful of this when I see a young person who has been the victim of child abuse. If I can focus on helping them to be positive about the future, we can usually figure out what services they need to move forward.

“Note to self: Every time you were convinced you couldn’t go on, you did.” (Anon.)

When Children Die

Like many other people from Ottawa, I have been very much affected over many years by the courage of Jonathan Pitre, who passed away on Wednesday evening. He was 17 years old and suffered from epidermolysis bullosa. There have been tributes for Jonathan from so many, including hockey players and civic leaders and journalists, as well as Moms and Dads and all the rest of us. One of the most moving tributes came from the journalist, Andrew Duffy, who has followed Jonathan’s story over many years.

Hard upon this story came the news of an accident in Saskatchewan that resulted in the death of 15 members of the Humboldt Broncos of the Saskatchewan Junior Hockey League. Most who died were under 20.

When I read through the tributes to Jonathan Pitre and his mother, or those for the Humboldt Broncos and their families, I feel so grateful that I have never had to cope with such a difficult event in my life. I wanted to write about this, but I wanted not to focus on advice on how to manage such tragedies.

I’ll give some references, in case some readers were hoping for advice. This is a great article from The Guardian considering one woman’s experience with the death of her child. I found that this article really helped me to contemplate how to be a comfort to someone facing this tragedy. I also found this article addressing what not to say to a parent whose child has died very helpful. The only guidance I would add to this list is: Be extra cautious about social media – it can catch people unawares, causing additional, unnecessary hurt.

I learned all I ever need to know about what it would be like for a child to die from the two women in my life from whom I have loved the most: my mother and my daughter.

My mother had two children who died very young. My oldest brother died of influenza in 1955 at age 2. This was 18 years before the World Health Organization first introduced flu vaccine recommendations for general use. A second brother died in 1956 of RhD hemolytic disease of the newborn. This is a condition that occurs when a mother who has an Rh negative blood type develops antibodies after being exposed to her child’s Rh positive blood during pregnancy. These antibodies may affect Rh positive children in subsequent pregnancies. The antibodies can cause severe illness, including death. In 1968, anti-RhD immune globulin (Rhogam) was introduced. By injecting inject mothers who were Rh negative with Rhogam, RhD hemolytic disease could be prevented. My brothers died too young to benefit from these medical discoveries.

As a child, and even as an adult, I could never completely understand my mother’s ongoing sadness over my brothers. However, in the hour after my daughter’s birth, having held her for not more than twenty minutes, I understood what every new parent also quickly understands: I could not bear it if I lost this child. I ceased to wonder about my mother’s sadness. I no longer wonder at any parent’s sadness. I know I would be inconsolable if I lost any of my children and that is what Jonathan’s mother and the families of Humboldt are going through today. Are we not all with them in spirit?

I also have one piece of advice that I can give. It is contained in this blog I wrote for The Scientific Parent. Sadly, it is one of the most popular blogs I have ever written. It provides advice on how to help children cope with difficult news. The Scientific Parent used the blog so much that they developed a graphic to go with it. I would like nothing more than for its circulation to end, but more realistically, I am glad if it is helpful.

Violence in Mental Health

My work is full of violent actions – my violent actions against others.
I have chased youth. I have called codes to have others restrain them. I have completed paperwork so that they can be picked up by the police.

Many times, because of documents I have written, young people have been picked up by the police and brought to a hospital in a police car, often handcuffed, although that is changing as police become more knowledgeable about mental illness.
I have ordered that young people be observed on a one-to-one basis, not allowing them even to go to the bathroom without having a Mental Health Worker’s foot held in the door to keep it open.

Many psychiatric inpatient units have a double door locking system, much like a prison.
Medication is sometimes used to restrain patients who become violent – not all of them are suffering from delusions.

These actions are taken to keep people safe, both from themselves, and so that others are not hurt. Each of these actions requires specific documentation on my part. But, make no mistake, these are violent actions.

These violent acts are the most overbearing tools available to keep people safe. But, whenever I am obliged to use them, it is a failure. It is a failure because these violent actions, carried out to keep people safe, delay healing and recovery.

People do not always understand how violent these measures truly are, but, if you have ever experienced them, you know. You know these are violent actions. You may understand why I have had to take these measures but I will always see these as a failure, in some way.

One of the most important results of early intervention in strong outpatient programs in psychiatry is that we can avoid hospitalization, as well as these violent measures. That is always the goal. Hospitalization itself is a failure and the less time a person spends in inpatient psychiatric treatment, the better.

