The power of story in psychiatry

Book concept Landscape young boys walking through crop field at sunset
Book concept Landscape young boys walking through crop field at sunset

As a psychiatrist I have the privilege of hearing many stories, those of my patients and also the stories they tell me about their loved ones. The narrative they use often tells the story ‘between the lines’ and these subtle clues make the structure that forms the basis for psychotherapy.

For some patients, the only place their story is heard is within the walls of the therapy room. In this place of impartiality and non-judgement, they can lay out the impact of their journey, and examine the magnitude of events that have occurred within their lives. Often they are moved by the story themselves, once they express it openly thus unlocking many years of thoughts and images and seeing them for what they really are. Often the unveiling of the story is way too confronting and they run from the therapy space, only returning when they have fostered more resilience.

So, yes, one of the most rewarding and powerful aspects of my work is listening to stories. I hold them confidentially, they can play on my mind, but hopefully they are always treated with respect. If I have to relay aspects of the story in referral letters back to their GPs I hope I reframe what I have heard as carefully and accurately as possible. Sometimes when I hear a story that is filled with injustice or total praise I want to tell that story to others so I can advocate for the patient and the system. Sometimes I can do this in a de-identified way, but I write with trepidation, as I would never want a patient to recognise their story in another medium.

As a psychiatrist I often hear the remark “ I bet you could tell a few stories”

The voyeur in all of us would like to know other’s secrets and inner pain. Sometimes people open up to me and reveal their story because they know I am a psychiatrist, others more wary, but I hear stories wherever I go.

So, as a passionate writer I did in fact publish a story. My story of my journey through psychiatry training, what I do all day and what I think about my profession. It was arduous, confronting and difficult at times, but it is one of the things I am most proud of. People bought copies and told me what they thought. And on quite a few occasions I have been told my story resonates with theirs. The most humbling and rewarding comment I could receive; that when my story fell out onto paper it had true meaning to somebody else.

Nowadays I take any opportunity I can to blog and continue to tell stories. And the more I write, the braver I get. Because there is so much to say in psychiatry, and certainly so much to do in advocacy, especially for those that don’t get to tell their story.

Dr Helen Schultz is a psychiatrist and author of How Shrinks Think, her story of her journey through psychiatry training, and life beyond. She is appearing at “The Power of Story” on Friday 4th September 2015 in Melbourne, alongside other health care radicals who are passionate about storytelling in health.

The delicate balance between quantity and quality – my view on the increase in prevalence of mental illness in children and adolescents

iStock_000014067068SmallGreetings all,

It’s official. What we at the coal face see has been confirmed by a recent study, “Young Minds Matter” that concludes thousands of children and teenagers suffer from mental illness. And, as we know at the coal face, they largely suffer in silence.

What a sad state of affairs in a time when we know so much more about prevention and mental illness, what a tragedy for the next generation, what a social disaster. Continual erosion to the basics must play a part. Financial distress, the epidemic of drug and alcohol misuse, and the loss of the family structure due to poverty and violence. Incalculable factors, specific to some families but generalised as a whole. In essence, we have lost our way when it comes to remembering that in fact the family is an integral protective structure for children’s mental health and resilience, and attempts to threaten this will inevitably be felt by the next generation.

As a psychiatrist, I have seen a large number of adolescents over the years, and I know in many cases the problems expressed within the child generate from their environment. When that environment consists of those whom the children fear they will suffer in silence rather than speak up. Children learn from a young age whether or not their parents or other adults can cope with their ‘stuff’. In many cases children become parentified and learn to conceal their angst and be available for adult’s problems. They present later in life struggling to understand how to relate to others, unable to show kindness to themselves, or identify their purpose in life. And so the cycle continues.

This new study reports that 7% of Australia’s children and adolescents have anxiety to the point where it is a recognisable mental illness. One in 20 children have chosen a place to commit suicide. I am sure the rates are higher and there would be large spikes in incidence in sectors of society. I can’t imagine how prevalent anxiety disorders are for those children held in immigration detention centres. Or children with marked social disadvantage.  Of course they don’t tell parents. Their parents are often emotionally and physically unavailable.

When I underwent child psychiatry training I learnt all about the child within a system. I still operate within this approach when I see my patients; that is to recognise the ‘big picture’ and try and provide interventions that address these other crucial factors, such as parental conflict or school place bullying. I learnt that this work takes time and takes a team. Often the child that presents is not the patient. They can be the harbinger for a family in crisis.

So why then the gross dismantling of multidisciplinary services? Why at a time when family structure is crumbling under the weight of societal forces are we allowing mental health services to crumble too? The federal health minister, Ms Sussan Ley stated that she sees the results from this recent study as positive in that children are coming forward to ask for help. Her press release stated

“It’s also a credit to young Australians, and society as a whole, that so many are not only bravely opening up about their emotions and behaviours, they’re actively seeking out help and taking positive actions to manage them”

A credit? A tragedy that they have to ask at all. And more importantly, who are they telling and what happens when they do so?

At the same time as this news is breaking, so are the warnings about an alarming rise in the use of antipsychotic and antidepressant medications in this same age group. In particular is the distressing trend for young adolescents and children to be commenced on major antipsychotic medications such as quetiapine for off-label indications such as insomnia. Doctors are exposing children and adolescents to the harmful short and long term effects of antipsychotic medications, including weight gain, diabetes and potential cardiovascular disease without any evidence. Numerous reports identify this rise in prescribing of these agents has nothing to do with a rise in psychosis, but simply that such medications are seen as a benign broad brush stoke approach to any emotional distress and child could present with. It is not just happening in psychiatry but in primary care. We will regret exposing our children and adolescents to these medications in the future, I am sure, but right now, it seems to be the only approach to mental illness and emotional distress in a society where most psychosocial services are no longer funded or regarded as valuable.

So yes, the quantity is there – we do need to remember that our children and adolescents are vulnerable and experience distress borne from a modern society and new stresses and strains – but we fall short from providing quality care. And I am sure we will reflect on this time as a failed opportunity to use our knowledge and wisdom, advocate for a better mental health system based on evidence, where children and adolescents can feel safe, and go on to lead the lives they deserve.