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.

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.)

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.

Opioids and Social Capital

Over the weekend, I read the first article about the opioid crisis that made any sense to me. It was published in Scientific American last week and explained why so many of the strategies that we are using to combat the rising rates of opioid overdose have been ineffective in curbing the rate of overdose to any great degree.

The article summarizes the research that suggests that the best ways to address the abuse and dependence on opioids is to help communities strengthen the social ties between people. The author opines that the emotional reasons that we become dependent on any substance are factors that communities should seek to address in to reduce the morbidity and mortality related to opioids.

In one study published in the Journal of Health Economics, researchers looked at the impact of macroeconomic changes on opioid use in specific counties and states in the United States. For the region studied, researchers found that, when the county unemployment rate rose 1%, the opioid death rate per 100,000 rose by 3.6% and the opioid overdose Emergency Department visit rate rose by 7%. These statistics held throughout the state.

The article summarizes the science related to the body’s naturally occurring opioids – endorphins and enkephalins – these help us to moderate both physical and emotional pain. The science is outlined concisely and briefly and reminds the reader of those factors which increase the levels of these naturally occurring opioids. It also reminds us how this hormonal system insulates us from emotional pain in our lives.
I have never prescribed opioid medication myself, and most of the doctors I know are similar in practice to me so I have been bewildered about who all the doctors prescribing them could possibly be. I’ve seen the numbers, however, and I certainly know of physicians who have gotten into difficulties because of the way they prescribe opioids. I understand that physician regulatory bodies have sought to address the increasing rate of opioid abuse and overdose by offering courses on prescribing these medications.

To address this dangerously increasing use of opioids, communities have been distributing naloxone kits, setting up safe injection sites and running health prevention campaigns. I support these measures as urgent action must be taken in the moment to do what we can to prevent harm to those already at risk because of opioid use.
Having said this, it’s time to think about what can be done to address those social capital deficits. The OECD defines social capital as “networks together with shared norms, values and understandings that facilitate co-operation within or among groups”. These networks include such networks as family, friends, groups we belong to, or organizations that support us. According to the research, the loss of social capital is linked to increasing opioid use and all its attendant risks.

I’ve been thinking of social capital lately as I’ve worked to find supports in their communities for youth in my practice, supports such as groups where families might learn to cook or spend time with other families. As I did this research, I realized that some Ottawa communities are better at this work than others. It makes sense from this that communities might consider supporting community development as well as safe injection sites and naloxone kits.

Many reading this will believe that this is all about the social determinants of health but this is a reflection on the need for all of us to consider how we personally build communities. Do we go to groups? Do we initiate support activities? Do we go to community events? All things considered, cities can support communities but they can’t provide them the way they can buy naloxone kits or new services. They can’t make your neighbours neighbourly. That takes individual people getting out of their chairs, turning off the TV or their devices, and talking to people or working with people. While it does build a community to have skype meetings or online chats, this research is telling us that, if we truly want to have communities, then we must have some that we can walk to when we’re caught in a snowstorm or hurricane, or the power goes out. Perhaps if we volunteered at the food bank, it wouldn’t be so hard to go there for food, or even just company, when the need arose. Having community meals or parties or street events, bringing disparate parts of communities together, can help you find out what services you can have or help in your neighbourhood.

Last weekend, the Wellington West Community held an event on Wellington Street. As I walked along running my errands, I stopped off at a few services. I learned that one agency, Ottawa West Community Support, has a range of services to help seniors continue to live in their own homes. They told me that volunteering with them has helped many older people make the transition to using their services. That is social capital. I learned that the library helps anyone learn how to navigate the internet safely, from kids to seniors to newcomers. The library has an English Conversation Group. These are examples of building social capital.

This research and consideration has me thinking about how I could invest in social capital in my hospital practice and so I have been thinking about the kinds of groups that could most help youth in my community. I have a few ideas but would be interested in others’ ideas also. Please tell me. It seems a long way from the opioid crisis to me, but the research suggests that I am wrong. How do you build social capital? How do you think we could help?

