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.


If you take ice, avoid our emergency departments

Greetings all,

I write today about a topic I have become familiar with, after working as a locum psychiatrist in Far North Queensland. In no way do I think FNQ has problems that aren’t seen elsewhere, far from it, but it was my chance to see first hand what the drug ‘ice’ was doing to our society.

I work as a psychiatrist and hence within the public mental health system which to say is under resourced is old news. We are way past under resourced now and as clinicians move from crisis to crisis providing band aid solutions to complex psychiatric solutions all the time. I accept that fact and like many of us, aim to do my best with what I have. But I will not abide by the recent influx of demand that has occurred as a result of the increasing use of ice. I do this to support my colleagues as as well as patients being cared for in the mental health system.

Ice is one of the most powerful, addictive and dangerous substances that our society has known. A ‘bad trip’ on ice is not the same as an experience with heroin or other psychostimulants. Because methamphetamines, including ice, affect levels of dopamine in the brain, they will cause patients to become psychotic merely because of their ingestion. In other words, if you take ice, you have a very high chance of becoming paranoid, misinterpreting things around you, including within your own body (commonly feeling there are objects or insects under your skin) and you may very likely become more violent than ever imagined as a result.

Someone who is acutely intoxicated because they have used ice is not the same as somebody who is experiencing symptoms of severe mental illness that requires immediate treatment in an authorised mental health service. Patients who are intoxicated on ice will often be fine once the substance leaves their system. They don’t need to be labelled with a diagnosis of a severe mental illness, and as such take up hospital beds and terrify other patients who are in the wards for other reasons.

Yes, we do know that there is an overlap between the use of illicit drugs and psychosis with the use of drugs precipitating a psychotic episode in a person who is genetically vulnerable. But what we are seeing in many cases is acute intoxication of a substance that we know causes psychosis and these patients are being labelled as having a severe mental illness simply because we need them out of our emergency departments due to bed targets within a period of time. In a system where medical and nursing teams are expected to triage, assess and admit every patient in an emergency department within a designated time period, we have lost the ability to use time as a healer.

When I was a psychiatry registrar I was routinely asked to assess patients who were intoxicated with alcohol and expressing thoughts of suicide. I knew that for clinical, ethical and medico legal reasons, I could not assess the patient until they were sober. In the cold light of day, and once alcohol is excreted from the system, a patient may no longer pose the same level of risk. It is the same for ice. During my recent locum post I was disappointed and shocked to hear that psychiatry registrars were routinely called to the emergency departments to see patients who were ice users, intoxicated and violent as a result. When ice dried up in town, the request was to see people who had obtained the medication ‘Ritalin’, crushed up the tablets and injected that instead. When ice dried up, users would collect at the community clinics threatening staff and demanding prescriptions for Ritalin.

I know that some ice users do have an underlying psychosis and as such deserve a different model of care. It is a tragedy that patients with severe mental illness now have access to ice with disastrous consequences on the prognosis and course of their illness. But I don’t feel we should assess which camp the person belongs in before they ‘come down’, and we shouldn’t sedate them with heavy doses of antipsychotic medication which may cause breathing difficulties and lengthen the time in hospital.

I don’t feel we should admit ice users to a psychiatric ward, with other vulnerable patients and staff, without a very valid reason. Because I know that if given time to come down, many would not require any treatment at all.

In FNQ there exists diversionary centres, created as an alternative place for those intoxicated with alcohol that is not part of the forensic or medical system. Diversionary centres are seen as safe places to withdraw from alcohol, avoiding custody. Now that we are at crisis levels with the numbers of ice users increasing beyond our level of understanding or capacity to respond, a similar model could be employed. Such a model would provide a safe place for users to withdraw, away from clinical staff and other patients, and then a comprehensive mental health assessment could occur when the risk of violence had dissipated. We need to curb the tidal wave of admissions to psychiatric units by ice users, for the sake of our profession, our patients and our colleagues.

Coaching and training in preparation for the RANZCP M-OCIs

It has been a busy time helping IMG candidates with their exam preparation ahead of the next 2 weeks! As their current training pathway comes to an end (October 2015) I know many are keen to do everything they can to prepare for the long case exams.

