A psychiatrist’s view on internet dating

 

I thought I’d take time to write about internet dating, the kind that uses social media as platform. Its not intended to be a ‘fun police’ kid of discourse, but in an industry that is unregulated, with a myriad of available options that can have consequences, positive or negative on a person’s wellbeing, it is timely.

After living through the 2 decades during and since the time  “Sex and the City”  (SATC) was every girl’s best friend, I have noticed a huge change in the expectations and limitations of finding the right person and going on to live happily ever after. In twenty years the concept of dating has changed very little but the introduction of technology into the mix has been a total game changer. Remember that scene in SATC when a voicemail message from ‘Big’ on a clunky handset on the bedside table left Aiden and Carrie at the crossroads for the second time? I am sure 2018 Carrie would be the owner of a smart phone that could be silenced to avoid such catastrophes.

What I remember from watching every episode of Sex and the City, sometimes multiple times, is that meeting men was always random. The 4 main protagonists, Carrie, Miranda, Charlotte and Samantha would meet to discuss the men they were currently dating, lament, celebrate or remain ambivalent about being single or deciding whether to get married. The men that came into their lives in a perfectly orchestrated chaotic way, gave them something to talk about when they caught up at the café or over dinner. They would be introduced to a potential partner via a friend, be asked out at the gym, or while training for a marathon, and in Samantha’s case, after sharing a cab ride to the upper east side. Ex partners would painfully crush their sunny days as they literally walked into them on a Manhatton street. Partners came and went, sometimes coming back again, but the girls were frustrated they couldn’t really control the chaos. Watch this 20 second grab of the girls lamenting the inability to find ‘the one’

Twenty years later and during the in between, social media has evolved to create easily usable applications that bring dating to the customer (because that is what we are after all). Introduction agencies have moved into virtual solutions that can be downloaded within minutes onto our smart phones. With catch banners and fancy names we can be hooked to the certainty these sites offer, and guaranteed more certainty if we actually pay money as well.

The concerning part is that this industry is completely unregulated. The adage that one can find a very bad match in real life thus defending the use of online apps doesn’t make sense, as the apps are unregulated, the hard data about success and the terms and conditions are often terribly difficult to find. Purchasing a premium package online does not guarantee a higher quality of a match, it probably just shows which matches didn’t feel it was financially sensible to pay.

In addition, deleting an account does not mean you disappear from the virtual world. Consider this before you take that free “20 minute personality profile” guaranteed to make your chances of finding a compatible partner even more likely. Popular sites offer this only for the consumer to find  that the service has no functionality until you sign up and pay. Within those series of questions, these clever companies have learned more about you that you might not tell a partner until the their 3rd or 4th date. Via GPS, or by signing into other apps, such as Facebook® they know who you are and where you live. They know your likes and dislikes. Thy know  how many children you have and often how much you earn. By uploading profile photos they can see images or detail in the shot that may reveal more. In a world where we are quite rightly more concerned about privacy than ever, this allure of guaranteed success, a departure from loneliness and lack of intimacy on our terms may blindsight us to consider the implications of a rather explicit ‘tell-all’.

Also, If you take time to read the fine print you’ll notice you don’t get your information back when you delete your profile. Often profiles are left up despite being deleted, to increase the number of fish in the pool. So if somebody does not respond when you send a wink, kiss, smile or message, they may actually have departed months ago, and are currently down at your favourite café having a coffee alone and reading the paper. Also, your personality profile is the company’s data forever. Or until you go through the channels to demand it back.

More popular apps such as Tinder® have taken over the way older adolescents and young adults view meeting other people. In fact, Tinder® claims to be the world’s most popular app for meeting new people (via official website). In some cases this is the only way users know how to make new friends or communicate with others, outside of peer groups formed in school. Swiping right and left when bored or lonely is just the same as playing the poker machines waiting for the win. Chemical releases of dopamine in the brain, a neurotransmitter that is involved in the feeling of reward and pleasure, occur in those who achieve success with a match on Tinder® just as they do if they win $200 on the poker machines.

As a psychiatrist, one of the sad things I see is that patients with anxiety disorders such as social anxiety or body image disorders feel these apps are their best friend. They can be as confident as they like behind the phone screen. If they get a match they are temporarily exuberant, then crushed when this means they have to present their selves, ones they might not feel so comfortable about to a real human being. They are likely to ‘ghost’ their match, or be ‘ghosted’ or cancel just before the arranged meeting time. This causes a whole new range of emotions that can be experienced anytime we put ourselves out to meet others, but seems more common, and sadly more acceptable using apps. It is as if we have created a forum to showcase bad manners. More and more, my therapy sessions are spent helping a patient deal with rejection after an online swiping experience, and I am constantly dismayed by how more common and nasty this has become.

Some of the hardest experiences in life generate from the act of being vulnerable, liking ourselves enough to feel valuable and attractive to others and tolerating disappointment and loneliness. All of these experiences are essential to our make up as human beings. They are just as important as learning tools, springboards for growth as are happiness, exuberance, love and intimacy. With the creation of an era that seems to sell the promise of have the latter without the former, and in real time sends all of the wrong messages. A patient with social anxiety would be encouraged and supported in therapy to gain confidence, and try, step by step to move out more into the external world. A patient with a body image disorder would be encouraged to do the same. No therapist would collude with the pathology and suggest continuing with the isolation. If anything this would reinforce a disordered sense of self, one not worthy of all the love, acceptance, connection and happiness that is out there.

And, 20 years after Sex and the City, the yellow cabs of New York have not been replaced by ‘white knights’ in Ubers®, tracked via your app and delivered to your door with a customer satisfaction rating. Sounds absurd? The online customer expectation, or the one that is sold to you by the glitzy website, is trying to tell you it isn’t.

 

 

 

Leadership – What do we expect of leaders and how do leaders rise to the challenge?

A leader holding flag, leading team, and showing direction.

Recently, my son asked me if I thought leaders were born or made. He had to participate in a classroom discussion about leadership and was surprised to see that he was the only one who voted ‘born’. This led to some serious reflection on my part, someone who does consider themselves a born leader and the risk and responsibilities that go with that.

I focused on this a lot this past week, both in my professional and personal life. Life threw me a few leadership opportunities and I felt compelled to fill them. I also saw discussions in social media that, to me, represented a lack of leadership, or at least a difficulty identifying who the true leaders were. In addition, I discovered first hand what can be achieved when leadership and collaboration come together.

I naturally find myself saying yes when asked to fulfil leadership roles, but before I know it, self doubt and fear of failure tend to creep in. I wonder if this is true of all leaders. I presume I will be criticised or I will upset people. But because I have been born this way, I try and ignore the negative self talk and say yes. And if I am not truly sure, I always seek guidance from my mentors, brilliant leaders who often help me traverse the way.

It’s fair to say that leadership is expected whenever there is a an issue or a challenge that needs sorting out. It seems to be a common human trait to seek leadership in difficult times, and to assume there will be leadership. Anxiety and despair can follow if leaders are not tasked with the role in a timely manner, and are not authentic to the role they have been chosen to fulfil.

Some common assumptions seem to be:

  • Leaders are there to pick up the baton and advocate when we falter
  • Leaders are unwavering when we are vulnerable
  • Leaders know they are leaders.
  • Leaders unite people rather than divide them.

But these points can be debated, and are not always true.

