My Predictable Clinical Life

In the past week, I have started to work on an inpatient psychiatry unit for youth. It is not easy being a psychiatrist for an inpatient program, but it is interesting and more predictable than outpatient psychiatry. In an outpatient program, emergencies arrive with little notice, often disrupting one’s schedule on days when there is no room for disruption. On an inpatient unit, the emergencies are right there in front of you all the time. This is predictable unpredictability and I find this more manageable than the frenzied calls that can disrupt an entire afternoon’s clinic.

For the past week, I have arrived on the unit to calls of, “Can I speak with you now?” or “What time are you meeting with me? I have stuff to do.” With a much smaller overall caseload than outpatient psychiatry, and patients who need to be seen daily, there is an opportunity to get to know the youth I am working with so well that their needs can be more thoroughly addressed.

The most common reason for psychiatric hospitalization for youth is to stabilize acute symptoms of psychiatric illnesses but case formulation and diagnosis and treatment plan development are becoming even more critical in youth psychiatric care. The reasons for this are embedded in the shortage of Child Psychiatrists and of youth mental health resources in general. Outpatient child psychiatry programs everywhere are stretched to the limit, to the point where the World Health Organization found that many mental health needs of youth around the world were not being addressed directly but rather through programs addressing other concerns. For example, street-involved youth often get more mental health support through housing agencies than from mental health agencies or hospital or clinic mental health programs.

Inpatient psychiatry programs and their function and purpose are not always well-understood, mostly because evidence often supports community treatment for some patients who would prefer hospitalization and hospitalization for patients who find the restrictions of psychiatric units too difficult to tolerate. This concept was summarized best by a patient I saw many years who asked me, “Dr. Beck, how come the people who want to stay in hospital can’t but the people who want to leave aren’t allowed?” When I responded, “I don’t really have a good answer for that question,” I was met with, “You don’t have any good answers.” I wish I thought that wasn’t true.

The WHO report emphasizes the need for greater collaboration between inpatient programs and the community. The social advocate in me loves the idea of working with schools, shelters, food banks and public health to develop the partnerships that will improve collaboration. The best outcomes for the clinical conditions where psychiatric hospitalization is indicated can be predicted based on social conditions. This means that those of us in who work in youth mental health must work with community partners if we are to have any success at all.

It also means that I will be diagnosing and treating conditions that go well beyond mental health into personal and social well-being. Hence, on my first day back, it was predictable that I would find myself gowned and gloved, hair covered, combing through a young person’s hair looking for nits. I can answer most questions about lice, in case anyone is interested.

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.)

World Suicide Prevention Day 2016

Today from 12:00 to 1:00 I will participate in the World Suicide Prevention Day Facebook Know What to Do Event. The event will be hosted on the Facebook page of the Children’s Hospital of Eastern Ontario (CHEO).  As well as answering participants’ questions, I have a short presentation to make on talking to your child about suicide.

When I considered what to say, I realized that the most important thing for a parent to remember when they have a suicidal child is: Suicide attempts and suicidal thoughts are symptoms of serious illnesses. They are caused by many different factors. Talking about suicide with your child cannot give your child the idea to attempt suicide and so parents should never worry about raising the issue. This is important for parents, and, in fact, for all of us to remember since stigma and blaming oneself are still more implicated in suicide that the fact that it is the outcome of a serious illness.

Because suicidal thoughts and suicide attempts are symptoms of an illness, I encourage parents, friends and others to ask youth about suicide when they are worried that a person may be suffering from ideas of taking their own life. Indicate your concern and your wish to help. A young person contemplating suicide needs to understand that you care about them, that you love them and that you’re going to do whatever they need you to do to get them help.

I advise parents to ask a young person how they can help. Offer to do whatever the young person needs and be prepared to follow through. If a young person is reluctant to talk to you, find someone they will talk to.

