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

 

Throwing the branding baby out with the bathwater

I wasn’t expecting such a heated debate on Twitter when I woke yesterday, regarding the upcoming state RANZCOG congress, and now known as “Mirenagate”.  But I shouldn’t have been surprised because that’s exactly what happens on Twitter. The reason I love being a doctor on Twitter, and why I know social media has the power to change.

Some amazing doctors that I admire so much on social media, including Dr Nikki  Stamp and Dr Eric Levi has put forward their points of view regarding what could have been an absolute branding nightmare for the RANZCOG on 2nd January 2016. The Australian newspaper revealed that a branch of the RANZCOG was proposing a debate on whether female registrars should be given contraception to avoid breaks in training. It happened outside business hours, as these things often do,  and that is exactly why all organisations regardless of industry and craft need a strict social media policy that can firstly identify and secondly handle anything.

I call this a branding nightmare because I know as a coach and mentor of doctors in training, and past president of the AMA(Vic) Doctors in Training subdivision that the RANZCOG are leaders when it comes to providing flexible and supportive training for men and women. I speak as a total outsider, but hey they leave some other colleges for dead. I know that those within the RANZCOG have worked very hard to establish a brand, their college seal that when viewed by potential applicants, actually means something. To me it has meant that they mean business when it comes to workplace training and flexibility.

BRAND related text inside hand drawn jigsaw piece on chalkboard

This is why branding and mission statements are so crucial, and also why they are so vulnerable. Anybody of official status or anybody who represents the RANZCOG in a public forum needs to protect their brand and mission statement. This is especially at times of crisis, when negative comments hit the media, and should also reflect not just the content but the approach to training registrars. This includes choosing how to phrase topics on conference agendas.

I have spent the last three years learning the art and craft of branding and know a little bit about social media thanks to some wonderful friends I found in the Twittersphere. Oh and a brand accelerator program that cost a bomb. I am writing my article based on two viewpoints, but both on what branding means to me. Branding is powerful, so when messages are delivered that are inconsistent with a brand we feel we can trust, we feel let down. Speaking for myself, I felt hurt and disappointed to see such a progressive college take such a stance when choosing agenda topics, regardless of whether federal council knew about it, and also felt that eerie silence that follows when there is no official response, and the subsequent void which becomes swamped with outcry.

This article is an attempt to explain to those at RANZCOG why so many people were upset and shocked at the headline in the Australian magazine yesterday. I know the new owner of the @RANZCOG handle is an expert on branding and social media too, and I am not trying to tell him how to suck eggs. But maybe others within the college can listen to leaders like Dr Joseph Sgroi and take on what he knows about branding, consistency and social media.

I am also writing this as a mum who, like many who have spoken on social media, really copped a rough deal when pregnant. I wonder how many have suffered as they left parenthood until too late and now face infertility. Men and women that choose to share parenting roles (believe me I know that there a quite a few male registrars who are really looked upon as being totally selfish when choosing to go part time to share parenting).  So I couldn’t help but be shocked by the title for the debate at the RANZCOG congress. Even if it isn’t my college, once again I felt they were a college that were better than this, and it brought back what I put up with.

Here is my story, as a psychiatrist who only ever wanted to be a psychiatrist. At some stage I really wanted to specialise in child and adolescent psychiatry. I also wanted to have a baby. And soon because I went to medical school in my mid 20s, and time was ticking.

In 2006, I was working in an advanced training position in child and adolescent psychiatry, and passed my clinical exams when 15 weeks pregnant. I even blitzed the OSCE station based on a CPR scenario, with the mannequin placed at the feet of the examiners so I felt they could look down our tops as we did chest compressions. (The RANZCP did acknowledge this was a problem after quite a few complaints but female registrars were implicated and found to be at fault for not choosing correct work attire suitable for all work situations). Anyway I digress.