(This photo has been in multiple places on the internet. I found it in Lawrence Wall’s twitter feed.)

Normal and Bored

There are six million young Canadians starting school this week. From busy, excited little kindergartners to oh, so bored almost adults in their finally final year, yellow buses and slower streets will signal the end of summer as nothing else does.
At the psychiatric hospital where I work, we have four classrooms, all part of the M. F. McHugh Education Centre, and the young people who are receiving treatment for their mental health conditions will continue to have access to education, even though they are not all well enough to benefit from that educational experience as much as we would like or hope.
As a clinician, one of the elements I value most about the McHugh classrooms is that they are a constant reminder to my young patients that there is a normal life waiting for them once they are feeling well. The very presence of these classrooms and their teachers is a reminder that everyone working with these patients has every intention of helping them get back into an academic life, a normal life.
Whatever age you are, becoming mentally ill turns your life upside down as no other life circumstance can. Often you cannot manage the very basics of getting up in the morning, or washing your face, or putting breakfast into your mouth. The idea that, on top of this, you’re expected to read Hamlet or learn about cell structure or get from classroom to classroom can be overwhelming. Imagine a classroom that supports you to manage exactly those studies while, fifty yards away, in another part of the same building, on an inpatient psychiatry unit, you are learning to cope with the voices telling you to kill yourself. It’s a lot to put together.
For a young person who is struggling with mental illness, or other difficulties, school can often be the most stabilizing influence in their life. If your dad left home on Tuesday, on Wednesday your class will still be reading Hamlet. If your grandmother passes away on Friday, and you saw your grandfather crying for the first time in your life, it really can help that cell structure does not shift in one week. If, all of a sudden, your mind is just not making sense, it helps to have a classroom where the teacher knows that this has not always been the case and that you will not feel this way forever. I think it especially helps to have a person who can bridge you back to the world where Hamlet and cell structure are important, and you can be a normal person again.When I was younger, I had wanted to be a teacher. The normality of life is one of the things I most miss about my life as a doctor. Like every physician, even when I focus on the person with me, I am often still focused on how well they are. Can they concentrate? Are they enjoying soccer once again? Is their mother back to nagging them about their room being a mess?
When you see a psychiatrist, and you’re sixteen years old, you know you don’t have a normal life. But, if every weekday morning you can sit in Mrs. Scott’s English class, listen to Mary Jo Jones be Ophelia and Sam Smith try to be Polonius, you can feel as though your life is as blessedly normal as everyone else’s. You can go back to being bored and everyone who knows you will think it’s a good thing to be normal and bored.

(Note: As a new school year starts, I will be hoping for the best year for students and teachers and especially for those students and teachers in the McHugh classrooms around Ottawa.)

Game of Thrones Madness?

For the past few weeks, I have felt as though my husband and sons, not to mention many friends and acquaintances, have joined a cult. As a matter of fact, I often spend Sunday evening with my family, but tonight and for weeks to come everyone I know will spend Sunday evenings with characters from a fictional land.

Here are some of the comments I have heard in the past few weeks leading up to the 7th season of Game of Thrones which starts tonight on HBO:

Question: “What if we tape the whole series and binge watch them all at once for a kind of party?”

Answer: “You can’t do that because you’ll definitely have the plot spoiled by everyone talking about what has happened.”

Question: “If I go away for a week, do you think I should stop following the Twitter feeds and other social medial?”

Answer: “OMG I never thought of that.”

Question: “Do you think we can find out in advance who’s going to be live tweeting during the show and stop following them?”

Answer: “Good idea – and put up warnings for your followers not to post.”

Question: “Dr. Beck, will we be allowed to watch Game of Thrones on the unit?”

Answer: “Is there no escape?”