I remember watching the Beaconsfield mining disaster unfold on TV in 2006. It occurred in a small town in Tasmania, and the wait for the trapped miners to be found and freed was a desperate and public plight. It needed a leader, and a swift appointment at that. In a small town, and with international media coverage, somebody had to carry the responsibility. It fell to Bill Shorten, who was the Australian Workers Union national secretary at the time. Bill’s presence did seem to calm those watching the rescue attempt unfold.  In that moment, with so much uncertainty and despair, his role was crucial to wear the pressure of what could happen.

In the last 24 hours, The Hon Min for Health, Greg Hunt MP has announced national changes to the the mandatory reporting laws introduced by AHPRA. As a staunch and unwavering advocate for this change, I was thrilled to see such strong leadership for what was a very concerning contributor and barrier to doctor’s seeking help for mental illness. I met him once,  as part of a Grand Round at Peninsula Health, and was immediately impressed by how much he understood about this issue, the concerns arising from the medical profession, the accounts of families who had lost loved ones to suicide, and how he enacted change at yesterday’s COAG meeting. He was boosted by strong leadership around him, leaders from their respective camps such as The AMA, AMSA and doctor’s health advocates, including Dr Geoffrey Toogood, Dr Mukesh Haikerwal, AC, and myself. True change happened yesterday, and it was thrilling to be part of it.

What happens when an issue arises and there is no leadership?

Recently, a paper was published that examined data pertaining to the number of reports against Australian doctors based on age. It was written about in the Australian Financial review. In essence, an examination of reports against doctors revealed that doctors practicing in Australia over the age of 70 were 40% more likely to be complained about than their younger peers. This is despite the same article stating that many senior doctors provide high-quality care well beyond the traditional age of retirement and the study showed almost 87 per cent of doctors over the age of 65 were not subject to any complaints. In addition, the author states complaints about mental illness, substance abuse and problems with procedures were higher among younger doctors.

With the publication of one article, aspersions about the competency of all Australian doctors over 70 have been cast.  The Medical Board of Australia has announced it will introduce peer reviews and health checks on all doctors over 70. How this will occur and when has not been announced.

The fact that this decision has been met with general silence does not necessary mean acquiescence or consensus. But as reported by Medical Observer, it has been viewed as such.

For some reason, the idea of introducing mandatory competency checks on all doctors aged over 70 has gained near universal acceptance among medical leaders – at least if judged against their silence https://t.co/YEY3ytMnXt pic.twitter.com/FSWJOFb4jg

 

But, another way of  viewing this point is captured by this tweet:

I am concerned this demographic of doctors will be subjected to what seems to be age discrimination if leaders are not identified with haste, in order to provide calm and reason, as well as uniting a very valuable and experienced cohort of doctors. Notwithstanding this, the personal impact of this news on doctors who are approaching retirement sends a very clear message that they are not regarded very well by some of our medical peers, and especially not by regulatory bodies. They need a leader to unite them and oppose this argument.

Being a leader in your community

If you are a born leader, leadership styles and roles don’t usually stop at work. And I have taken a big step in that regard over the past month. Others may see it as small, but I am cautious about the responsibilities although I am excited about the challenge.

In the last month my 11 year old son told me he no longer wanted to play AFL football, something he had done since the days of Auskick at age 4.  As a mum who juggles work with ‘mum’s taxi service’ that would mean a lot more free time for me. But I really wanted him to continue, and help him over this hurdle in his very amateur career. After all, he plays with friends he has known since early school years and once on the oval, he enjoys himself.

His team was a new mix of boys and it needed some pretty heaving hitting volunteers to help out. Largely relegated to the regular roles of timekeeper, and provider of the oranges and snakes in past years, I decided to take a massive leap of faith and apply for the role of assistant coach. I did this based on the fact  I have followed AFL football for about 40 years, can manage a group of 11 year old boys and assist the coach who has the ability to teach them skills.

I had no idea how this news would go, or if I would be laughed at. But as it seems, It has been well received, and tomorrow I assume my new role, on the coaches bench. The first mum to coach for the club. Am I nervous? Yes of course I am! But am I a leader – absolutely. So I am pretty sure I’ll be all right.

And I’ll continue to pursue more leadership roles, after all I was born that way.

Dr Helen Schultz is a consultant psychiatrist, author and doctor’s mental health advocate. She is also a passionate member of the Western Bulldogs AFL Club. 

This post is dedicated to the true leaders in the recent fight to end mandatory reporting of doctors to AHPRA, the ones who stood out for me ;

Dr Mukesh Haikerwal, AC, Dr Geoffrey Toogood (creator of the #crazysocksfordocs campaign) and the Abbott family, who out of a time of sheer tragedy became the most inspirational leaders of all.

 

 

 

Is it possible to be a ‘good enough’ mother in a profession that demands perfectionism? My keynote from #IWD18

Today I presented as a keynote speaker at The Melbourne Clinic’s International Women’s Day breakfast. I spent a lot of time deciding what to talk about, given the audience was built from members of various disciplines. But I knew I wanted to incorporate my struggles to get through medical training as a doctor and mother, on behalf of all female trainees who fear speaking up.

I was asked by some if I could video the keynote but I decided not to, for it contained a lot of personal information that I did not want to reach the public domain. Nevertheless, I do wish to share some of the points I made about the rigidity and inflexibility of medical training and how that impacts on all trainees. But given it was International Women’s Day, I focused on motherhood and medicine. And being in a psychiatry setting, I drew on the work of Donald Winnicott, a paediatrician and psychoanalyst who defined the phrase ‘the good enough mother’.

This article describes eloquently Donald Winnicott’s actual definition when using the term, ‘the good enough mother’.

a mother is neither good nor bad nor the product of illusion, but is a separate and independent entity: The good-enough mother … starts off with an almost complete adaptation to her infant’s needs, and as time proceeds she adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure. Her failure to adapt to every need of the child helps them adapt to external realities.

The article states that being a ‘good enough mother’ is actually better than being a perfect mother when it comes to a child’s well being.

So, to examine the life of a mother who is also training to be a doctor, is this attainable?

When exploring this idea, I focused on my own journey through training. Motherhood waited until all of my formal training requirements were out of the way. I was lucky and fortunate that life turned out that way. Women are often blamed for delaying parenthood for the sake of the careers, but when I was brutally honest about my own predicament, I knew that the way training programs and workplaces run, with the degree of inflexibility and dismal variety of part time positions, I had to be a realist and wait.

After speaking to many trainees I know that the facts are that women are often asked (illegally) when they plan to start families when applying for roles, and women are looked down upon and viewed as ‘not dedicated enough’ if choose to train part time. Training colleges such as the Royal Australasian College of Physicians hold the most critical of exams on only one day per year. With he surplus of medical graduates and the bottleneck to attaining valuable physician training places, men and women, parents or want to be parents put their lives on hold to study for 1-2 years. It is difficult to comprehend in such an inflexible system, how one can adapt to a child’s needs to achieve being ‘good enough’. In many cases ‘good enough’ has to be re-classified as absent or at the very least inconsistent. A mother in this position would require enormous practical and emotional support to be able to meet all the training requirements imposed upon them to pursue their careers. Not all mothers have that. And why should mothers be expected to meet these needs at all costs, when they are such a vital component of our workforce?