At 30 weeks gestation I developed gestational diabetes and hypertension.  At 34 weeks my beautiful son was born. The week before it was decided that I should step aside from my office bearer role within the AMA as it was a very important role and should be handed over to somebody that was not about to go on to maternity leave, rather than seeing out my term (at this stage I didn’t know what was to happen the following week, and trying to come to terms with BSL’s of 11 despite eating food resembling cardboard). The day I was to start insulin, I started being a mum.

I was meant to become a mum around early December 2006. My 12 month post with my teaching hospital would end in January, as all of us registers are only employed for 12 months, hence no accrual of any entitlements. There was no planning or offers of roles, or even a discussion about what my plans were with regards finishing my advanced training. Because I became a mum in October, I got a few extra weeks leave of maternity leave.  Maternity leave ended at the end of my 12 month contract, and in early February 2007, I was an unemployed mother of a premature baby with severe reflux. My post was given to somebody else, but not as a maternity leave role.

I know I was classified as unemployed, despite paying money to the RANZCP to apply for a ‘break in training’. Because outside of medicine, if you don’t have a job, you don’t have a job. None of this ‘just get back in touch and we’ll keep you in mind, we’ll see what we have when you are ready to return’. Westpac bank wouldn’t cop it. I was unable to refinance my mortgage as I was unemployed. That was only one of many examples.

So after coming up for air, and recognising the irony that I was working in a sub-specialty that is based on attachment, infancy and how easy it is to stuff it all up, I didn’t go back to child and adolescent training and I didn’t go back to that hospital. I focused on my beautiful son and made damn sure I didn’t mess up what I could manage when it came to attachment and bonding. I finished my training in general psychiatry and got out. Not only out of training but also the public mental health system.

I know that many of us get caught between the interface of our colleges and our workplaces, both blaming each other, and doing a lot of ’keepings off’.  That comes at a personal price to us. So yes when we see topics like what appeared in the Australian yesterday we will be hurt.  And when we believe in a brand that represents a college that we do look to as one of the better ones when it comes to caring for their trainees regardless of gender, we might take to Twitter and shout the sky down.

 

 

 

The power of connection

On Thursday, the federal health minister, Ms Sussan Ley, announced a new framework to tackle what has been described the crisis in Australia’s mental health system. Key opinion leaders in this field from the AMA to top academics and researchers have had mixed responses to the announcement. For what it’s worth, this is mine.

I am a consultant psychiatrist working solely in private practice. I run a very busy clinic covering a wide range of clinical sub specialties and many of my patients have been coming for several years. Prior to this, I completed my training in a tertiary teaching hospital, and over 10 years have seen many  patients with all forms of mental illness. I have also worked in rural and indigenous areas and have first hand knowledge of what works.

Regardless of their condition, their social situation, their background, their journey, two things help patients recover. Hope and connection.

When my patients recover they tell me they were grateful I didn’t give up on them. As they became well, they could see at the very time they were most unwell they truly believed things would never get better. So my ability to hold their fears, and reinforce with consistency and kindness that things would improve, were the most therapeutic ingredients to my package of care for them. Connection with a stable consistent provider of healthcare was paramount.

As doctors, we often forget how important we are in the care of our patients. This is particularly true in psychiatry when there are so many other ‘key stakeholders’ in the delivery of care to those with mental illness. We often relinquish our roles, shy away from leadership and stifle our voices when we see care we don’t agree with. It’s almost as if the system can only work if we remain silent. But I find that very hard to do.

For what it’s worth, I have been involved in the care of patients with all forms of mental illness since the era of deinsitutionalisation, firstly as a pharmacist and then as a psychiatrist. I have seen fundamental changes to the care they receive over the past 25 years.  I liken this new round of changes to a homeopathic treatment for the mental health system.