As a trainer, I often see the same thing happening with candidates, and as such I thought I would jot down some key points as well as provide you with some written material about how best to approach the exam. I am available for individualised coaching, and booking up ahead of the July and October 2015 RANZCP clinical examinations.

  • Being ‘nice’ rather than asking direct questions or drilling down into the information you need. I see this time and time again. Being nice does not equate to missing out on key information, that if known would help the patient in the end. If a patient appears guarded and defensive it is probably a useful clinical sign to notice, rather than taking it personally.
  • Focusing on the formulation and running out of time to prepare an action plan. The action plan is marked in a separate domain, formulation isn’t, and many candidates fail as their plan is not well considered or specific as they have left it to the last few minutes to prepare. Remember to weave the demographic details into the action plan to make it specific.
  • Pay attention to cues, and ask patients to tell their story so you can observe their narrative and non verbal communication that goes with it. By doing this we are truly dong what good psychiatrists do, synthesising all the information available to us, and allowing the patient to be truly heard.

Here are some other tips, please share!

Announcing our next Present2Pass full Mock OSCE/M-OSCE

Greetings all,

Our next full 3 hour mock OSCE/M-OSCE will be held well in time for the next round of the RANZCP exams.

This will be the third time we run a full 3 hours exam, with examiners and professional actors, simulating the real thing. Our exams are very popular as it is a genuine opportunity to run through a full exam, with original stations (no past papers) incorporating ‘hot topics’ that may appear on the day. In addition our dedicated team of examiners and actors will provide you with personalized feedback about your performance.

Unlike other exam workshops, ours remain popular because we offer small group format, individualised attention and an opportunity to desensitize yourself to the real thing.  You achieve exam success because you get to perform a full ‘run through’ rather than listen to lectures about how to manage the OSCE/M-OSCE’s.

Places strictly limited.

We have 4 places for candidates, as well as 4 for observer spots. 4 candidates will run through a full 3 hour examination. 4 observers have the opportunity to ‘shadow’ and observe the exam as it moves through the stations.

After the morning exam is over, we will debrief over lunch and move into a 3 hour workshop designed to offer more tips and tricks for success in the OSCE’s!



Saturday, 22nd August 2015


  •  OSCE/M-OSCE 10am to 1pm (arrive by 9.30am for briefing)
  • Afternoon OSCE/M-OSCE fundamentals and debrief 1.30pm to 4.30pm


CPD Formulations Pty Ltd, 394 Church St Richmond 3121

To Book, click here

Early bird offer!

For those who book by July 1, 2015, you will receive one of our full Mock OSCE/M-OSCE archive stations every 2 weeks until the real thing! These archives contain all you need to run through stations in your study group, including instructions to candidates, actors, examiners and marking sheet. 



Would you like some medical education with that?

Greetings all,

Well Linkedin told us it was our birthday! CPD Formulations Pty Ltd is now 8 years old.

This is no mean feat given that CPD Formulations Pty Ltd was born from a shelf company, into a niche area, with constant changes to income, and maintaining a very flat organisational structure (well most of the time it is a very small team and myself).

Nevertheless, I wanted to mark the occasion, reflect on how far I have come, and  thank those who posted comments or have been there for the journey.

By way of background, I began working in medical education while undergoing my psychiatry training. I worked as a medical writer then director for a couple of organisations, and then branched out alone. I have always believed that doctors are keen for unbiased, quality evidence based education not linked to direct pharma marketing and not just because we have to satisfy requirements for college accreditation.

Over the years, I have created and rolled out a number of niche medical education programs in the area of sleep, HIV, neuropsychiatry and more recently the use of social media in medicine. My most favourite courses have been under the umbrella Present2Pass, a name and logo I trademarked over 7 years ago. I have coached and trained over 250 psychiatry registrars and IMGs since this time, and helped them via small group learning and one-on-one coaching, in order to help with the ‘non-clinical’ skills required to pass the RANZCP examinations.