Two years ago, The Royal Australasian College of Obstetricians and Gynaecologists added the following topic for debate at an annual scientific meeting – “Membership before maternity leave: Should every registrar have a Mirena?” (an form of contraception for women). It was designed to encourage debate about the very issues I spoke about today. But it was brutal, and deeply hurtful for many trainees around the world. Because to many it described what is actually spoken about in the workplace, and flies in the face of colleges who purport to offer flexible training conditions. There was no parallel discussion about the need for male registrars to use contraception.

In addition to this, our work, our training, our ability to enter medicine requires a degree of perfectionism. Our patients expect we don’t make mistakes. We are asked the most intricate and minute details of medical conditions in our exams. Things we may never see in real life, but we have to be on top of to pass. How does a mum switch out of the behaviour of a perfectionist when approaching or juggling motherhood?

In my case, and I know for most doctors employed in the public system, we are employed on one year contracts. This is so we can’t accrue leave entitlements afforded to most other women. So when I went on maternity leave, I was given around 8 weeks. My contract was not renewed, and I was told to contact my training hospital when I ‘felt like returning to work’. I was therefore unemployed, despite paying ongoing fees to my training college. This had financial and emotional repercussions on my family, and I did not return to that hospital to complete my training. In 2018, working mothers are rostered to be on call but there are still no child care options after hours available to them.

I make these points because as a consultant psychiatrist I am safe to do so. Trainees can’t speak up. So we must combine our efforts to fight for their conditions, as our successors.

The rest of my presentation focused on two issues I hold very dear to my heart when it comes to my approach to being a mother.

  1. Normalising mental illness so my son accepts it is common and treatable. Just like colleagues in other specialties in medicine, he came to the hospital and sat in the nurses station while I did my rounds. He knows what a psychiatrist does which is better than many in the population. He knows his mum is a doctor and helps people.
  2. The vital role mothers play in their son’s life about teaching them how to treat and respect women. Leading by example, standing up for myself if feeling mistreated and talking about good and bad experiences in the playground or society.

I’ll elaborate on the second point, one of the most amazing ‘a-ha’ moments of my life, and the one I reflect upon when unsure if I am being ‘good enough’ when fulfilling these goals. My son had to choose a famous Australian who had made a difference in society to research when he was 10 years old. He chose the Former Australian Prime Minister, the Hon Julia Gillard, without my knowledge or influence, and some of the key features he elaborated upon were that she proved women could change stereotypes, and her advocacy for gender equality. I was thrilled to be able to provide her with a copy of my son’s work at a recent event.

So, is it possible to be ‘good enough’ in medicine as a woman and mother? I argue yes, but it is all in the timing. And until we afford women the same rights as in other professions it will remain that way. At the expense of losing a significant amount of doctors from the workforce when we need them, because they have chosen to be mothers.

Dr Helen Schultz is a consultant psychiatrist, author, public speaker and doctor’s mental health advocate. 

The ins and outs of doctor mental health

On Friday 16 February 2018, I took part in a Grand Round at Peninsula Health in Melbourne, Australia that talked candidly about the current state of play with regards doctor’s mental health. Alongside me was Dr Geoff Toogood (convener and instigator), Dr Mukesh Haikerwal, AC, and Australia’s current federal health minister, the Hon Greg Hunt.

 I have been involved in the doctor mental health space for several years, as have my colleagues on the panel. I shared my experiences about doctor’s help seeking behaviour from the point of view of a psychiatrist with a special interest in treating doctors and students with mental illness.

Over time, I have seen more medical students and doctors at all stages of their career, from all different crafts come through my door. I am aware that by the time they have made it to see a psychiatrist they have navigated quite a lot of practical and emotional hurdles to get there. Unfortunately, in some cases, they have presented very unwell, as they have tried to move past the point where others would put up their hand for help, for fear of discrimination or retribution. As a doctor working in this space I do not minimise this at all, but am dismayed that in 2018, with all the talk about reducing stigma in the medical profession, it is still alive and well. And I become particularly moved when I hear about doctor suicide – probably doctors who never made it to the consulting rooms of somebody who could help them turn their life around.

The ‘ins’

At the heart of the matter is the fact that doctors are hard wired and built exactly the same as all human beings. Our neurotransmitters are the same, our organs are the same, our vulnerability to disease is the same. As a consequence of this, we are also able to recover and move on just like any other human being. I am somewhat overstating the obvious because in countless discussions about this topic it is often argued that somehow we are not. The flip side of this and the irony about doctor help seeking is that we also respond to evidence based treatments and recover just like other human beings.

Doctors and medical students are invariably perfectionists. We have to be to jump hurdles and treat patients, focusing on the detail while looking at the big picture at the same time. It is like body building. We focus on one particular muscle group, but may not know inherently that other muscles that work in tandem need to be trained as well to avoid injury. Just like an athlete who runs for kilometres but forgets to stretch. Inevitably their results will improve but they are susceptible to injury. Our most overworked ‘muscles’ are tied into perfectionism and success, our most atrophied,  are the ones that are linked to humility, compassion towards ourselves, and forgiveness. So when we become injured, when we set our standards very high, and often unrelenting, when we miss out on sleep, or friendships, or significant life events, we fall over.

The ‘outs’

There has been much discussion about external factors that impair help seeking behaviour in our medical profession. I plan to focus on two of these factors.

  1. Mandatory reporting

I understand the requirements to report doctors who pose a risk to the public under current AHPRA mandatory reporting laws. I know some of my colleagues don’t. I know doctor’s help seeking behaviour is directly impacted because doctors and medical students don’t know which camp the doctor they attend falls into. I also know of cases where reports are made behind the doctor’s back, coming as a complete surprise to the notified doctor.

Nobody would argue that a doctor or medical student who is posing a risk to the public for whatever reason, including practicing with untreated mental illness or substance misuse should be reported from an ethical perspective. But this does not have to be mandated and is not in Western Australia.

Reporting of doctors and medical students to protect patients should not occur at the expense of risk to the notified doctor

The reporting process in itself is gruelling enough. But the investigation that ensues has been shown to cause further deterioration in mental health of the doctor being investigated.

Suicide whilst under GMC’s fitness to practise

Last week, a widow in the United Kingdom spoke about her husband’s suicide. He was reported to the GMC and the claims were found later to be of no substance. But it delayed the family’s move to New Zealand, and, according to his widow, triggered a severe case of depression. It may have been a contributing factor to his decision to suicide. That remains unclear as in many cases of suicide. What was the final tipping point? What we do know is that there is a growing movement for families of victims of suicide are coming forward to talk to the media about their experiences to help us understand.

The only answer to this issue around mandatory reporting is to get rid of it. It makes doctors very mistrustful of asking for help, despite all reassurances that they wont be reported, when there are already way too many other barriers. It was pleasing to hear the Hon Minster for Health, Greg Hunt state he would do whatever it took to see this law removed.

   2. Stigma around mental illness is alive and well in the medical profession

As a psychiatrist I encounter stigma from my non-psychiatric colleagues on a regular basis. There remains an inherent misunderstanding around what psychiatrists actually do, which is why I wrote my book, “How Shrinks Think” in 2014, in an attempt to address this. Medical students complete about 6 weeks of psychiatry training and during that time see very acutely unwell patients. They have little or no exposure to most other aspects of psychiatric care, and are unable to follow a patient through their illness to recovery due to the length it often takes to recover from  a mental illness. This astounds me as there are many other areas of medicine where patients remain chronically unwell, such as patients with renal failure waiting for a kidney transplant. Yet many physician trainees still aspire to become nephrologists. I have spoken to many medical students who are turned away from psychiatry as ‘nobody ever gets better’. Nothing is further from the truth, but their exposure to psychiatry in their formative years skews their perception.