Each time a new strategy or overhaul of care is delivered to great applause, it is as if the policy makers have diluted the pool of patients with mental illness to such a point that they focus on only the smallest fraction of those who need and deserve our care. The very small number of people who have the insight,  and know how to go and seek out some help. They talk about ‘support’ ‘engagement’ ’empowerment’ and ‘resilience’ like they are evidence based measures of successful outcomes. They talk about strengthening partnerships and improving access without any tangible way of assessing what that means. The rest are diluted out and discarded.

For the past 25 years not one single mental health policy has addressed the needs of those with severe and chronic mental illness.

Over 25 years I have seen patients with schizophrenia, bipolar disorder, borderline personality disorder, melancholic depression, anorexia nervosa and many other clinical presentations be moved from pillar to post, often quickly and at the hands of a new government. Every single time this happens the two most valuable aspects of psychiatric care, hope and connection are fundamentally destroyed. The argument that ‘well this approach ain’t working, so let’s replace it’ drives this move to destroy hope and connection.

For the past 25 years not one policy has looked at what we have and tried to improve it, rather than reinvent it.

Let’s be sure of the facts, the ones that are diluted out in the homeopathic process that is labelled mental health reform;

  • Many patients with severe and chronic mental illness require lifelong care and frequent hospitalization.
  • Being hospitalized for mental illness is not a failure of anybody but exactly the appropriate type of evidenced based care a patient needs if acutely unwell, and at risk to themselves or others. And a long hospital stay often means a patient is very unwell, not that the services are incompetent.
  • We have turned our backs on those already in long term and residential care, the very thing policy makers said they would not do when patients were turfed out of asylums. They are still here, with us, deserving of our care just as in any other severe illness, but are firmly entrenched in an overflowing ‘too hard basket’.
  • We already have a mental health system which is failing not because it is hospital based, and the idea of building primary care networks for this group of patients has no merit. Patients with severe and chronic mental illness deserve multidisciplinary care that can be flexible in a ‘step up-step down’ way and can move to provide the care and risk reduction required. The reason this doesn’t work now is not because it is based in the hospital system, but because the services are so poorly run down they can’t offer what the patient needs. Administering ‘care packages’ to these patients, already known to the professionals in the public mental health system will lead to a doubling up and waste of valuable money that could be used to create extra beds and fund more staff.
  • It is not the patient’s fault that they fall through the state government/federal government convenient ‘diffusion of responsibility’ construct.
  • Improving knowledge and awareness of mental illness by providing fact sheets and e-health approaches are good for some but this should not be applied to mentally ill patients in a broad brush way.

There is evidence for these arguments everywhere, it’s just that the whole mess that began after deinstitutionalisation is so large now that nobody wants to talk about it. Patients who left asylums in the late 1980s moved through an era of case management, mobile support teams and crisis assessment and treatment teams. But then these services became so overwhelmed they could no longer deliver assertive outreach to the level they should. With nowhere else to turn, many became ‘frequent flyers’ in our state hospital emergency departments. When they were ready to be discharged from hospital, there was no room at the chronic care units if they needed it. NGO’s that provided wonderful support and consistency such as Richmond Fellowship and St Mary’s House of Welcome suffered massive funding cuts. And rather than improving medical comorbidity in patients with mental illness, mainstreaming psychiatric services into major teaching hospitals has led to more stigma and a sense that patents with mental illness are purely bed blockers.

There is so much devil lying in the detail of this new mental health reform. It is also very disappointing that it was announced without any increase in funding for the public mental health system, and in top of that, Medicare cuts for patients with severe and chronic mental illness. I have many questions about this implementation of primary health networks (PHN’s) and it is hard to ascertain any information. In particular, I wonder who will be staffing these organisations, to what level of acuity can they provide care, and how does a patient and a health professional interface with a PHN? What will be the role of the GP, the one who should be the cornerstone of medical care for all patients? How does the private psychiatry and psychology system fit with this? How long will PHN’s be around for and what happens to the patients after the funding runs out? Allow me to be cynical because I have seen it all before. I work every day with patients with mental illness, I wear all the responsibility and I know how complicated it can be.