Over the years I have moved with the times and traversed the area of medical education which has had a very shifting landscape. When I started out, it was prior to the global financial crisis. In addition, it was prior to Medicines Australia’s changes to legislation about marketing to doctors, including the provision of medical education. In 2008 and 2009, I worked closely with pharma to deliver medical education programs funded by unrestricted education grants. Pharma could not control content but were crucial in providing funding for what were very successful education programs, such as SleepSchool, HIVMatters and Shifting Clocks.  Our most successful program was SleepSchool, delivered in most capital cities across Australia ,and with the help of CSL Biotherapies educated many psychiatrists about the link between sleep and mental illness.

As pharma sponsorship became more and more difficult to achieve despite some very successful campaigns, I had to continue to move with the times and deliver programs that were cost effective yet maintained good value. In a landscape where it is still very difficult to charge registration fees, CPD Formulations has had to ‘shelve’ some very successful programs. We have DVD archives of some of our most popular keynote speakers, and will continue to develop on line education, maintaining our commitment to quality unbiased medical education in niche areas of medicine.

Our most recent workshop, Medicine Social trended exceptionally well on the day, with  #MedicineSocial the top trending hashtag in Australia for 4 hours straight. We had 20 million impressions world wide, and this is evidence that medical education is moving to the social media space. We are ready to embrace this change.

Hence the new website, which has much more capability than offered by the current one. We will continue to upload content to our YouTube channel, and CPD Formulations Facebook page, as well as produce a highlights DVD for MedicineSocial, held on 16th May 2015.

We will be asking our loyal followers to move across with us, to utilise our platforms and remain up to date with our latest programs and workshops. And at this time of the year, as for the past 7 years, I am focusing on training and coaching registrars with the upcoming RANZCP examinations not that far away. In addition, we will be announcing the next mock-OSCE well in time for October 2015.



How to spot a bully in medicine and what to do about it

Greetings all,

Over the past weeks it has been reassuring to see so much lively debate about the concept of bullying in medicine. Despite the sensationalism, there has been a groundswell of those within and without medicine who simply cannot understand why professions such as medicine can’t adopt the attitudes of most child care centres and kindergartens. The way we encourage 3 year old children to name the behaviour, hold up their hand and say:

‘ Stop it, I don’t like it’.

After completing this first step, 3 year old children are really good at performing the next task. That is,

tell a grown up.

The grown up responds at the time, not days later, sits both down and helps them find a resolution. If discipline is needed that is explained too. Everybody learns and keeps going. Children feel heard, children learn what is unacceptable, and also that grown ups are around when they feel out of  their depth, often for a cuddle and reassurance they are OK.

This consistent measured response that infants can understand and take on as they grow up is crucial as a preventative measure for bullying behaviour. Simplistic, kind, immediate actions that leads to long term resilience.

The behavior we see in our profession is the antithesis of this.

So what happens somewhere between leaving the sand pit and entering the operating room? (I say operating room as apparently that’s where the media feel real doctors hang out so it’s always the background scene)

What happens is complex, multi factorial and beyond exposure in a 1 hour documentary. In this blog I am going to explore a bit more about how bullies get to be where they are, the absolute devastation they can cause at the expense of keeping their ivory tower polished and pristine, and why I can’t think of a single organisation that can be the ‘grown up’ in this issue.

Often the ‘grown up’ is the bully.

My definition of bullying is a culmination of my clinical knowledge, my own lived experiences, and where I see the state of play in medicine. It is written entirely as a mark of respect for those of my colleagues and peers who may not have believed they could get through bullying experiences and chose to die instead. Just as in the world of cyber-bullying, suicide is a tragic and common outcome. I am a victim of bullying, and I have had times where I found myself believing their criticism of me, their comments that I should ‘shut up’ and not answer questions for fear of making others look stupid rather than embrace and foster that I was keen and willing to learn.

For no other reason, bullying is dangerous because it takes our minds off our patients, derails us from contributing to medicine and causes us no end of distress and hardship.

A bully is anybody who does something either verbally, physically, or emotionally, with no other reason but to make themselves feel awesome and you to feel dreadful.