In addition, the way I have been spoken to by non-psychiatric colleagues is also borne of ignorance of what we actually do. We are life savers just like cardiac surgeons, or emergency department physicians, and many others. It’s why we all do medicine. If medical students and doctors in training are exposed to the dialogue around psychiatrists being ‘real doctors’ why would they ask us for help if mentally unwell?

Where to from here?

There is so much active discourse and tangible movement in this area. I remain hopeful that we have enough of a growing movement to end mandatory reporting laws in Australia, and doctors hopefully will be more accepting of care, and at an earlier stage of their illness so they recover more quickly. I continue to be hopeful that we address the inherent stigma within the medical profession about mental illness, the factor I see as the greatest barrier of all to seeking help. I also implore any medical student or doctor who is struggling to start by seeing a general practitioner, and if it is recommended that they need to see a psychologist or psychiatrists that they do so. For the sake of themselves, their families, and for the profession that needs them and cares about them.

 

If you find this content distressing, please reach out to emergency and crisis services including the “Suicide Call Back Service”

The anniversary reaction and doctor suicide. Why it matters

To remember those we have lost, who live in our memories and come back to remind us how important they were to us

This time of the year, and for the few months preceding Christmas I am usually helping patients come to terms with painful memories and themes of grief and loss around the festive season. And yes, while this work was undertaken in abundance, I couldn’t help but be drawn to the loss and suffering endured among colleagues within the medical profession due to doctor suicide. In 2017, a number of families spoke openly and candidly about losing a loved one to suicide, demanding answers, offering clarification to counter rumours and to beg that ‘something must change’ These actions became more common, unlike years gone by. And I have continued to wonder how they were, as we commiserate their loss and face anniversaries.

As human beings, we are hard wired to feel a range of emotions from despair, sadness, loneliness, anger and panic leading up to the anniversary of losing a loved one. And maybe we are hard wired like this for a reason. Maybe to actively forget, which appears appealing on the surface and in the moment of utter despair, may pay disrespect of the magnitude of how much somebody or something that we no longer have shaped our very being. That to be able to forget someone after a short while would mean their sudden disappearance would allow us to forge along with little consequence or impact.

A number of episodes of the Netflix® series, Black Mirror® attempt to examine ways of manipulating memories, often traumatic and repetitive, with horrific consequences. In reality we know, that for many of us living with memories and being changed forever because of loss is part of our make up as humans beings.

This article is dedicated to the concept of living with painful memories after loss, and in particular, the anniversary reaction, and how it manifests in the context of doctor suicide. This is because in the past week I am acutely aware a number of families would be struggling with this. In early January 2017 we lost four doctors in training to suicide, and in 2015, at the same time, another four. So that is eight families known about. With countless relatives, colleagues and friends affected. It makes me wonder if we can do more than commiserate and pay respect but to use anniversaries and the emotions attached to them to keep buoyant in this battle to stop doctors taking their lives.

It is also written in sincere respect to honour very significant recent anniversaries. The death of Dr Chloe Abbott, who died on January 9th 2017, days before her 30th birthday, her recent birthday on January 31st, 2018 and the ongoing grief and sorrow those who know her and loved her demonstrated via social media this past week. It also serves as a tribute to the four Victorian doctors (three psychiatry trainees) we lost 3 years ago. The article about the suicides was written by Julia Medew and published on this day in The Age in 2015.

At this time in 2019, we will be remembering the anniversary of Dr Frith Foottit, who according to his wife’s report in The Morning Bulletin took his life on Jan 1 2018.

We cannot comprehend how families continue on after any loss, let alone sudden losses that seem inexplicable to others. Death by suicide is particularly difficult to reconcile, as often those who suicide conceal their feelings, set a date in their minds, and appear well, to either ‘trick’ others they are OK and can’t be stopped, or because they are genuinely relieved their pain will stop. They are long past seeing themselves and their world they same way as others around them, and cannot be convinced otherwise. This compounds the terror for those left behind who cannot comprehend that their beautiful loved one couldn’t see they were special, meaningful and unique, and that nothing mattered more than them being alive.

Anniversary reactions are often not talked about, but are very real. The understanding is often derived from those with post traumatic stress disorder and who have survived traumatic events. Tragic and horrific events often capture media attention at the times of recent anniversaries, and one wonders whether paying such public attention to them traumatises those involved more or offers some peace – a collective bringing together of those who all experienced something somebody never should. This is particularly pertinent as we have just remembered and paid respect to the “Bourke St Tragedy” which occurred in January 2017.

What I have learned about anniversary reactions is that they might not always be so obvious, can be triggered by other memories and affect ones’ feelings and emotions out of the blue. Patients often ask for permission to feel a sense of panic, loss of profound distress on a day that has no ‘calendar’ relevance to the event of losing a loved one. They are often relieved to hear that the way our memories are stored and retrieved, particularly around negative events may be more random than that.

I lost my childhood friend in 1992, when she was 23 years old. We were born 6 months apart, our parents were friends who worked together, and worked out how to raise us together, before our siblings were born. I have photos of the two of us in high chairs with our first solid foods, me with my crimson red hair and a face covered in eczema. Photos of us playing under the sprinkler in summer, going to pantomimes, playing at Queenscliff all summer long, and spending our birthdays and Christmases together. Eyeing off each others’ gifts to see who got the latest Barbie doll, or nicest new shoes, and being happy for each other. We spent all of our holidays and special events together, and for all accounts, she was my cousin. She always received pink carnations for special events. “Hall and Oates” and “Blondie” were always the favourites for rollerskating soundtracks.

My friend was killed suddenly in a motor vehicle accident by an unlicensed driver who was profoundly intoxicated and recently released from prison for drink driving offences. It happened on the weekend of Mother’s day 1992. Her birthday was Valentine’s day. So I suppose I thought I understood why those days, all these years later made me think of her, as they were public days celebrated by Hallmark cards and intense feelings like love. Thanks to consumerism, there were memories everywhere.

However, in May last year, I had a very profound dream about her and woke up with panic and a sense of foreboding. It was 12th May 2017. I immediately began searching the records at the memorial park where she was placed after cremation. Somehow I knew I needed to do this, after never visiting that register  Her funeral was on 12th May 1992, exactly 25 years before. A quarter of a century had passed, her life trapped in a time warp with 80’s music, big hair, shoulder pads, and Christmas holidays at the beach. I drove to the memorial part the next day after hunting for pink carnations everywhere to take her- and I found her plaque and sat with her, placing the carnations next to others of variable freshness, a sign others had remembered too. How or why I was reminded that it was important to mark 25 years since her funeral is not understandable to me. But it didn’t matter, because it allowed me to spend an afternoon with her at her plaque and think about how she would respond to a world post 1992, what she would look like, and how much I missed her.

So I guess I am writing this blog about suicide among the medical profession, to join the countless other articles currently circulating around this very significant topic. But I write it from the perspective of a psychiatrist and as a way of trying to ease some pain that feels quite tangible this week. Also, as a way of examining whether we can take some of the sadness from anniversary reactions and help us in the doctor’s mental health space stay true to the cause.

