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)

The Curator

I am desperate to understand why I cannot keep my desk clear. It is as if the objects that accumulate there have a life of their own.

At Christmas, I took two weeks off. One snowy day in late December, I sorted through the piles of paper and organized the piles of books. By the end of a full day, I had reduced the pile of books to the one book I was currently reading and the paper to one two-inch pile.

It is now February. There are now six books on my desk. The pile of paper is now four inches high and there is a smaller pile of “urgent” paper beside it.

What is “urgent”? The Annual Report of my church for next week’s vestry meeting is “urgent”. The incorrect reservation for my trip to London, England in May Is clearly “urgent” since it must be changed. The details on how to set up a simple crystal meth lab using readily available household supplies are on the “urgent” pile because I need to check whether one of my patients could have done set up such a laboratory. I realize that this sounds far-fetched, but the situation is real and could be “urgent”. The “urgent” pile is every item that must be addressed quickly.

What is on the other four-inch pile of paper? The book review for a textbook that I’d like to buy, this month’s edition of my favourite literary magazine, and the newsletter for the Osler Library have all crept onto this pile and snuggled in between recipes, newspaper articles and Aunt Stella’s letter. The last item may need to be moved to the “urgent” pile to be answered in decent time.

There is also the pile of books, of course, but, since these are all library books, it seems to me that they don’t count as my pile.

I am a psychiatrist. I spend entire days helping others figure out why they behave as they do, but I am completely crippled by one small housekeeping task. I have read more self-help books and consulted more websites on the topic of office organization than I ever thought existed. There are so many books and websites on this topic that there are lists of the top websites and books about organization. Most of these lists rate the top ten books or websites on organization, but one poor reviewer couldn’t even declutter the list and so she has listed the “Top 15 Books on Organization”.

The problem with these references is that they consider all of my paper to be “clutter”. The references consider my papers and articles and objects to be unnecessary, even a hindrance, for productive living. All these experts look upon the elimination of these piles of paper and books on my desk as a housekeeping task. But, as I said at the beginning, the objects and paper have a life of their own. These lives begin in my imagination. They are the offspring of my wish for my life to be more than I can manage. I am not ready to eliminate some of the tasks I have assigned myself with these piles of paper so that I can “declutter”. I want to hold onto the people, events, or activities that each book or piece of paper or object represents.

Consider the life each of these items has. Consider my aunt’s letter. I know that when my aunt dies, the letters written in her hand, using the phrases she used, will bring her to mind more vividly than my memory alone can do. Recipes are often collected less for me than for my husband, or my children, or a friend. Knowing how to set up a crystal meth lab will illustrate to a young man with a bad drug habit that I am perfectly aware of how risky his life has become.

I consider each of these objects to be artifacts and I am a curator of sorts, acquiring in piles that must be sorted the items necessary for a retrospective, personal exhibit of this current era in my life. When I have time, and when my aunt is much in my mind and I feel like speaking with her, I will take the letter she has written and answer it. There must be time to consider what she has said and respond. Then I will save the letter in the correspondence file I have of all her letters to me. This file is truly alive and so it is no wonder that the pieces of the file insinuate their way onto a pile on my desk before they get to the place where they will finally live. They want my companionship.

Similarly, the recipes I save are eventually scanned, or found online and saved to an online recipe collection, ready to be the main dish in a family birthday celebration or a special treat for a friend. This collection has become so like an exhibit that my family and friends ask for regular access to the collection or for items from it.
Finally, such ephemera as the instructions for a crystal meth lab are meant to be temporary exhibits, to be used in the service of a single event or circumstance. If recorded at all for posterity, this research will be documented as a footnote in my patient’s electronic medical record.

Perhaps this vision of myself as a curator of small exhibits, shown only to a limited public or for personal enjoyment is too grandiose. Perhaps it is just my excuse for the fact that I never seem to be able to keep my desk uncluttered. But I know that I am not unique in this curatorial style. I am suspicious that the organizational experts with tidy desks cannot truly understand my wish to catalogue and deliberately acquire emotional artifacts. How do they organize their inner lives? Are they ever on exhibit?

Those of us who maintain these small collections of personal literary memorabilia, longing at times for clear work surfaces and tidy desks, are often also the chroniclers. Our artifacts are our inspiration – for letters, for reports, for speeches, for essays. Why else do we keep files of letters and notebooks of quotations? Who but us will leave the evidence of what daily life was like in our times? From pictographs in caves, to hieroglyphics in tombs, to the Dead Sea Scrolls, to illuminated manuscripts, to the Gutenberg Bible, to Penguin classics, to the Cloud, we have left our mark over the centuries. We have informed our descendants about the life of our times.

While historical figures of every period and nation have kept tidy desks and fashioned careful histories of the legacies they prefer, those of us whose only goal was to capture personal memories for private exhibits leave a very different legacy. Our recipes, letters and vestry reports left behind on untidy desks and in filing cabinets and on hard drives have lives of their own, our lives. We do not have time to organize everything into a well-shaped monument, or to order the possessions in our tombs. We will be found frozen in time, like the citizens of Pompeii, at the moment our lives stopped, still working on tidying our desks, still writing.

(Note: I’m sure you will notice that this essay is different from my usual posts. I wrote it for a writing course, where it drew such a positive response that I thought I would be brave enough to publish it here, on Christmas Day. This is the kind of writing I would love to have time for, although I don’t know what value it is. To anyone reading this, have the best holiday!)

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.

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.)