I am going to use this blog to profile one of the biggest bullies I had the displeasure to meet through my medical training and beyond. This person still works as a doctor and holds a number of high profile office bearer positions. I am doing this to showcase what is bullying behaviour, how it takes years to develop and to question why it simply continues when everybody knows. Those relevant to my profession will know who I am writing about. Everything I write can be substantiated by others. If I don’t lead by example, I see myself as someone who is colluding with bullying behaviour, allowing the next generation to experience what we did. Those people just like me that couldn’t find a grown up, or instead of getting that reassurance, were treated with disdain, told to shut up and cop it just like everybody else. After all, we are told

being a victim to a bully makes us stronger.

In my scenario, the perpetrator is a male. I preface by stating this is not a gender specific issue, and I have met women who were quite good at bullying as well.

Let’s paint the scene,

A bunch of keen medical students sitting in a large tutorial room of a major teaching hospital waiting for the “Prof”. Waiting as we did at the same time every week for a spray and perhaps a glimpse of something worthwhile learning.

Prof enters the room when he feels like it. He is after all, extremely busy, and often began tutorials by naming which prestigious media person he had just been speaking to on the phone.

We sit in silence. After all, he is the Prof, and we have all heard really scary things about him….

Prof begins the session by reaching into his wallet and pulling out a fistful of business cards, which he then proceeds to flick across the table like some random card game at a casino.

His first question for the audience;

Do you know who I am?

Well, yes, we do, but nobody has the guts to say. Then the following answer to his own question;

I am everything my business card says I am. I am the recipient of all these awards and merits. When I get on the phone to the media, my call goes straight through. I am one of the most influential people in my field.

This was the beginning, middle and end of the tutorial. We all left with a business card after watching a DVD made by a pharmaceutical company, featuring the Prof who had left the room by now.

Now, hopefully, most of the audience saw this  ‘tosser’ behaviour for what it was. But maybe some didn’t. Maybe some really started to believe from that moment on, this person was the one to impress if you wanted to get anywhere. Sadly, this was the case. You did have to be a golden child of the Prof to enter his kingdom.

Also, crucially, Prof was being very strategic and targeted with his ‘tom cat’ marking of his territory. He was making very sure that he was and would always be the smartest person in the room. Intolerant of criticism, and insightless to his behavior, not least of which was discouraging some fine future doctors from his area of specialty, the Prof legend continued to grow and the power imbalance became greater.

In later years, if you did decide to chose to enter the Prof’s turf, that is, choose the same specialty as him, and then become his registrar, you would be subjected to public humiliation on a weekly basis. The weekly ward round was your chance to present a case, in front of the patient you were speaking about, as well as the rest of the multidisciplinary team. All would watch in horror as the Prof took you down, bit by bit, in order to once again demonstrate he was still the most important and intelligent person in the room, and that humiliation was the best way to get you to think on your feet faster and suffer the rigors of being a real doctor.

This public humiliation went on for years, consistently, and without any attempts at intervention.

The complexity continues, as the needs of the Prof grow to maintain relevance over the years, to be seen to be furthering his career at every opportunity, getting onto boards, into professional organisations, marking his territory, and ensuring he remains


So faced with this, what do we do? How can we simply say with any hat that we have a zero tolerance to bullying, as if that will solve the problems without understanding where it all began? Shouldn’t we instead say to our peers, do not be defined by the criticism of bullies, but by those you trust and respect as they are everywhere too. Above all else, be defined by your own self worth which should be more than obtaining a fellowship to a college.

I don’t believe any organisation has the capability of removing bullies from medicine. The Australian Medical Association is a membership organisation that takes subs from bullies and victims. It also has a role in defending members who are wrongly accused of bullying. Colleges also cannot rid their hierarchy of bullies, and because of this, cannot offer assistance to members who receive threats from bullies.

In this whole argument, nobody is declaring they have a clear conflict of interest in dealing with bullies

As a doctor, a mother of a son who has been told how to manage bullies in the playground, and as a psychiatrist who sees patients that are suicidal as a result of bullying, I say the best way to manage this is;

1. Keep safe, get help and remember, you are so much more than what your supervisors write on your assessments. Bullies do in fact have much more to lose than you.

2. When you are ready, and if you so choose, name your bully’s behavior to protect others. If you can’t find a grown up to tell, be that grown up yourself and name it to your peers.