Psychiatric hospitalization is sometimes necessary, but it is usually best to avoid this measure, if at all possible.

Think about the measures I have described. How would you like it if these happened to you?

Will More Beds Make A Difference in Youth Mental Health?

It is almost one month since Ontario Health Minister Eric Hoskins announced that the provincial government would be investing in increased hospital beds to improve access, especially during flu season.

The investment includes 61 new mental health beds and, while I don’t want to sound ungrateful, or discourage investment in mental health, if I had a choice of how the money will be spent, I would not want inpatients beds, I would want outpatient services.

Most youth with mental health problems do not need hospitalization. They need outpatient treatment, perhaps including medication and often a treatment proven to have a positive outcome, like cognitive behavior therapy or dialectical behavior therapy, treatments that have been tested in controlled trials.

Since none of the treatments are long term, the Minister would not have had to worry about people being in therapy for years. Research demonstrates that the number of CBT sessions needed is between 5 and 20 sessions, lasting 30 minutes to one hour in length, and usually spaced every other week. Neither a referring physician nor a family should expect a youth to be followed long term unless they have a condition like Schizophrenia, or Bipolar Disorder. Even with these conditions, most of the treatment occurs in an outpatient setting. Most hospital psychiatry programs take accountability very seriously. The measures we use at my hospital to ensure satisfactory care include careful monitoring of symptoms using standardized scales; goal completion questionnaires completed by youth at least every other session; and less frequent focus groups with youth and families to ensure the best quality treatment.

If Minister Hoskins had asked me what I wanted, I’d have asked for nurses and social workers, maybe one psychologist or two. If there happened to be enough cash to make a longer term investment, I’d have suggested that we really need more psychiatrists. Based on the number of psychiatric residents training right now in Ontario, there will be a shortage of psychiatrists for at least 30 years. That’s as far out as the projections have been calculated, but I don’t expect the numbers would improve moving forward unless some action is taken.

Another measure that would serve many more youth would be to empower Psychiatrists to work more closely with colleagues in Primary Care or Paediatrics by facilitating the development of teams in the community, or by finding a way to include them in existing teams. If these teams could have access to nurses, social workers or psychologists, they would reach even more youth.

Minister Hoskins might also consider services for a few groups of youth who have complex needs and for whom services are very inadequate, including:
1. Children and youth with Autism Spectrum Disorder
2. Children and youth with developmental disabilities.

What I’ve just set down is not the best articulated, or most comprehensive approach that might be taken to youth mental health, but it does reflect what many groups have been considering and what the people I work with have wanted. The Ontario Psychiatric Association did provide this advice, related to Youth Suicide. Many of their recommendations overlap with mine.

There are some regions in Ontario with a greater need than Eastern Ontario for mental health beds for youth, but I suspect they also need access to outpatient resources to follow patients once they are discharged from an inpatient program.

My greatest frustration is that, like so many health measures undertaken in recent years, this seems like an isolated measure undertaken in a crisis. We need a well-conceived plan, and accountability. If my patients and I are completing scales and questionnaires regularly to establish our efficacy, why should governments not have to do the same? Shouldn’t the Health Minister have to prove that his “treatment” is “effective”?

(Photo credit)

Learning Disabilities

I was twenty-one years old when I first truly understood learning disabilities. I was in my clinical clerkship at McGill University in a psychiatry rotation. One of the patients I was following had dyslexia. Like every good medical student, I read everything I could about the condition. But it was the definition that was personal for me: “the general term for disorders that involve difficulty in learning to read or interpret words, letters, and other symbols, but that do not affect intelligence.” I am not sure where the definition is from because I have copied it today from the journal I kept at the time.

This disorder was important because of how my mother had always described her own academic abilities. My mother always told us that she “could never spell” and was “a slow reader” and that her younger sister was “the smart one”. My brother and sisters and I were given very easy to spell names because my mother had struggled to spell her own beautiful given name, which was Othelia. She didn’t like this name, I suspect because it always made her feel “stupid”.

“I can’t even write my own name,” she’d say.

But, on the other hand, she could talk your ear off and no one could recount family stories as wonderfully as she could. Her vocabulary was sophisticated, her grammar perfect and, if she could have written them down, she would have produced some of the best stories about life on a small Ontario farm in the Ottawa Valley during the Great Depression. She also got the best marks in math in her family and, for many years, made her living as a bookkeeper.