So what do I think we need? Well, it’s not that glamorous, and doesn’t contain a lot of rhetoric, so it probably won’t get up. But I reckon after 25 years in this area of medicine I might be onto something. My simple recipe for mental health reform (totally undiluted):

  • Allow psychiatric triage services that exist in all our major hospitals across Australia the resources and staffing to be able to pick up the phone and respond when a patient is in crisis. These clinicians often know the most unwell and vulnerable patients in their network. They have managed them for years. The know what they are doing. And they have a connection with them.
  • Boost the crisis teams and assertive outreach teams, bring back the homeless teams and all the wonderful services that could respond in a timely and safe manner.
  • Look after staff who dedicate their careers to helping some of the most disadvantaged people in our society, so they remain in the system and continue the connection.
  • Have places of haven for those who live with symptoms all the time. Be kind to them.
  • And above all, invest in acute services that know exactly how to manage mental illness and have been doing so for years.

Bring hope and connection back to the forefront of what we are trying to achieve. Not another layer of bureaucracy and more strangers that may come and go in and out of a patient’s life.

Dr Helen Schultz is a consultant psychiatrist and advocate of patients with mental illness. She is also passionate about doctor’s mental health, and attracting doctors to the wonderful profession that is psychiatry. She is the author of How Shrinks Think

Anxiety may follow you home from Bali, even if you didn’t pack it.

Hi all,

I’m continuing to write and help out where I can, because I feel quite uneasy myself, and really missing home. As a psychiatrist working in private practice I would usually have seen about 15 patients this week by now, and handled a pile of inquiries via phone as well. So having this enforced break in Bali after my flight was cancelled 5 days ago is feeling really surreal, and I am feeling for my patients who have had to move their appointments until I get back.

I have heard that some people have managed to arrive home, but have noticed that the anxiety has followed them there. As a psychiatrist I can understand why, and I know it doesn’t make a lot of sense intuitively. I’m sure these people are hearing lots of comments, which are not helping the situation at all, such as

‘what do you have to be anxious about, you’ve just come home from Bali?’

Returned travelers understandably may have expected to be relieved and grateful when they finally walked in their front door. But instead they may have experienced a range of emotions, good or bad, ranging from mild disappointment to symptoms of trauma and everything else in between.

It is really important to accept it is OK to feel anything you might be feeling when you get home. Only you know and experienced your personal journey to get back in your front door.

As I have been writing about, humans love our structure and certainty. Uncertainty is a fertile breeding ground for anxiety. This structure includes daily routines which work best when they align nicely with our own circadian rhythm, or internal ‘body clock’. When we are on holidays, structure goes out the window in a really beneficial way, and because we don’t have to wake with an alarm clock or fit in with other schedules, we sleep when we want, eat when we want and we feel better for it. However, when we travel home crossing time zones and disrupting sleep (who can sleep on planes at the best of times?) we disrupt our circadian rhythm again, but in a negative way. This has a negative impact on mood and anxiety levels.

It ain’t just post holiday blues, there are known structural connections between the sleep centres and the mood centers in our brain. The good thing is once jet lag or transient sleep disturbance rectifies itself, so should you mood.

But what happens if, on top of all of this, there has been major sadness, disappointment or even illness or loss compounding the situation? What if you have been stranded like I am, annoyed and irritable that I have really no idea what will happen, fed up with comments telling me to enjoy my extended holiday, and then you finally get home? What if, instead of feeling relief and jubilation that you are home, you are teary, on edge and just plain miserable? There may be additional factors, complicating what has already happened with circadian rhythm disturbance that may be making things more difficult for you, including;