3. Take up the charge to rid bullies from the profession we are passionate about, understanding how much they will hang on, and appreciate how entrenched they are within the organisations that state they are trying to ‘out’ their bullies.

I have ‘named’ a bully. Now it’s your turn.

Sleep and psychiatry – time for a tweet chat!

Greetings all,

I have been involved in the area of sleep psychiatry and have been running medical education workshops, known as SleepSchool since 2008.

I have been running these in conjunction with Dr David Cunnington, director at Melbourne Sleep Disorders Centre, and creator of Sleep Hub.

We have run quite a number of workshops around Australia since 2008, but haven’t done so for a while. We used to have great support from pharma but for many reasons this is no longer the future of medical education.

Anyway, not to worry, as now that both David and myself are actively engaged on social media, and I am guesting at @WePublicHealth this week, we have decided to trial a tweet chat that highlights the intricate relationship between sleep and mental illness. This will occur on Friday 22nd May 2015 at 1430 AEST.

We will be using the hashtag #sleepschool although popular around mums and babes with sleep issues, it carries on our workshop name as it moves into the Twittersphere!

Find out more about #SleepSchool here



Uncharted territory – cyberstalking in the new age

Greetings all,

I spoke to the topic of trolling and cyber stalking at @MedicineSocial on Saturday. I chose the topic as I wanted to explore whether this was a new phenomena, or simply, what we know about stalking behaviour in general, but on a different playing field. I also wanted to relay the message that on or offline stalking is a crime, victims are protected by the law, and that they are often very distressed by the behaviour.

I also wanted to provide a profile of the different types of stalking behaviors well known to those working in forensic psychiatry and the judicial system.

What I found when I researched this area, was that other terms and behaviours such as trolling were less well defined, and often confused with stalking. It speaks to the heart of the matter that most of the information I could find about internet trolling  was derived from Wikipedia and Google. Hence I believe we are walking into uncharted territory when it comes to these understanding these behaviours.

When it comes to trolling, it is very hard to recognise or manage the behaviour when we are still unsure about how to define the behaviour.


At @MedicineSocial, I made the point that I do believe trolls differ from stalkers. Notwithstanding this, the behavior of trolls causes all sorts of distress and can lead to catastrophic outcomes for the victim. The victim is often shocked and thrown off-topic from the feed the are contributing to. The troll’s motivation seems to be to cause intense emotions in somebody they have often not even met. I have noticed trolls pop up and go away and don’t seem to have a consistent pattern to their behaviour, except to throw everybody off the topic and cause anguish. I mentioned that it seems consistent that the best way to deal with trolls is to block them and most importantly not to engage with them.

I also made the point that trolling is not the same as somebody having a different view to you and expressing it in a way that upsets you. That’s the world of social media. Post something, and you may very well upset others by your comments or beliefs. It’s the way that trolls go about their business that seems different to me, that is, they tend to show discord on the internet by;

  • Starting arguments
  • Upsetting people
  • Posting inflammatory, extraneous or off-topic messages in an online community

with the deliberate attempt of

  • Provoking readers into an emotional response
  • Or of otherwise disrupting normal on-topic discussion.

The references I used to present this can be found here.


When preparing my talk I thought back to my training in forensic psychiatry, and re-visited the types of stalking behaviors that Prof Paul Mullen, Michelle Pathe et al identified way before Google and the internet. One of their first articles published can be found here. Their work has well and truly stood the test of time, and I note that some of these types of stalkers now carry on with the same behaviour using the internet as a new way of carrying out their acts, often alongside off-line behaviour.  And although social media sites state they have methods and policies around incorrect use of the internet, I wonder if they truly understand the complexity and diversity of these behaviours. For example, reporting such behaviour may have an alleged stalker taken down, who can obtain another twitter handle or facebook page with another email address and continue along their way.

Also, if a potential stalker is reported and blocked one may be placated that they are safe when in fact all that happens is  they can no longer see what the alleged stalker is up to 

My best advice is to take screen shots of everything you may see that you will need as evidence before blocking and reporting potential stalking to behaviour to the sites and/or the police. If their site or page is taken down, or you block them, you lose your evidence. Don’t presume sites such as Facebook will assist you in retrieving this information.