The more I read about this condition, the more I realized that this was exactly my mother’s problem. Educational institutions were just beginning to accommodate for learning disabilities in the 1970’s and I astounded my supervisor with the amount of work I did to get those accommodations for my patient, who was struggling to complete the mandatory English credits to get her Architecture degree. This young woman had been discouraged from studying architecture because “it’s a difficult job for a woman”. That’s another quote taken from my journal.

Female medical students were just as rare as female architecture students in the 1970’s, which was another factor that kept me engaged. Not to mention enraged, when a senior resident at rounds suggested that part of the management plan ought to be for my patient to switch to a “woman’s career”, like “teaching”. I had a great supervisor at the time, a former Associate Dean of Admissions at McGill University’s Faculty of Medicine who was committed to bringing more women into medicine. He said to me, “I can tell by the look on your face what’s about to come out of your mouth, but don’t say it.”

With my supervisor’s assistance, I appeared with my patient in front of the School of Architecture’s Examinations Appeal Board. I provided clinical records that proved that her mental health had been affected by an Acute Depressive Episode, a well-recognized medical condition. Then I brought documentation on Dyslexia and requested that she be able to have accommodations to allow for this condition. Universities weren’t used to providing accommodations at the time, but a Professor of Medicine and former Associate Dean is hard to argue with and so we were successful.

Fresh from this success, I went home, thinking to convince my mother, who had just started Community College, to get accommodations for her own education. She had decided to go back to school to get a postsecondary education, which was a dream for her. She was failing all her essay assignments and exams for reasons that were now completely obvious to me. I tried to explain dyslexia to my mother, all my articles and research in my hands. Of course, those articles were meaningless to her because she couldn’t read a word.

” I’m not as smart as you,” she said. I felt like I was being mean to her when I convinced her to let me try to get accommodations for her. She came with me to the student advisor at the College, who was more enlightened about learning disabilities than Professors in the School of Architecture had been. From then on, my mother was allowed to complete her exams and assignments orally. She graduated with honours, of course.

Today, when I am working with a youth with a learning disability, what I remember most vividly is how “stupid” my patient and my mother felt all those years ago. Working with my patients now, I can always find skills they have that demonstrate how they intelligent they are. There is much more information now about learning disabilities, including this web site which shows what text can look like to someone with dyslexia.

After my psychiatry rotation, my supervisor stayed in touch with me. Medical school exams were difficult for me because they were multiple choice. I have failed every multiple choice exam I have ever written the first time I wrote it. When I look at a multiple choice exam, I feel like a starving person with a menu and I feel stupid that I cannot pick out the correct answer. Ironic, isn’t it?

(Note: Dr. Alan Mann, Professor of Psychiatry at McGill University and Psychiatrist-in-Chief at the Montreal General Hospital, former Associate Dean of Admissions in the Faculty of Medicine, had the most influence in my career of any of my teachers. It was one of the greatest honours of my life to serve as Chief Resident at the Montreal General Hospital during his tenure.)

(Credit: This image is from Time Magazine.)

Let’s remember to Look After Mental Health Advocates

January 31, 2018 is Bell Let’s Talk Day. For the last month, a series of short video clips has been circulated by Bell to promote its important fundraising and awareness raising day. The video clips feature people who have experienced mental illness and they are worth watching because they are so inspiring. I can never listen to these stories without being moved. Everyone who knows me knows that I cannot help but be affected by these stories. I even become tearful, to my chagrin, because I am so amazed that there are people so willing to share their stories and their pain so that others can be helped. (Note: My daughter, who has this same affliction, has called this “the stupid, emotional gene”. We both find it embarrassing.)

I am privileged to know individuals who are, have been, or likely will become mental health advocates. In my experience, they are entirely motivated to prevent other people having to experience the degree of pain they have suffered. To do this, they tell their own story. They have stories of recovering from their own mental illness; to remind others that recovery is possible and not to give up. They have stories of a loved one who did not recover; they work to build the services their loved ones didn’t have and they remind us not to give up. They have stories that finding mental health can be an ongoing struggle but not to give up. That is the overwhelming message: Don’t Give Up!

