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. 

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. 

 

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

OCA fundamentals masterclass 3 hour workshop

Registration fee includes supper, and a complimentary copy of one of our new DVDs, ‘Tips for success’ Data gathering process, valued at $82.50!

Its a new era as RANZCP trainees and IMG’s move from OCIs to OCAs throughout their training. But just because you are being assessed in the workplace, the assessments are as challenging as ever, in that the marking domains from the OCIs are still being used, and you are being examined at a level of a junior consultant from as early as second year.

Now more than ever, you need a structured, tailored approach to your training. We understand that your supervisor and peers are time poor, and your ability to access training for examination preparation is reducing.

Hence, we are hosting a one-off information evening on Thursday 26th November 2015, from 6-9pm at CPD Formulations Pty Ltd. Over three interactive hours, based on small group learning and in vivo rehearsal, we will cover the following topics to leave you with a clear strategy on how to tackle this component of your training.

  • How to approach the interview in different clinical scenarios
  • Rapport building and communication skills
  • Presenting concise specific action plans to your case
  • How to present a mental state examination, including a cognitive examination
  • Managing anxiety and uncertainty
  • Balancing exams and assessments with your clinical work and personal life.

Glen Hancox is an expert in facilitating and presentation skills and has been working with Dr Helen Schultz, helping exam candidates since 2008. We know what trainees go through, and all of our programs and coaching are practical, hands on and tailored to your needs.

Purchase your place at this event and receive a free copy of our latest DVD 4, ‘Tips for success’  Data gathering process, valued at $82.50, prior to the event!

There are strictly limited places for this event, please don’t miss out!

Disrupted passengers both ways. We’re all in this together.

Today I thought I’d write about those that have had a really difficult time during the recent volcanic eruptions in Bali, disrupting their travel plans. Those who couldn’t get here and those who are stranded in Bali draining every cent that would have been put towards future holidays.
As a psychiatrist, I see first hand the emotional and medical consequences of banking up a sleep debt, rest debt and ‘catch up with family and friends debt’ all the time. So many of us, including me, continue to put off what is immediately beneficial and rewarding. How many times have we thought about how much we enjoy having a coffee with a friend, only to lament about how long it has been between drinks? Finding time for a coffee and a catch us seems insurmountable yet the benefits last longer than the coffee does. Likewise, planning a break from relenting commitments, daily schedules, obligations and structure can often be the only way we cope with it all.

I think about how exhausted I was before heading to Bali. I didn’t even realise until I almost collapsed into the lounge by the pool and couldn’t move. Daily morning yoga was a total struggle; I hadn’t practiced yoga for over 2 years and my busy mind made me lose my balance way before my muscles did. But after about 3 days, I was, surprising to me, completely relaxed. After 5 days, one of the guests, soon to become a friend alerted me to the cancellation of flights and the volcanic disruption occurring all around me. Because, from the resorts in Bali, there is no evidence at all there is an ashcloud.  From that morning on as speculation grew we all succumbed to the lack of daily updates, uncertainty and the very real situation that we wouldn’t be returning home on time.

But what about if it was a week before? What if I hadn’t made it to the yoga mat?

I think if I hadn’t made it to my holiday in the first place I would have needed to have thought of a pretty good plan B by now. I admit I have fallen into the trap of ‘it’ll be OK, just get through this week, this financial quarter, this year’, wishing days away waiting for a break. When we do this we take a toll on our own health, often silent, succumbing to more viral infections, or mildly raised blood pressure, chronic fatigue, and so on. We somehow justify that things will all rectify themselves, once we get on that holiday.

In this current situation, many people just like me have banked up the same amount of debt but unlike me just didn’t get to Bali, or did, but are trying to rationalise the situation by eating into funds for the next holiday. If you are one of these people I am sure you have struggled with the uncertainty, the hope you’ll depart then the disappointment when you don’t and by now are absolutely fed up.

Faced with the certainty of a volcanic eruption, completely at the hands of mother nature, it is time to take charge of some certainty over your predicament. Because, if you were operating on limited reserves like me up until now, it’s time to take back some control.

Some things to try;

  • Sit down with your family and work out what it was that you wanted from the holiday in the first place. ‘Chill out’ I hear you say. Reflect on what it is in your daily life that doesn’t allow you to ‘chill out’. Write it down and save for later. Now is not the time to try and make the most of things. You need a break right now.
  • Negotiate your way into a new holiday, whether it be shorter or to a different destination. I’m not saying to put yourselves in debt, but desperate times call for desperate measures, and I know the airlines are very happy to offload passengers to another destination to get them off the queue. It may be shorter, and it won’t be Bali, but it will be something.
  • If you now have unexpected days at home, use them wisely. Don’t try and overload them but instead spend them doing things you always put off.
  • If you are on an extended stay in Bali, live in the moment. None of us know what next year will bring. There is no reason to believe that this delay due to no fault of your own, means you will never holiday again.

Remember your thinking is probably clouded by your current predicament. It won’t feel like this once you do come back from your holiday or get home. 

The one thing I have seen most in medicine is that none of us know our fate and despite our best plans, sometimes things just happen. As humans we don’t think about this that often, until the inevitable happens. As a word of advice, it might be best to avoid call centres as much as you can. Lip service right now, when you are as frazzled as I am, is not going to help. The operators have to behave a certain way, and we all know, if they just said they didn’t know we would all be happy. I understand that the most frustrating thing right now is not feeling heard or understood.

Take care and find your yoga mat, it is waiting for you.

Dr Helen Schultz is a consultant psychiatrist currently stranded in Bali. She has had the most amazing time and met some fantastic people but it is time to go home. 

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. 

Announcing my new range of DVD ‘Tips for Success’ in the psychiatry clinical examinations!

Greetings all,

I have had a great time creating and producing my new range of DVDs for psychiatry trainees and medical students. It has been 6 years since I released the original series of Present2Pass ‘Tips for Success’ range, and i felt it was time to add to the range and refresh the content!

Thrilled to be working with the talented Glen Hancox from ACTREAL again, and combining the filming and production skills of Mick Russell from LinchPin studios.

Anyway, enough explaining, watch our trailer!

And click here to order them!

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.