  • Nobody at home gets what you have been through. Friends, family and work colleagues only apply what they have seen on the news or have heard from other people, and you can feel they genuinely don’t understand your predicament. This invalidation may make you question your own response, feel deficient in some way, or lead you to holding back or pretending things are fine.
  • You have more FOMO. FOMO, or fear of missing out, may apply if your delays have led to you missing significant events going on for others at home. You may feel inappropriate guilt or anger because this awful unplanned event made you miss something very special to you.
  • As a coping mechanism, and because you felt helpless and uneasy, you may have coped with your extended time in Bali by being somewhat detached from the situation. This is a normal coping mechanism but also occurs when people are anxious. When reality hits you, when you see the credit card bills, or open the mail, all the emotions you may have not experienced while away may come flooding back.
  • If you have been diagnosed with depression or anxiety, you may have inadvertently missed doses of your  prescribed medications due to protracted travel home, or you may have run out while away. These feelings may actually be symptoms of a relapse of your illness and understandable.
  • You are constantly checking FaceBook feeds or news reports as you feel a connection to this situation and you feel inappropriate guilt that you got home. This in an extreme form is akin to ‘survivor guilt’, experienced by those who survive traumatic events and feel guilty that they did. This is complicated when well meaning people remark ‘how lucky were you’ and other things that make people hide their true feelings about their experiences.
  • If your time in Bali was complicated by further adversity, such as illness, theft or violence, you may be re-experiencing the event every time you see more updates, especially if the media at home is sensationalising things. You may feel a need to keep connected to social media as a way of trying to reassure yourself, which is keeping your mind on the past, and not on the healing properties of the present.

So if any of these factors (and I’m sure there are more) sound familiar, first and foremost do NOT beat yourself up for feeling the way you do. I often tell my patients that they feel anxious, depressed, sad, angry, lonely or whatever just because they do. Acknowledging how you feel regardless of whether you feel it is inappropriate or not is your first step to accepting it, then nurturing and healing yourself.

Other practical strategies to try (once again these are general guides and not specific to all cases);

  • Limit or avoid news updates about what is happening in Bali. It doesn’t help to let your mind wander into what is still happening to others. There is a fine line with feeling connected to others who understand, and perpetuating feelings of helplessness and sadness.
  • Connect to 1-2 friends who truly understand and talk to them. But if you feel overwhelmed by sharing, retreat for a while until you feel stronger.
  • Get your circadian rhythm back on track ASAP. Do not stay up late reading updates. Re-establish your normal daily routine. As bad as you have slept the night before, get up at the same time and go for a very short walk, not for the purpose of counting steps but to get some bright sunlight on your face. This will reset your melatonin levels and ensure your sleep cycle returns to normal as soon as it can. Sneak in a coffee or tea on the walk, it may help with motivation!
  • Connect with good memories and times that did happen. Print our photos of smiles, beautiful scenery, a picture of you in a relaxed happy state. All the reasons why you went to Bali in the first place.
  • If these tips do not work in a couple of days, or if you are having worrying thoughts, see your GP as a matter of urgency. You might be going there anyway, for that often needed dose of Bali-belly remedy. Make sure you tell your GP if you are not coping. Key symptoms to report are sleep disturbance, excessive worry, disturbed concentration, and more seriously thoughts of self harm.

This is not a time to think all the feelings you are having are due to you being weak, ungrateful or any other silly idea that may try and pop into your mind. Be kind to yourself, don’t avoid your feelings or excuse them away. Stay grounded. At home.

 

Dr Helen Schultz is a consultant psychiatrist in Melbourne, Australia, generally reachable by air from Bali. Right now she is stranded in Bali, churning out blogs and missing her son like anything. 

While I wait to get home, home finds me here

I am so amazed and truly inspired by all the people who read my blog yesterday and left such thoughtful comments. Like many of you I am feeling quite helpless as the days drag on and my proposed departure date is further behind me. It is really comforting for me to share my knowledge and try an help, while I am so far away from my patients in Australia, who keep getting moved to new appointment times.

Yesterday I wrote about the importance of keeping your health and safety as key priorities. That includes your mental health. Mindfulness is key here; if ever there is a time to be extremely vigilant about remaining in the present, it is now. Constant distractions and worries about home will only hamper our efforts to stay calm and we all need to be calm.