What makes mental health advocacy successful? This study of how mental health advocacy was established in Sierra Leone considers the factors that led to its success and the barriers that it faced. Before this advocacy began, there was almost no consideration of mental health in this poor African country so this elegant study allows us to extrapolate from its prima facie case to our own situation in Canada, where mental health advocacy is not new. A review of the factors that helped and the barriers is striking in that there is little difference between Canada and Sierra Leone. Consider what this means: our mental health advocates in Canada must overcome the same barriers to achieve their goals as those in a country that most would consider to be far less sophisticated. If you talk to a Canadian Mental Health advocate for five minutes, you will find out how evident this is – and how discouraging.

Why do mental heal advocates do this work and what do you need to know if this is a path you’ve chosen? This article by Erin Hodgson, who leads the Jack Talks program at Jack.org addresses these two questions. My favourite part of this article are her six self-care strategies. These are important for everyone, but especially important for mental health advocates who, in my experience, give so much to their work. While you’re reading the article, you can find out about Jack.org itself and their important advocacy work with young people.

Mental illness comes close to all of us. It doesn’t take the usual six degrees of separation to find someone who has suffered from a mental illness – most of us know well someone who has had a mental illness and, often, we are that person. Personally, my father and two brothers died before I was twelve. My father’s death brought other losses and I am, in many ways, an expert at loss and grieving and they have been my window on mental illness. I consider myself lucky to have suffered no worse affliction. During my days of listening and watching others cope with the heartache and aftermath of mental illness, I am awestruck by people’s persistence and courage. I don’t know if I could manage as they do, I often don’t know how they manage and I consider it a privilege to help them do this. When these people decide that they must work for others, I am always blown away.

I have seen too many advocates become overwhelmed by their memories and the task they have chosen for themselves. I also know that the system offers little organized support and so I try to keep my door open for them. I am not trying to be their caregiver, unless it is clearly my job, but I will try to find them the help they need. My goal is to be an enabling factor as described in the Sierra Leone Study, or the nudge to remember the self-help strategies that Hodgson says advocates need.

Mental Health Advocates need our support, and by that I don’t mean professional help. I mean they need all of us to remember that they are doing something we could all do if we wanted to, if we had their courage. I am not that brave and so I will support mental health advocacy by supporting them. On Bell Let’s Talk Day, I will be one of the best tweeters and Facebook posters. It’s the least I can do.

(Note: Image from Sydney.edu.org)

It’s Not Your Fault

I am thinking about families today, and especially the families of those who have attempted or completed suicide. Suicide is the most serious consequence of having a mental illness and a suicide attempt and suicidal thoughts are always reminders of how dangerous a mental illness can be.

When someone dies of a suicide attempt, those who know and loved them suddenly become victims of the stigma that continues to plague mental illness. How does that stigma manifest itself?

The stigma is evident in the fact that most family members and friends will ask themselves, “Was there something more I should have done?” For the most part, if your mother or your sister or your child dies of cardiac arrest or cancer, you do not ponder the circumstances, concerned that you were neglectful or remiss. But suicide and suicide attempts are different in that there are always lingering doubts about what signs we might have missed. We go over final statements and conversations, finding meanings that we believe we should have caught.

I want very much for everyone reading this, who has had someone close to them lose their life because of suicide, to read the next sentence carefully, knowing it is the most important thing to remember about suicide and suicide attempts.

It’s not your fault. It’s no one’s fault. The problem is that suicide and suicide attempts are symptoms of a serious mental illness.

I wanted to emphasize those sentences and that paragraph above, but I mean this plea to be gentle, a reminder of how insidious mental illness can be. Mental illness has a different contagion. It is as if we can catch the guilt and low self esteem of our loved one from their suicide or suicide attempt. No other illness does this.

Next week, January 31, is Bell Let’s Talk Day. Already the Commercials are playing, raising awareness about mental illness more effectively than any other campaign. During the campaign, we will hear from people with great courage who speak about their mental illness, in voices that systematically work against the stigma that still marks the afflicted.

The suicide rate in Canada is 11.5 people per 100,000. The number of family members and friends affected by these deaths is too extensive to capture. Probably about one third of us have been affected by a suicide or a serious suicide attempt.

I am thinking about those of us who have been affected by a death by suicide or a suicide attempt. I am writing this so that we remind ourselves not to be infected by the contagion of stigma, not to fall into the trap of thinking that we were at fault for a death by suicide or a suicide attempt. I want us to remind each other, because I find it hard to remember this on my own.

(Note: Tabitha Suzuma is a British author of fiction for young adults. This image is from Pinterest.)