It is important for us not to judge suicidal thinking – it is the symptom of an illness. Ask over and over what you can do to help. Remember that statements such as, “You have so much to live for” or “Think how this will affect your family” are not necessarily helpful to a person with the despair that is another symptom of depression. Suicide and suicidal thoughts are not wrong – they are the symptom of an illness.

There is no perfect way to ask about suicidal thoughts. Just say, “I’m worried about you and I need to ask whether you are having thoughts of suicide.” Say, “I’m sorry if this upsets you but I want to help.”

As I write this, I am reminded of the many young people I have cared for who suffered with mental illness and suicidal thoughts for many months and even years before treatment began to be effective. I see their troubled faces first and then their smiling faces once they were feeling better. I work with a great team of social workers, psychologists, other psychiatrists, nurses, teachers, child and youth workers, recreation therapists, occupational therapists and experienced managers and office staff. We have teams at The Royal, at CHEO and at Youth Services Bureau. We all work together to provide the treatment that is needed for serious mental illnesses and to prevent suicide.

I want to end where I began: Suicidal thoughts and suicide attempts are symptoms of a serious illness. Children and youth do take their own lives and that is a tragedy. My thoughts are with those who have lost a loved one to suicide. My thoughts are with those who are suffering because of mental illness. On World Suicide Prevention Day, this is the message: “Let’s never give up. We can prevent suicide.”

knowwhattodo

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.”

Living the Dream

I have not written in about ten days. I have been busy living a dream. On May 2, I began a new job as the Director of Youth Psychiatry at The Royal. This is truly a dream come true for me: to provide guidance to the best team of mental health professionals and to consider how to address the mental health needs of the 16 – 18 year olds in Eastern Ontario.

As I embark on this challenge, I am buoyed by the good wishes of my colleagues. I have worked with many of the staff for fourteen years and their dedication to patients has always been inspiring to me. If it were not, it would have been impossible for me to even consider this new job. The staff go above and beyond their normal duties to ensure that patients get the best care and that their families understand that care.

In the few days since I started this job, I have found myself looking for extra hours in the day and extra weeks in the calendar. I do not quite realize that I’m going to have to give up some of my patient hours to get this new job done. As I set about managing my time, I thought, “I cannot give up the Thursday clinic” and “I’ll still be able to do Dialectical Behaviour Therapy”. “Are you still going to be able to see me?” is the most common question I hear from my patients. Everyone who knows me knows that I will not just drop anyone so the last question is easy to answer, but some clinical commitments will have to change – I almost get it.

Another interesting thing is that I have meetings – more meetings than I ever thought possible, for committees identified only by acronyms or letters. I asked someone today, ”What is the ABC Committee?” You know you are in serious difficulty when the acronym listed as words does not help you understand what a committee does.

The nature of a physician administrator’s work brings a doctor directly into the conflict between the patient and the system, with the necessity that the patient must get the best service and care at the same time as the system improves. Finding the best care often requires the system to be more flexible than is possible. Improving the system often changes many of the elements of care that patients and their families felt were helpful.

Doctors are the one link in the health care system permitted a degree of professional autonomy because of the mechanism by which they work in a hospital. Instead of being employees of a hospital, doctors are appointed to a hospital’s medical staff through a process in which they have privileges for certain activities, such as admitting patients. Balancing professional autonomy with a hospital’s public mandate is a conundrum that a physician administrator has to consider – it’s so much easier to fall back on clinical work.

Having said this, an administrative role such as my new job gives a doctor a chance to facilitate the changes that will improve care. I’ll decrease the paperwork, get electronic prescribing, improve the electronic health record…I’ll make a difference. That is the hope. Even if I don’t understand what my committees do, or how I’m going to do all the clinical work I want to, I know that having this new role is gives me a unique opportunity to help both patients and my local healthcare system. Someone said to me, ”I can see how pleased you are to have this job, you brighten right up when you talk about it.”

I hope that I’ll wake up gently as I begin to realize what I’ve gotten myself into.