I also write this for three very different and important audiences:

1. To the families, friends and colleagues of those lost to suicide. Never be afraid, or embarrassed to grieve, stop still or pay respect. Practice kindness and compassion to yourself every day. Don’t try and over-interpret why certain memories may reappear – maybe it was a song from your past, or a recipe, or even a flower. Just pay respect to the fact you can remember. The harder we fight to forget, the louder and more pervasive the memories will be.

 

2. To those who find themselves at a state where the really see no reason for living, get help right now. I can promise you that you are not seeing clearly and you are not seeing yourself the ones who truly matter see you. The ones who will do anything to help you get out of the state you are in, provide practical and emotional support while your point of view takes on a whole new meaning. The ones who will have anniversary reactions forever if they lose you.

 

3. To the administrators, politicians, figureheads and lip-service enthusiasts be warned – we will never give up fighting to prevent suicide among our medical colleagues. For all the reasons above. I personally have not forgotten losing three psychiatry registrars, one a friend, in early 2015, although I see little has changed. But I will always use their anniversaries as a force of strength, to keep me on track, to keep me determined and to keep fighting.

 

This blog has been written by Dr Helen Schultz, a consultant psychiatrist and author. She has worked in private practice with many patients to enable acceptance over traumatic life events.

She sees medical students and doctors in her practice, MindAdvocacy, offering after-hours appointments with utmost confidentiality for medical students and doctors.

She is currently meeting with families who have lost a medical colleague to suicide (whether it be their father, mother, sibling, child), using her knowledge of psychiatry to identify key factors as to why suicides occur at such an alarming rate in the medical profession. She hopes this work will clarify where initiatives and support are best placed to prevent more suicides. If you wish to speak with Dr Schultz, please contact her at her rooms on (03) 9428 8321.

The only way we will make real change in this space is by talking about suicide openly. However, if after reading this, you feel unsafe or need to speak to somebody, please call myself on the number above, your GP, Lifeline on 111314, or BeyondBlue on 1300 22 4636

Breaking news – medicine is not depressogenic

Abandoned scratched vintage metal ex USSR whirligig. Isolated.

From where I sit the doctor’s mental health debate has gone around in circles like a spinning top, only to fall over sideways. Almost discarded and relinquished to the toy box for another time. Stalwart warriors in this space are beginning to become very frustrated, and rightly so. As a stalwart warrior for many years, I have spoken to politicians, lobbied and campaigned extensively and despair as I hear about more suicides. Imagine the near misses or attempts nobody hears about.

But this article is not written as another to add to the growing content forming the doctor’s mental health debate. It is based on my concerns that we are losing focus and our campaigning may be off the mark. So may be our attempts at finding solutions.

I fear for medical students who read about the high suicide rate in the medical profession. I fear they will believe their future profession will cause them to become depressed. That they  believe they are going to exchange valuable resources such as money, time, energy, enthusiasm, passion and drive for a lonely miserable existence. That they will follow Twitter feeds that debate this, and keep their head down even more.

These issues are not unique to medical students, and there are similar concerns for students of veterinary medicine, nursing, dentistry and pharmacy. Rather than seeing these professions as ‘callings’ to help others, they are directly blamed for causing mental illnesses such as depression in the very people chosen to commit to the calling.

As a psychiatrist, I have treated numerous medical students and doctors, as well as other members of the health professions. I have also spent time with family members who have lost a loved one to suicide. I use evidence based strategies to deliver best practice. Part of my work is thorough history taking, including a detailed past and family history. Just as with many other medical conditions, thorough exploration leads to revealing information. And these patients are no different to most of my other patients. Doctors in their 30’s will talk about a time in medical school that would have fulfilled the criteria for a major depressive episode, if they had told anybody about it . It may not be the first time that the patient has experienced suicidal thinking, but may be the first time they have told anybody about it. They may have a parent or sibling with a diagnosed mental illness, or a relative who was talked about as being unwell. They may have witnessed or experienced devastating childhood adversity, leading to problems with personality, but nevertheless gifted and skilled in so many other ways.

Medical training does not cause depression. But impairments in help seeking, both within the person and within the system, leaves that person untreated and vulnerable.

Mental illness is common in the community, so why do we believe that medical students, who live in the same community are somehow immune? That if we make them ‘resilient’ by offering a few lectures in medical school about managing stress we will ensure that they never go on to experience an episode of mental illness? Medical students, like everybody else who may have depression deserve early, evidenced based treatment delivered in a sensitive, caring and compassionate manner. And despite all the rhetoric, the lip service, the campaigns to educate to ask for help, there still lies an impediment to asking for help.

The very reason for this is the entrenched stigma the medical profession has about seeing mental illness as a weakness or impairment. It is an extreme case of ‘do as I say not as I do’. And medical students are exposed to that from the get-go. As consultants and leaders we may reinforce these ideas. Medical students may believe it to be true in themselves, holding their own stigma. The system is gruelling and unyielding at times, but this could be endured and even enjoyed if those who are struggling receive the help they need, rather than blamed or discouraged from speaking up.

I must be very clear that I am writing about depression, and not other issues such as vicarious traumatisation, compassion fatigue or even post traumatic stress disorder. These serious conditions occur as a result of external factors and should be seen as such. We are all vulnerable to these conditions by the very nature of our work.  Yet even these conditions are stigmatised when we know that they can be treated as well.

The era of mandatory reporting, and variation in states such as New South Wales, have directly damaged doctor’s help seeking behaviour. Regardless of all the talk that doctors and medical students who are actively seeking help and not putting patients at risk do not need to be reported to AHPRA, the message is drowned out by anecdotal evidence and fear mongering. Competition for scarce training places, the introduction of more medical schools purely for money not clinical demand, and the high rates of bullying and harassment well documented in the profession can destroy one’s capacity to be brave enough to speak up.

So, as doctors we know that depression is an illness that is treatable and that early, evidence based interventions lead to recovery. We know that an episode is invariably brought on by a combination of internal (often genetic) vulnerability and external stressors, whether they be in personal or professional life. So is the solution that difficult?

Why don’t we apply a more logical and reasonable approach to this most awful situation? Make it as easy as possible for medical students and doctors to recognise they are experiencing symptoms of depression, and deliver that care just as we would for any of our patients? Eliminate external stressors that we can do something about, by actively campaigning to adopt Western Australia’s stance with regards mandatory reporting, and fight back about building more medical schools.  Check in with our own feelings about stigma, and be honest. Would we regard a colleague as inferior if they were taking antidepressants? Would we feel the same if they took insulin for Type 1 diabetes?

There are many things we can do, and we must if we care about the next generation of doctors, as well as the current ones. And guess what, ad hoc mindfulness training, or throwing an afternoon barefoot bowls session for staff simply doesn’t cut it. Finding caring professionals, believing you are worth receiving help, and getting better is much more enduring and successful, and there are people out there who will do that. All you need to do is ask.

Ten Reasons Why “13 Reasons Why” Is So Wrong

The unseen emotions of her innocence is an acrylic painting, Ink and watercolor on Canvas of a young women crying colors..Sometimes our outward appearances mask what going on inside us. (Courtesy IStock)

 

Warning: This blog post contains references to a series depicting teen suicide and my explanation of why I am very concerned about it. If you read this and find the content distressing, please ask for help. See your GP, call LifeLine if reading in Australia, and don’t suffer alone. There is always hope and help somewhere. 

