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.

Bleak Midwinter

The holiday season has officially started. I have begun to make a list of the families in my practice that should receive grocery vouchers so that they can afford food for the holidays. I also make a list for the teenagers who are living on their own. I confirm addresses and watch young people’s faces closely so that I can discern whether they are, in fact, housed. I ask them if their housing is safe, looking them right in the eye. I have a list of numbers on the corner of my desk for families or youth to call if they need housing. I have lists of where free holiday dinners are provided and where one can sign up to receive gifts. I am not trained for any of this. In fact, few doctors are trained for this work, but we all do it.  The hardest part of this work is finding a balance between the fear I have about how precarious my patients’ living situations can be and the realization that I have a responsibility to make that situation more secure.

I know there are many who will say that this is not a doctor’s job, but I cannot escape the knowledge that I have that says otherwise. Every doctor I know works for the best for their patients even when the best has nothing to do with pathology, physiology or medicines. Every doctor I know asks their patients questions about their income and work and family life.

The sharp contrast between the glittery mall displays and the realities of many lives is especially evident at this time of year.  While so many are focused on what they want the holiday to be, others are thinking of what they need so that the holiday is bearable. The impact of this contrast on mental health is significant.

At a time of year when family is glorified, the difficulties in one’s own family become highlighted. The support of family members is known to be a factor in good health, but how many people do you know who dread the “family” events that come with the holidays? How many of those events end much differently than sitcoms would have us think? Many of the youth I see live in care. Some will be preparing for a visit with family of one kind or another. Some will have days or even a week with their family. Helping youth stay realistic about these visits and the holidays is very difficult for those of us who care for these youth.

I am always most concerned about the youth who do not have a family to visit. Most people around them will be planning a visit and excitedly buying and wrapping gifts and planning travel. The youth without a family will be sharing their Christmas lists with a youth worker or social worker. You will receive gifts, often thoughtful gifts of things you want, but you will not have what you really want which is love, true affection from someone who has known you all your life and is happy for just being able to hang out with you. As a psychiatrist, I could point out the link between “hanging out” and endorphins but I think this just serves to distance us from the feelings. If you can understand what a young person with no family is feeling, you know that this feeling is not good for someone’s mental health.

As a physician, I always take some time off in November or early December to prepare emotionally for the holiday season, whose starkness is so evident in psychiatry. Then I come back to work ready to spend the next month social determinants of health.

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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.”

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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.