Once again, I need to impress upon anybody working in customer service and trying to assist us;

We don’t really want to call you or make your day any more stressful than it is. In fact, we would rather leave you alone, but we need to do so as the delays drag on and we search for certainty to combat feelings of despair. So please understand from our point of view that if you continue to provide consistent, clear messages and update when you promise, we will feel reassured and take ourselves out of the queue of calls waiting for you.

If you are experiencing an exacerbation in anxiety or your mood is affected adversely, remember to do what ever you can to stay calm. That may mean avoiding busy places that you may be visiting in order to kill time, or use WiFi. Sensory overload may not be helping inner anxieties, once again check in with your own anxiety and see how much you can withstand. Consider it a finite, valuable resource.

If you have run out of medication or are experiencing symptoms of a relapse of mental illness, it may be a good idea to try and call your GP at home. Although they may not be able to assist you as comprehensively as a visit to a doctor in Bali, you may be able to get some basic advice, and they may be able to reassure you. Likewise, your pharmacist at home may be able to help out. I would imagine that the local hospitals and GP clinics in Bali will currently be overflowing with requests for repeat prescriptions and treatment of acute physical and mental symptoms. I would imagine that they cannot cope too well with the huge demand, and my heart goes out to the doctors and nurses trying to help. If you are already anxious, an extended wait in a crowded emergency department may make things worse. Having said that, if you are feeling unsafe or acutely unwell, you must attend there for care.

So, from a psychiatrist’s perspective, here are some things you can do to boost your mental health reserves. they are not a substitute for specific medical advice, but they might help;

  • Use psychological and behavioural strategies such as distraction and relaxation techniques. Believe me, they work. Anything that can bring baseline levels of anxiety or depression to a more manageable state should be your first priority.
  • Exercise is extremely therapeutic. Nature walks are much better than trying to walk along crowded roads. Walk along the shore and feel the water on your feet. Cover up, and focus on your breathing. Leave the FitBit behind (I drowned mine in the pool, oops) this is not about steps or fitness. It is about the very beneficial mental health benefits of exercise. Walk as slow as you need to and as far as you need to until you notice your thoughts calm down.
  • Try and only focus on real concerns immediately affecting you, not the ‘what if’s’. Believe me, I have a huge list of ‘what if’s’, as a mother with a son back home in Oz that I was meant to get home to 4 days ago. This is what I am doing, you may find it useful as well.
    • Pull out a piece of paper and pen. Place all of your most important concerns in a column down the left hand side.
    • On the right hand side, allocate each concern to somebody to manage. You may be able to delegate some tasks related to home to someone at home. It will seem better when you notice that a lot of the tasks, such as getting someone to water the garden, pick up the pets, check the mail, contact your employer for updates, cancel or postpone appointments waiting for you can actually done by one person at home in a short space of time.
    • Authorise someone at home to speak on your behalf and this may cut down on your need to call from Indonesia. The time you free up can then be used to work on your relaxation strategies. And seeing a list with items ticked off is extremely therapeutic.
  • For all your fears, worries, what if’s, try visualisation work. Every time an anxious irrational fear pops into your mind, rather that fight or ignore it, put it somewhere – visually. Whether it be in a suitcase or an elaborate parcel made with banana leaves and decorated with frangipanis… you get the idea. Use your imagination to take the heat or the fear out of the worry. Let the worry know you have acknowledged it, but it is not that useful right now, so you will put it away for later. If you fight it, it will get louder and scare you more. The more you feel in control of your worries, the less they can hurt you.
  • If you are looking for medication substitutes, I would strongly advise against purchasing herbal preparations, or products with ingredients you don’t recognise. Any preparation, ‘natural’ or not has the capacity to interfere with your prescribed medication, and may cause a whole new set of symptoms. Avoid health related discussions on chat rooms,  or calling on Dr Google. If you are really desperate, once again a call to your pharmacist in Australia may help, if they have a list of ALL your medications, not just psychiatry medications.
  • It may be tempting to pass the day away with a few extra cocktails, under the proviso that you ‘deserve’ them. I am not trying to be a party pooper here, but if you already feel anxious or depressed, a big night on the Bintangs will make everything a whole lot worse tomorrow. And tomorrow might be the day you get that call you can fly home, so you need to be prepared to cope with a crowded airport, different route home, different airline (breathe, visualise….). Everything in moderation. Including social media.