I have been wanting to write this post for some weeks now, after putting myself through watching the complete series of  “13 Reasons Why” on Netflix®. I put myself through watching the series as I felt it important to understand what my patients were talking about. As a psychiatrist with extensive experience treating adolescents with mental illness, I want to offer advice about how to handle emotions experienced after being exposed to this series. In particular I am deeply concerned about the effects of the final episode. I was horrified at the scene where the main protagonist, Hannah Baker is shown after she completes suicide. I was horrified as a mother and as a psychiatrist. If I was horrified, how would a vulnerable viewer manage?

It has been written by others that the show wastes a valuable opportunity to discuss mental illness and distress. It chooses entertainment and controversy over an opportunity to show the devastating effects of suicide on family and friends left behind, and how so many things can be done before this tragic final outcome. “13 Reasons Why” is dangerous and misleading. The creators have been largely irresponsible for not advising viewers what do do with their distress. They have also failed to depict accurately a person with mental illness and how they would behave.

So, here are my 10 reasons why this series is so wrong:

 

1. Some of my patients are talking about it in their therapy sessions and they are not happy.

Yes, the show has shaken them up, but they are not happy for other reasons. In particular, they feel the series is inaccurate in its portrayal of a person who decides to take their own life. They feel it causes another layer of stigma that people who commit suicide do it for attention or revenge. Patients who have had experiences with losing others to suicide see the depiction as disrespectful towards what is profound suffering and a desperate act at a time of utter helplessness. I fear for patients who are not in therapy and don’t have an opportunity to discuss how this show made them feel.

2. The series plays out like a horror story or murder mystery, when really it is depicting the tragedy of suicide.

By choosing sensationalism and entertainment, keeping viewers engrossed in the series, the creators have misled the audience. Suicide is never sensational or entertaining. It is an awful downward spiral that is often secretive and terrifying. The attempts to understand why someone suicides almost never lead to resolution, even when there is a suicide note. It is generally inexplicable, and certainly can’t be wrapped up in 13 neat episodes.

3. The main protagonist, Hannah Baker, doesn’t have depression

This is the issue I have most concern with. Hannah Baker is most definitely distressed by what has happened to her, and she is sad sometimes. She is also angry, happy, vengeful and totally nasty at other times. She pushes people away when they try to help. She tests out limits of others. She forces people to abandon her, such as Clay, and her school counsellor, to see how they behave. She is manipulative. She has a very poor sense of self. She shows good self care, can enjoy events, and appropriately feel very distressed by others. Yes we talk about how some people can hide their depression, but this is not a case of a person ‘wearing a mask’. She is not depressed. It is unfair to depict this as a case of depression. It is unfair to those who are depressed as they would not relate to her behaviour and demeanor. People with depression would not have the motivation and ability to plan the content for 13 audio tapes, let alone create the content, and scheme about who receives them.

4. Most people who commit suicide after a traumatic event decide to die because of shame, not to seek revenge.

Unfortunately, victims of trauma and bullying can often, inappropriately, blame themselves for somehow having a part in the act inflicted upon them. They can feel immense shame about what has happened to them, and therapy for victims after such an event would focus on this shame. This series depicts that suicide can be used as a way of enacting revenge on perpetrators. Whilst this may be the case in some suicides, most who have suicidal thoughts and ideation also feel very hopeless and have low self worth. They are more likely to inappropriately blame themselves and feel the world is better of without them, than carry out a well planned act to make a perpetrator suffer.

5. In this series, the act of suicide is portrayed as a hateful vengeful act designed to ruin the lives of those that tried to care for Hannah.

I admit I cried when I saw the impact that Hannah’s behaviour had on her friend Clay. His actual terror that he killed her. She actually accused him of such. He was so consumed by guilt that we watch him standing on the edge of a cliff, thankfully not jumping. He genuinely doesn’t understand what he did wrong – because he didn’t do anything wrong. And as he listened to more of the tapes you can see his pain and at times total terror consume him, resulting in outbursts, but unable to talk to anybody. Most people who hear about a friend or loved one, or even an acquaintance who commits suicide feel they could have done more or helped prevent it. To be treated the way Clay was would result in life long agony, and was in some ways worse to watch than Hannah’s struggles. The show plays on the desperate wish of those left behind that they could ‘just have that last conversation then maybe things would have been different’.

6. Too many people kept too many secrets.

This goes against the current campaigns about seeking help if someone is struggling, or if people are concerned about others. After all, the main characters in the series were adolescents or young adults. They were also children to adults, some of whom came across as being available for their children, including Hannah’s. It is interesting that  Hannah’s parents were scripted to be pharmacists, health care professionals that would know something about mental illness. By not disclosing the audio tapes, and believing in the ‘chain mail’ blackmail, further tragedies may have been prevented. Close friends may have avoided hearing the distressing material on the tapes. Respecting the wishes of Hannah for fear of being exposed led to untold distress. The opposite should have occurred. The most distressing character was Tony, who seemed to be gatekeeper of the tapes, and held off from telling Clay that Hannah in fact didn’t hold him accountable (or did she?). This was in the context of the backstory of the well meaning teacher who started a communications channel for students which came across as trite and not respected by the students.

7. The role of the school counsellor.

Mr Porter had one impossible task. He was trying to hold together a bunch of teenagers who knew way too much, didn’t disclose the context of their distress, and seemed to have no supervision or support himself. He tried his best with Hannah, after all, she stormed out of her session with him when he did come across as being available. Blaming him for not caring enough, or choosing to end her life because of this was distressing to watch as a psychiatrist. Health care professionals, as a rule, care, and would react to the news of a patient or student’s suicide with the same feelings of helplessness and doubt as the classmates did. At the time Hannah presented to him, she was behaving in a very erratic and impulsive manner- not in a place to listen or receive help. She believed everybody was against her, and in fact, knowingly or not, manipulated the session with Mr Porter to enact that feeling of abandonment, hence her justification for storming out. Why did she not approach Mr Porter sooner? Mr Porter was unable to perform a risk assessment. His rooms were unprofessional and lacked confidentiality – everybody could see who was talking to the school counsellor. It was unfair to blame him or his behaviours or lack of, as the whole system of care in the school had deficiencies.

8. Nobody had the parent’s feelings in mind.

How troubling to watch Hannah’s parents move through days after their daughter’s suicide, not knowing why. Blaming themselves for not noticing if there were signs. Finding her. Through these days, acquaintances of Hannah knew more about her than they did. Withholding the information from the parents was cruel and selfish.

9. The show sends clear messages that suicide is an option if bullied or treated poorly by peers.

Regardless of the trauma, the event or the situation there is never any justification to choose suicide as an option. The series depicts many well meaning parents and teachers that could have been approached to talk to. The depiction in the series is dangerous given the rise in cyber bullying in society, and feeds into the shame victims may feel after being the victim of an assault – that they don’t deserve to live.

10. The sequel.

I watched the sequel to “13 Reasons Why” that was made after the backlash to the show. I watched the producers, creators, directors and actors reiterate what I have written in this blog.

I can’t ignore the irony – if the show was about why not to choose suicide, why was it a show about the opposite?

“13 Reasons Why” will remain a lost opportunity to guide adolescents and parents about the dangers of having suicidal thoughts. It also failed to demonstrate how to seek the help everybody deserves to move on and lead the lives they should lead, with peace and resolution if also victims of crime and abuse. 

 

Dr Helen Schultz is a consultant psychiatrist and author. She works with adolescents and adults in private practice in Richmond, Victoria, Australia. She believes that suicide is never an option. 