I know exactly why the series does not appeal to me. I find too much graphic violence disturbing. It’s perverse, but I am more fascinated by trying to understand why certain television series can develop cult-like followings. How does it happen that certain shows can become so popular that there’s no point in even inviting anyone over on a certain day around a certain time unless you’re holding an event related to a certain series. My gourmet dinner club held a Downton Abbey event. I know of people holding Game of Thrones parties as the new season starts.

The research on why certain cultural phenomena become popular indicates that the capacity to identify sympathetically with characters, especially when the story line allows us to struggle with concepts of good and evil, can be cathartic. It can help us to resolve our own conflicts safely, especially if, in discussing a show’s dilemmas with others, we can begin to understand how our friends or family members are themselves resolving conflicts.

The cultural phenomena that are television shows or movies have never been as cathartic for me as those I read and, of course, there is research on that as well. This research considers the reasons why some people are drawn to stories told via one medium over another. Again, this research shows that we are drawn to the medium that most engages our emotions, that allows us to enter the conflict of the story safely, so that we are not overwhelmed. I don’t mind imagining a bloody conflict, but I find it overwhelming to watch. I will also admit that I skip over parts of tv shows or movies that I find too difficult to tolerate, but I never have to do this when I’m reading a story.

Finally, whether you watch or read or listen to a story, stories show us how difficult it is for humans to live in the present, to “enjoy the moment”. We flip to the back of the book. We watch every episode. Do we not all want to know the end of the story, even when the story is good all the way along?

Not Just Any Village

In recent months, I have come to learn more and more about the difficulties indigenous youth have in obtaining mental health services. In part, this is because local, provincial and federal news reports are calling attention to these difficulties but I am also very much aware of the needs of these young people in my own community and practice.

It is especially distressing that, despite the goodwill of governments and their financial investment, all the measures that have been taken seem to have no impact. How can this be?

I have come to understand this only in the context of being a mother myself and it is only using this reference point that I can make sense of why our efforts have been so ineffective. Let me see if this helps you to understand what is missing.

Imagine that your child has serious mental health problems. She is twelve years old and started using substances like cannabis, or alcohol, or solvents. (I have seen indigenous youth who started using substances, especially solvents, as young as seven years old.) School is a struggle and because of this, the child feels hopeless about the future. Perhaps as a parent, you can understand this because you were in the same situation at her age. You are desperate for your child to get help and so you agree that she should travel hundreds of miles away from home to get that help. You agree to this even though you will miss her desperately, and worry about her all day, every day. You know she is anxious and will cry because she misses you and her family, but you know that you cannot travel with her because there are other children to care for, or your job, or even because you yourself do not have the emotional strength to support her. Who cannot relate to the desperation of this situation? Of this parent? Of this child?

The research evidence is overwhelming that children’s health depends on family support. It takes the first year of our life to be able to walk. It takes us until we are two to utter a few words. We begin to have the skills to read, and write, and do math around age five. The evidence says that our enormous brains can take until age 25 to fully develop. We clearly need personal support to grow and develop and every culture relies on families to provide that support. When we are unwell, we need that support even more.

How do we expect these children to heal when we send them away from their families? If we must do this, could we not at least set up those sophisticated telehealth networks and facetime for parents and children and grandparents and brothers and sisters to stay in touch? “It takes a village to raise a child” is an African proverb that recognizes the universal truth that we need our families and kin – our village.

When I am having a hard day, I will often count my blessings and the blessings I remember first are the people of my personal village: my children and husband and family and friends.

Do we really believe that indigenous youth (or any youth) will become stronger mentally away from their families? Have we really learned nothing from the experience of those sent away to residential schools? Are we really not listening?

If those African philosophers will permit, I do have one slight modification to their proverb. I agree that it takes a village to raise a child, but not just any village will do. Each child deserves the support of their own village: their own family, their own friends, their own people.

(Photo credit: Family Ties sculpture by Kevin Barrett)