Some people who stalk victims on the internet may be mentally unwell. They may have a paranoid delusion that in some way a person or an organisation they may have never met has caused them harm. Sometimes this is the case, often it is up for debate, but no matter what, the matter should be dealt with off-line through appropriate channels. In these cases, the actual stalking behaviour occurs as a way of ‘exposing’ or ‘getting back’ at someone they feel has delivered them a gross injustice. No matter what, victims must and should feel able to report such matters to the police, and in an ideal world, a forensic psychiatry assessment would occur as part of the investigation.

I also spoke about cyber-bullying, which is more clearly defined, probably as a result of high profile cases with tragic outcomes that have turned society’s attention to this phenomena. Bullying is bullying no matter where it occurs. It has been thought that the main targets are adolescents who are often bullied at school, but now, the behaviour doesn’t stop when the school bell rings. In cases I have been involved with as a psychiatrist, the victim is well known to the perpetrator, often a classmate or a peer. But this is not always the case.

I concluded my presentation with reflections I gleaned after reading the wonderful new book “So You’ve Been Publicly Shamed” by Jon Ronson. In this latest book, one of my favourite authors has interviewed victims of shaming that has generally occurred on-line. Shaming that has occurred in the name of ‘good’.  That is, an interviewee has made a monumental mistake on social media, often even one tweet as in the case of Justine Sacco, but has had no way of coming back from that. Jon Ronson’s article in the NY Times can be found here and is a very thought provoking read. After I read it, I came to the conclusion that:

Just as we need  policies and guidelines about how to behave on social media, we need policies and guidelines on how to be able to apologise if we make a mistake.

It led me to ponder the idea that if we expose someone on social media whom we as an online community feel has behaved badly, and we shame them by setting up hashtags for retribution, or lobby to expose them, are we in fact trolling? Don’t we also cause harm? Isn’t it just better to promote forgiveness in certain cases?

A final tribute to another favourite author, Dr Samuel Shem, who wrote the incredible novel  ‘The House of God’. In this novel the protagonist is an intern at ‘The House of God’ after graduating from ‘BMS’ (Best Medical School). The novel chronicles his journeys through internship and many years later, still resonates with junior doctors worldwide.

One of the laws from the ‘House of God’ was;

At a cardiac arrest, the first procedure is to take your own pulse. 

Perhaps, if we take our pulse before we reply to something that enrages us on our twitter feed, and decide to delete the post before sending, or even mull over it before we do, we may continue to keep the social media space as kind as possible.

Special thanks to Dr Tim senior and Dr Brad McKay for helping me prepare my talk on this important topic. 




The legal fraternity may disagree,

Good morning @WePublicHealth!

Greetings all,

Between caring for patients and advocating for doctors mental health, I will be managing the popular twitter handle @WePublicHealth.

I am extremely honoured to be given this opportunity, and plan to tweet on matters social media and medicine after running a highly successful workshop for doctors, called, MedicineSocial last weekend in Melbourne.

I am extremely passionate about writing, blogging about all matters psychiatry. I truly believe most stigma around mental illness lies within the medical profession, and that many doctors don’t actually know what we do! Many of my patients are unaware that I am a doctor with a specialty qualification in psychiatry. This lack of understanding of what we do leads to an under utilising of our our ability to diagnose, manage and treat mental illness.

I also know that psychiatry is controversial. I struggle at times with how to work within such a broken public mental health system. I care about doctors mental health, as I feel that without a healthy workforce we cannot expect patient health.

I will be tweeting regularly, and welcome your questions and thoughts. In particular, I am going to be investigating how the professional and powerful use of social media can break down barriers between doctors and patients, allow us to be on the front foot when it comes to the delivery of evidenced-based scientific health information, and to allow us to learn and grow as a community of like minded people.

I have also been asked to talk about the rise in cyberstalking, the phenomenon of trolling, and the roles of caricatures and parodies in delivering messages around health. I spoke about this on the weekend, profiling types of stalking behaviors based on what we know about off-line stalking, and how this is playing out on social media, often with deleterious consequences.

Please share my tweets, reply, tell me what you think, and keep it real!

Best wishes,