New Doctor’s mental health workshop – tackling crucial conversations

It is fantastic to be running a workshop for RANZCOG addressing doctor’s mental health in one week’s time. I have been advocating in this space since 2003, when armed with the important role of AMA(Vic) President, Doctor-in-Training Subdivision. At the time we were rocked by the news of suicides among our registrar population. In 2003, some of the responses made by consultants included;

Maybe they weren’t cut out for medicine

Maybe they just weren’t ready to face the pressure

Maybe they shouldn’t have sat the exams

Maybe they chose the wrong career

What are the current factors impacting on doctor’s health and wellness?

In 2017, 14 years later, I hear the same thing. I hear that somehow when a tragedy such as suicide occurs, it must be something to do with the doctor’s weakness or vulnerability. Few real conversations have focused on the external factors that push doctors to the edge. Seldom do discussions focus on how doctors reach out for help, are spoken to in the workplace, or suffer when they speak out against intolerable conditions or heartbreaking situations.

Some shifts doctors endure contain enough graphic content that if a movie would attract a R 18+ rating. Doctors are inherently resilient because they turn up again the next day for more. So the conversation we need to have isn’t about resilience or self care. It’s about true advocates standing up for others so we can have safe, compassionate workplaces and rewarding careers.

So, after spending so much time in this space, participating in many committees and panels, speaking at conferences and treating so many doctors and medical students, I am using this opportunity to go straight to the heart of the matter. How to have a crucial conversation. What can happen when conversations go well and what can happen when they don’t. How breaking bad news can lead to suicide or a positive outcome. How third party regulators such as AHPRA and our colleges have conversations with us, whether we are prepared to hear them or not. Knowing when to put our hands up and ask for help and when to keep our opinions to ourselves and go elsewhere for what we need.

Communication is the key.

So, most  of the agenda for the RANZCOG doctor’s health workshop will play out via role plays using the brilliant acting skills of Mr Glen Hancox, professional actor and director of ACTReal. Glen has worked with me for 7 years, and together we have run through hundreds of scenarios to display rather than preach valuable learning. We have coached and trained many doctors in key specialty areas, worked in the corporate world and now developing conversations around doctor’s mental health.

So what sort of conversations will we be examining in depth?

The clinical scenarios I have written to be included in the workshop are based on conversations and interactions I have either witnessed or have been involved with. They will encapsulate the following;

  • doctor’s help seeking behaviour
  • the need for every doctor to have their own GP
  • managing performance rather than being labelled a bully 
  • how to relate to junior colleagues to be the mentor you truly want to be.

 

All are raw and controversial, designed to be so that we can have real conversations to evoke change. They are also completely fictional (including names).

Keen to read more? Here are the teasers:

  1. That corridor conversation. After a multidisciplinary team meeting,  Dr Anne Salter, a psychiatry registrar working in consultation-liaison psychiatry (wanting to be a perinatal psychiatrist) is approached by Dr Alex Scott, an O&G registrar. Alex is being paged but wants to have a ‘few minutes’ with Anne to ask her opinion about something….
  2. Doctors treating doctors. Dr Alex Scott consults with Dr Simone Davige, a GP in a busy family medical centre. Alex is nervous but after talking to his wife, and trusting in Anne, he decides to open up and be honest about how he is struggling…..
  3. The supervisor asking “So,  how’s it going?”. Dr Ian Anderson is a senior consultant in the gynaecology department. He is well meaning, but quite detached from the issues facing junior doctors. His idea of mentoring a junior doctor is to share his own experiences that he thinks are valuable to hear about rather than listening….
  4. The consultant delivering negative feedback. Dr Peter Richard is a consultant and supervisor. He has had feedback from the college and other peers that his registrar Dr Sophie Donald is ‘not up to scratch’ He hates conflict but knows he has to tell her some hard truths….

By working through these scenarios, and with the guided expertise of Dr Mukesh Haikerwal, and Ms Mayada Dib, we hope to uncover what is at the heart of the matter for doctors who have mental ill-health and need our help. They are, after all, valuable, meaningful people who have devoted their lives to helping others. We owe it to work out how to help them, or not put them in a situation where they are distressed.

And all kudos to RANZCOG who are holding their regional scientific meeting in Albury NSW after they lost a fellow to suicide in Albury in 2016. They have opened the event up to all health professionals regardless of specialty.

If you would like to contribute to the discussion to help our colleagues please register here

See you in Albury,

Best wishes,

Helen

 

Christmas – #itsjustanotherday so make it the day you want it to be

Full Length Photo Of Santa Claus Lying On Psychiatrist's Couch, Wallpaper in background.There is a photo of swinging pocket watch on the wall.The image was shot with Hasselblad H4D

As Christmas approaches, and after 7 years in private practice it’s time to get real. I am not trying to be a Grinch but in fact write this piece as a way of empowering many of us to say no to a lot of the drama that happens at this time of year. Yes Christmas is a magical time, especially for children, but only if we allow ourselves to make the day and the season to be what we want it to be, rather than feel obligated or guilty about doing otherwise.

I can only recall a few patients over the past 7 years that have been excited about the prospect of seeing some of their family members over Christmas. Or even having a strategy to handle the practicalities of leading up to the festive season and providing a perfect Christmas day celebration with excitement. It is more common that as soon as the carols begin to play in the department stores many begin to feel an unease or in some occasions notice their mood plummet.

I once spoke to a psychiatry colleague about this phenomena, which many health professionals working in the mental health space would be familiar with. The sadness, the loneliness, the repetition of trauma and flashbacks in some patients was too significant to overlook.

He tried to answer my query with humour:

“Have you heard the story about a bunch of psychiatrists sitting around in the dead of a European winter, sometime in January, lamenting that there was no work to do. Nobody was venturing out into the cold to see them. So they came up with the notion of Christmas as a way of bringing families together and business boomed forever”. 

It would be funny if it weren’t so true.

Most of my clinical work around this time is helping those who have been products of dysfunctional families, and sometimes even victims of abuse. The saddest cases are those who have been abused as children but are obligated to see the perpetrators at this time while the family keeps secrets and pretends nothing happened. In not so sad but still stressful occasions, relatives who are largely avoided for most of the year come together, with awkward small talk until somebody finally loses it. Family rifts, financial pressures and sibling rivalry add fuel to the fire for those who are tired, stressed and would rather be anywhere else that day.

Why do families do this? Why do we have to believe that it is OK to acknowledge, accept and avoid certain behaviours for every other day of the year, only to tolerate them on 25th December?

Why do we feel we have to be inclusive because we are related to people?

Excusing bad behaviour

Some of the reasons why bad behaviour should be tolerated and excused include the following. On any other day they would not apply.

  • Let’s do it for the children. We’ll be happy for them (whilst the grown ups fight in the corner and believe children are ignorant).
  • We really have to invite uncle so and so. Yes we don’t like him and he upset us last year, but if we don’t he’ll be alone on Christmas day (isn’t that uncle so and so’s problem?).
  • Let’s do it for Mum/Dad/Great uncle/Grandmother etc. They’re getting older and we don’t know how long they’ll be around (news flash – nobody knows how long anybody will be around regardless of age).
  • Yes cousin so and so drinks too much but if we get the food out early she’ll be manageable (whilst everybody pretends not to notice her demise).
  • Yes aunt A and uncle B don’t contribute or host Christmas but we can’t leave them out – They’re FAMILY!  (well actually you could call them on it and arm them with a task, no matter how menial. Shopping for Bon Bons is a good one).
  • I am happy to do all the cooking for everybody, and offers to contribute will be politely declined so I can have that melt down I needed to have all year. After all I’m the superhuman sibling – IT’ S WHAT I DO (everybody has the right to say no).
  • Yes grandfather did horrible things to mum when she was a child but he’s old now and we need to move on. (Move on? When most of the year the victim has been working in therapy to heal?)
Practical tips that may help minimise or avoid problems on Christmas Day

If you know it’s going to be tough, tackle it head on. Nothing is worse than walking on eggshells waiting for the explosion. Any strategies to make the day as happy for children should be attempted. My patients often recall horror stories of Christmas’s past, many that could have been avoided if the adults remained as adults. Don’t fight around children. Ever. The old adage “If you can’t say something nice, say  nothing at all” applies here.