I’ll endeavor to write daily whilst I am stranded here, and when I get home. Notice I say ‘when’ not ‘if’. Make a conscious decision to only say things to yourself that help you feel grounded, calm, and ready for whatever tomorrow may bring.

Best wishes,

Helen

Dr Helen Schultz has found herself stranded in Bali after booking a well-needed holiday, and writing her first book, How Shrinks Think. She is now spending her time practicing what she writes about, and writing. At any other time, she would consider this her dream life. 

 

 

Grounded by an #ashcloud? How to keep yourself grounded while you wait to get home

After 8 wonderful nights relaxing in Bali, I too have joined the long list of travellers trying to make it home to Australia. It has been 7 days since flights have departed and arrived without disruption. I am witnessing and experiencing first hand how it is to deal with airlines, hotels, insurance companies and generally anybody you don’t wish to bother unless you are actually in need and trying to find a solution to a problem.

I am struggling with trying to be present in the moment and at the same time managing professional and personal issues at home, things I would be doing as part of my usual life if my plane departed on schedule on the weekend. Meanwhile, around me I notice people struggling with the same thing. We all meet again at breakfast, at the pool, share stories about what we have read or heard and try and connect to feel we aren’t alone in this. One common theme is evident,

Now, just like any other time, past or present, we can’t predict the future, and that really makes people very anxious.

In our day to days lives we are often reassured that we can control a great deal of what happens, and most of the time we do a pretty adequate job of it. That’s because humans are hard wired to work best with habit, routine, and structure. We learn how to function by recognising what has worked in the past. Such as booking a holiday, turning up at the airport, arriving at the destination, leaving the accommodation and heading home. We can often leave our comfort zones and relax on a holiday because we know what will happen when its over. When there is any disruption to this, feelings ranging from unease to panic begin to emerge. This is understandable, even in those not predisposed to anxiety. For those who are, this change in routine and dealing with uncertainty can trigger every vulnerability.

It is OK to feel uneasy. Comments like ‘just enjoy the extra few days break’ might be annoying and make you more anxious if you are experiencing financial or health concerns due to being away longer than you have budgeted for.

People with anxiety disorders often fear the worst. They fear things that will probably never happen. This distortion in thinking is purely a symptom of anxiety and not a character fault. If you are prone to anxiety, or even if you aren’t but feeling anxious right now, here are some practical strategies that can help;

