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

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

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

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

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

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

She said yes.

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

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

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

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

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

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

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

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

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

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

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

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

 

Am I OK with #RUOK day? If rhetoric matched reality then maybe.

As a psychiatrist I am not so sure about public disclosures of mental illness.

Today is #RUOK day. It’s also a week where two of the top headlines in media have some sort of personal and professional significance to me. A famous AFL player asks for leave because of ‘mental health concerns’. And the Royal Australasian College of Surgeons (RACS) admits to widespread bullying and harassment of its members by members.

Why do both these topics hit a sweet spot? Well, both highlight the point that society functions better when we adopt the approach ‘do as I say not as I do’. In both instances, the message is the same. Don’t tolerate what is bad behaviour, don’t tolerate stigma, and practice open disclosure if you are struggling.

If only,

As a psychiatrist who works with patients with psychiatric illness every day, I know more than many the personal impact of mental illness on the lives of those experiencing it. That’s why I strive so hard to manage my patients and advocate for their rights and wellbeing. Why I focus on recovery. Why I care. Because I know that mental illness is common and treatable.

So what has got me feeling like I live in a parallel universe? It’s the imbalance of the strong public health messages such as asking ‘R U Ok?’, and the real life situation for many victims and patients who feel they have no voice or no audience. Because they have practical, tangible reasons to keep silent.

So, this week Lance Franklin has been given leave from his professional career as an AFL footballer as he is struggling with something. As he should. What I disagree with is the notion that one is brave only because they speak up and ask for help in a very public way.

I have seen many patients who have disclosed to their employers that they have a mental illness. Patients who need to see me and need a medical certificate to substantiate their whereabouts away from the office. Patients who are actively managing their mental illness and getting better. I have seen the same patients become victims to harassment in the workplace, and I have been placed in the untenable position of providing reports to validate that my patients are ‘safe’ to be at work. When I am not the employer but the treating doctor and confidante. Some of these patients actually work for organisations that donate large sums of money to organisations that work to reduce the stigma of mental illness. Hence the parallel universe.

In one tragic example, an organisation knew an employee was seeing me because my name and contact details were on a medical certificate I provided. They contacted me ‘as a courtesy’ prior to sacking the employee to ensure that they made attempts to keep the employee safe after breaking bad news. Without the employee, my patient, knowing anything about it. I knew the patient was to be sacked before they did. I was placed in an impossible situation, and was furious at the way the matter was handled. On numerous occasions I have been asked to be involved in workplace assessments if a patient of mine is recovering from an episode of mental illness and returning to work in a graduated manner. Very quickly, reports turn into assessments of competency and performance. My role shifts between keeping my patient from relapsing or suffering untoward as a result of these behaviours and explaining to employers why I will not compromise patient confidentiality. In some difficult cases, my notes are subpoenaed and confidentiality is broken anyway.

So, see why the public health message does not add up to the real life experience?  Although everybody knows what is the correct way to act. That is, ask for help if you need it.  Of course I agree because I know help is available and is lifesaving. I just really implore people to be careful who they are telling.

This year has also shone light on the impact of mandatory reporting of impaired doctors and doctors asking for help. New AHPRA guidelines outline that doctors must be reported to our regulatory body if one suspects they are practicing whilst impaired, thus placing the public at risk. Doctors are under intense scrutiny to prove they are competent to work, as they should be as health professionals. Yet they endure monitoring from both their employers and the regulatory body, AHPRA. There is data emerging that this will only serve to drive doctors who are suffering underground, away from care that will help them. As a doctor that treats doctors I know this is a defining factor in whether or not to tell anybody you are struggling.

And now RACS have been shown up to harbour bullies within their ranks, at a rate that would close down any other organisation overnight. We doctors are not surprised. We all have scars from the misuse of power whilst training whether it be from surgeons or senior members of other disciplines. Hopefully RACS will choose to ‘do what it does not what it says’ and out the bullies, rather than asking trainees to speak up. They have enough knowledge and information now after all, and can no longer pretend to be ignorant of these cases.

I know if had done the ‘right thing’ during my psychiatry training and spoken up about bullying, I would not be a psychiatrist today. The bullies do determine your fate.

So, how do I feel about campaigns such as #RUOK in the light of recent events? It would be lovely to believe that we exist in a world where stigma about mental illness can be overcome. That we can move from choosing celebrities as  role models to accepting that 1 in 5 people go through an episode of mental illness. That it is just as much of society as is the common cold. That bullies can be exposed and dealt with by organisations with more power than an individual. That people can speak up about having a mental illness or being bullied without retribution but instead complete compassion. I will continue to try and traverse both universes, yes I will continue to ask my patients, colleagues and friends if they’re OK beyond today.

But I will offer the sage advice based on experience and my own journey;

Ask for help because you deserve it and it is waiting for you. Ask because you only have one crack at a rich fulfilling life. Just seek out the right people to tell. They are waiting. And ask in a way so you feel empowered, safe and above all, cared for.

Dr Helen Schultz is a psychiatrist in Richmond, Melbourne, Australia, and author of “How Shrinks Think”.

 

 

 

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.

 

Welcome to the website for Dr Helen Schultz

Greetings all,

Welcome to the new website of Dr Helen Schultz, incorporating her private practice of MindAdvocacy, and medical education company CPD Formulations Pty Ltd.

Dr Schultz works in private psychiatry practice in Melbourne, Australia as well as being the founder and director of CPD Formulations Pty Ltd, a medical education company that delivers training to doctors and doctors in training.

Dr Schultz has worked as a coach and mentor of doctors in training and runs courses for psychiatry registrars and international medical graduates, known as Present 2 Pass.

Dr Schultz in now a published author of “How Shrinks Think” launched in November 2014.