  1. If there are tensions or rifts, plan to have balanced discussions about them as a way of mending what can be repaired prior to the masses arriving on the doorstep. Acknowledge disagreements and try and find mutual understanding about what topics will be left to talk about another day.
  2. People choose their own behaviour. If a family member continues to disrupt celebrations, consider leaving them out. It may even be helpful to explain this to them and they may actually learn something from it. They may even have the capacity to reflect and change.
  3. Share the load. It’s 2016 and very few people can do everything. Consider a roster or task list (preparing the vegetables, doing the dishes, setting the table). In most cases people feel less awkward if they have something to do. For financial reasons, ask family members to contribute to the lunch. Very few families can afford to provide the lunch depicted on the supermarket ads, regardless of special deals, and neither should they. Or try a more low key affair, such as a barbecue, donating the savings to a charity the family agree upon. For those relatives who ‘expect a traditional lunch’ let them know they are more than welcome to provide their own.
  4. Call out bad behaviour before it happens. If somebody is prone to overindulging in alcohol, set some house rules. Offer plenty of alternatives. Or switch lunch to brunch. Remember the children are watching.
  5. Pro-actively manage your time, down to the hour if it helps. Start the day with a walk to be mindful of the things you are grateful for. Drop in to see relatives rather than accept invitations to stay for lunch or dinner if only doing it out of obligation. Take the children to the park to play with their new toys rather than stay in the house. Think about how you want the day to be before it happens. Control what you can and don’t own the rest.
  6. If you decide to stay away from your family because of past trauma or intolerant behavior, do so with pride. Do something really special just for you to mark the occasion. Honestly, you are not the only one alone on Christmas day. And it is, really, just one day.

Hopefully you are reading this and it feels very unfamiliar. Hopefully you belong to a family who can behave and genuinely enjoy celebrating time together. But this piece is written for those who don’t, or find it hard to say no to guilt and obligation. Out of respect for those who truly find the day very distressing and feel at odds with the world as if there is something wrong with them, I write this piece. And for the brave and tenacious patients who work so hard all year in therapy, keep your boundaries and be confident. If it’s tough, we can always reflect again in the new year.

Share your ideas on Twitter for an authentic Christmas day that avoids conflict, using the hashtag #itsonlyoneday. Post photos of what you are up to. You’ll be supporting others as brave as you.

Merry Christmas,

Helen x

 

A new way of thinking about Psychiatry. Moving from tertiary to primary models of care within Primary Health Networks (PHN’s).

It’s been a long time between blog posts and upon reflection, I feel it has come about as I have wavered about a sense of direction. Working as a psychiatrist in clinical practice is extremely rewarding, but I find that I need time away from the intensity of the work in order to write.

The last 6 months have been filled with some tremendous opportunities. Opportunities that I could never have imagined, but in some way have been working hard towards, and have come about from one single tweet.

The tweet was on the back of a blog I wrote about regarding the establishment and funding of Primary Health Networks (PHN’s) by the Australian Federal Government. When I heard about the development of a new layer of ‘care’, ‘service delivery’, ‘approach’ or ‘solution to the mental health crisis’ I was angered. Upon reflection, the anger stemmed from this deeply held belief of mine that as psychiatrists we were being overlooked and undervalued for what we did. That if only a new layer of bureaucracy was introduced the ‘mental health crisis’ would go away.

That federal politicians knew more about caring for patients with mental illness than I did.

So I decided to take this one to Twitter and made a request of the Hon Minister for Health, Ms Sussan Ley.  I invited her to come to my private practice in Melbourne and see what psychiatrists do. I wanted her to understand that myself and my colleagues probably weren’t that excited about precious dollars going to a new service model. We wanted funding to do more of what we did well.

She said yes.

After our meeting in January 2016, as promised, Ms Sussan Ley introduced me to the Executive Director of the North Western Melbourne Primary Health Network. My ‘PHN’. So, rather than continue to criticise, I was able to learn more about what this PHN in particular wanted to achieve.

All of this has been quite revealing to me, because it is a really powerful example of what happens when you presume others know what you do, or what you can offer. When you presume you command a certain level of respect and you find out, you don’t. See, in my world that is private practice, the best I can hope to achieve is to make a difference on an individual level. I become consumed with the needs of the patient, and become blinkered to what else is happening around me in the mental health arena. I lose sight of the fact that I cannot presume to have a role in the delivery of services to those with a mental illness at a systemic level purely because I am a psychiatrist.

Because, as I have found out over the past few months, most people within and without the mental health space see psychiatrists as largely irrelevant.

Very few psychiatrists have been consulted about what they feel patients with mental illness need since the era of de-institutionalisation. Some revolutionary ones have set up services they believe in and are proud of. Most psychiatrists I know feel completely defeated by the amount of work and the lack of funding that defines mental health care in Australia.

And the lack of funding and sheer amount of work that psychiatrists must encounter has led to a very dangerous mis-perception in society. That mental health services can function without our input.

We are described as inaccessible, scarce, and unavailable to meet the needs of many Australians with mental illness. We are seen as a ‘last resort’.

Hence, why I believe most of the mental health reform that has occurred within Australia has involved all the other mental health professionals out there. And yes, we desperately need multidisciplinary approaches to patient care, but there is a level of ignorance that during this time we have maintained our relevance and authority.

We are in fear of losing our most highly valuable place within the psychiatric multidisciplinary team.

And the proof is there. In the PHN that I work within, the population groups are as diverse as the field of medicine. There are areas of some affluence, but also marked poverty. The network covers five correctional centres, accommodation for refugees, homeless people, significant amounts of Aboriginal and Torres Strait Islander people, as well as people with gender and identity issues. Substance use disorders are prevalent across all of these groups. There are layers and layers of trauma. There are also plenty of skilled clinicians working as best as they can for these very diverse and vulnerable patient groups.

Very few services, away from major metropolitan hospitals, would have any access to a psychiatrist.

So, I now have this opportunity to take an in depth look at the services within my network and evaluate to role and value that psychiatrists bring to it. I want to think about caring for patients in a different way to the tertiary care model. I want to know what services and their patients think about us. I want to know if psychiatry trainees feel they can manage these complex areas of mental health care, or if they feel their training and exposure to such areas is missing or substandard. I am excited by the challenge and have embraced a new way of thinking, that is, bringing services and care to the patients, rather than the other way around. I could continue to resist, but at the end of the day I don’t see that the way we are currently meeting the needs of those with mental illness is working anyway.

Dr Helen Schultz is a consultant psychiatrist and author of “How Shrinks Think”. She begins her new role as Independent Expert Advisor, Mental Health, NWMPHN this month.