  • Reassure yourself that you will get through this, and no matter how inconvenient or stressful this may be, making rash decisions that could put your health or life at risk are not sensible. Remember to remain somewhere where you feel safe. When people are prone to panic or are distracted they can be impaired in decision making, and may be more prone to accidents or adversity. Remember to be safe crossing roads, entering areas you don’t know and so on.
  • Connect with as much home or certainty as you can. If that means a phone call or Skype chat to someone at home then make that a priority at a frequency that reassures you. Choose a person who will listen and help, rather than friends who may be there for the gossip and drama. Set up a small list of close friends on Facebook that you can contact rather than filter through all the noise on your feeds. Chose who you want to support you right now. Nominate a spokesperson at home who can call airlines, your employer etc on your behalf.
  • Where are your FOMO levels? ‘FOMO’, or fear of missing out, is a real phenomenon and is pretty rife right now, as we learn that social media channels, including unsolicited ones are updated faster than traditional means of communication. This is good and not so good. Certainly, as a group we can force airlines and insurance companies to respond to concerns faster than as an individual trying to call through on a landline. And we can feel falsely reassured by refreshing our social media feeds or listening out for notifications on an almost habitual basis. It is a typical conditioned response. You feel anxious, you press ‘refresh’, anxiety levels drop, there is nothing there, so you search more frequently and on wider platforms. Before you know it, you have spent hours staring at mindless information, in the fear of missing a notification from your airline or travel agency, and feel worse than before. Be very strict about checking for updates and stick to it. Checking your phone constantly, driven by a need to know something, will keep you completely focused on the problem.
  • Be specific about where you will look for information.  As the days go by there are more groups and information making it to our Google searches.  However, what is happening is many of the unsolicited groups and even the official sites are being drowned out by hearsay and personal experiences that may do no more than increase panic. Remember, Facebook pages are often set up by people who are generous with their time as moderators but really don’t sign up or are remunerated to deal with an influx of posts, filtering through for what is genuine or not.
  • Remember you are in one of the most tranquil places in the world, rife with ways to relax. Take this test to see how much you need to use what is here right now with you. Turn on you timer on your phone and set it for 5 minutes. That’s 300 seconds. Press start and lie back and close your eyes. Check how many times you had to resist checking emails or Facebook for updates. Feel how difficult it is to resist the urge. If you have not made it to 300 seconds, or have felt very uncomfortable after that time, you need to embrace some practical ways to help. Focus on the horizon, or where the waves are breaking out in the ocean. Watch the leaves on the trees sway in the wind. Pick up a handful of sand and see how long you can hold onto it before the grains fall to the beach. Come back to the present.
  • If you are a parent and have children with you think about the language you are using to describe your situation. If you are irritable or anxious, or need to have a conversation about your predicament, do it away from the children who will pick up on your anxiety.

Finally, the type of customer service large international companies can offer right now is on display. But now might not be the time to vent anger as it is most likely to make you very anxious, and the call centre operators very defensive. Don’t worry, I have had my fair share of difficult phone calls, when I am able to get through. Just think about what you will achieve right now, and what can wait till a very comprehensive letter of complaint when you get home.

Some tips for major companies when handling calls;

  • Assume everybody you talk to on the phone is calling because something has happened to them and they will be anxious and irritable. The best way to diffuse that is to provide clear directions and allow them to express their concerns.
  • If you broadcast that you will post an update at a certain time then do so. Even if you think it might change, do it anyway. If passengers need certainty, and all they have is a time for the next update then adhere to that.
  • Instead of delivering bad news all the time, educate passengers about what you will do when the ash cloud dissipates. Details such as the number of planes that will be dispatched to fetch stranded passengers, how the priority situation works if you need to get home due to medical emergency and so on. Pretty much every passenger is with you that we don’t want to fly if it is dangerous. there is no argument there. If you truly don’t know the answer, there is a lot of comfort in saying ‘we don’t know’.
  • Employ professional social media strategists to run your Twitter, Facebook and Instagram accounts. Irritated passengers can see right through comments that come across as patronising. Last week I was told “enjoy the pool, it is raining in Melbourne anyway”, which is no comfort to me when I have obligations at home. Social media is a powerful way of delivering effective communication as it happens, use it as such and the amount of negative comments should dissipate, hopefully as quick as this ash cloud does.

Remember, the ash cloud will pass. Don’t buy into fear mongering or shared anxiety of others. Home will be waiting for us. What we can do when there is not much else to do, is let go of what we cannot control. Continue to remain as resilient as you can using the resources around you. Stick together as couples and families, or if alone, remain connected to loved ones at home. We are all in the same boat.

Dr Helen Schultz, when not stuck in Bali, is working as a psychiatrist in Melbourne, Australia. She is now actively putting into place what she advises patients to do – mindfulness, relaxation and reading books. Oh, and waiting for travel updates.