Is this really radical?

[00:00:01] Lucy: This podcast has conversations around different mental health experiences that may be distressing for some people. If that doesn’t feel like something you want to explore today, you might want to visit another podcast and come back to us another time. [00:00:14] Rachel: discovery college acknowledges the traditional owners of country throughout Australia and recognises their continuing connection to lands, waters and community. We pay our respects to Aboriginal and Torres Strait Islander cultures and to the elders, past and present. They have never ceded sovereignty. [00:00:32] Lucy: In this podcast, we share stories that help us learn from each other, connect us and inspire growth. We want to acknowledge that this way of being, of coming together to share knowledge and stories, is a tradition that has already existed on this land for hundreds of thousands of years as a part of the culture of First Nations people. [00:00:51] Rachel: discovery college acknowledges the views shared in this podcast are about mental health experiences, but are not a substitute for professional mental health advice and support. The views in this podcast are not the views of Alfred Health, but are the views of the individuals we’ve had conversations with. [00:01:07] Lucy: The stories we share on this podcast aren’t just stories, but memories of the people who have bravely shared their experiences with us. Remember to take care of yourself as you listen, as well as to take care of the stories that you hear. [00:01:33] Rachel: Extremely Human is a conversation about the profound experience of extreme states. When we speak about extreme states, we want to explore a more humanistic way to understand people’s experiences that aren’t always shared by others. [00:01:47] Lucy: Each extreme state holds different meaning for each person, including those related to psychosis, depression, grief and addiction. As we chat with a variety of humans, we explore the important question how can we respond to distress with greater compassion and humanity? In this honest chat with Paul, he helps to bust some myths about common misconceptions in the medical world. Paul speaks about the value of humanizing people's experiences rather than medicalizing it, and how including people's loved ones in their care can make a real difference. [00:02:33] Lucy: Here we are again, Paul. Thank you for joining us in our humble little studio. [00:02:38] Rachel: Pretty excited to have you here, Paul, and to talk with us about. [00:02:42] Paul: Don't give me too much pressure. [00:02:43] Rachel: Yeah, no pressure. [00:02:46] Lucy: For those who don't know you, Paul, can you just tell us a little bit about yourself? [00:02:50] Paul: Sure. Well, I'm a child psychiatrist and I actually came up to 20 years working at the Alfred a few months ago, so I've been in my job as like clinical director of Alfred Kim's for that time. [00:03:04] Lucy: Wow. Long time. [00:03:04] Paul: Long time. [00:03:06] Lucy: A lot of knowledge. [00:03:07] Paul: Well, you might say it's too long. [00:03:10] Rachel: This is totally putting you on the spot. But if you had to give one sort of short statement to say what you stand for as a psychiatrist, what would it be? [00:03:18] Paul: Wow. I don't know if I can do it in one statement, but like anyone, you're hopefully going to try to make the system better. I mean, I've got quite a privileged position because I'm in charge of, I think we've got about 200 staff. So really, my job is hopefully help people get the best out of themselves. That's my job. And it is something you can't take lightly, because I do actually have power. And if you're not going to use that for good, then it's a shame. [00:03:48] Rachel: That kind of reflects why we thought you might be a good speaker today, because the issues that we're talking about is really about how do we make the system work better for people who are in extreme distress. Before we get to that, we have a bit of a standing opening question. [00:04:02] Lucy: Yeah, Paul, I'm sure you have across your time, but have you or anyone you know had a disproportionate reaction to anything? Anything at all? [00:04:12] Paul: Yeah, I think it's hopefully, this is supposed to be a bit light hearted, because I don't want it to sound trivializing what we are going to be talking about. But I did think about this question before I came, and I did burst into tears after Richmond won there, or actually before Richmond won the 2017 grand final. I think some people think it's a game and why you're getting so emotional about a game. But we actually hadn't won a grand final for 37 years. And I don't know, just the way it happened as well, underdogs and what it meant to a lot of people. So I'm trying to justify why it wasn't disproportionate, but I think a lot of people would think that's pretty extreme disproportionate to us when you're game of football. [00:04:52] Paul: We sort of interested, Paul, when we talk about the word or the phrase extreme state, what comes to mind to you? What do you think about? [00:05:01] Paul: Honestly, I didn't know that term until I attended the discovery course that you guys ran, because as a psychiatrist, you get trained in using more medicalized language, like psychosis, or in fact, we talked about schizophrenia. So what comes to mind when I hear that word is what I learned there, which is a more humanistic way of describing an experience for people when they're out of touch with reality or their emotions are out of control or their feelings are out of control. And that's actually a new concept for me. It's probably trying to be a bit less prescriptive or a little bit certain about what's behind it. I think that language, using that language helps humanize the situation. Also having people not jump to conclusions about what might be behind it. And also, I think it helps less medicalize it. [00:05:57] Rachel: Can you say a little bit more about what you mean by medicalizing the extreme states and what's the problem with that? [00:06:06] Paul: Yes, I think there is a problem that in our Western culture, I believe that over a period of time, lots of emotional distress or mental distress has become too medicalized, and it leads to a real narrowing of being able to help people. And it's also very. I think it's part of our culture, too, which is very individualistic, and the responsibility for everything lies within the individual. I think it causes heaps of problems because it particularly often leads to unhelpful solutions like that. An expert knows best that drugs are the way to help with these things, only that there's some underlying medical problem, which is usually not the case. I mean, it's sort of comforting in a way, and helps reduce guilt and shame and things. So there are some tempting things about it, but the negative is that it's actually not really based on an actual factual basis. The best example I can think of is recently what I learned is that 90% of people in Australia believe that depression is caused by chemical imbalance. That's a cultural view. So 90%. And in fact, it's been shown that that is actually not the case. There is no evidence for a chemical imbalance. So that's a big problem. And a lot of the drugs that have been manufactured or designed to help with that problem are based on that idea that there was a deficiency of serotonin or some sort of chemical imbalance, which means the whole thing, for me, becomes quite problematic. Not saying sometimes people aren't helped by medication, obviously, sometimes they are. But the basis that it's a medical illness is a problem for me. [00:07:53] Lucy: Sounds so absurd when you say it like that, because it's like, how are we treating people properly if we don't even know what the issue is to begin with? [00:08:03] Paul: Yeah, I agree with you, Lucy. [00:08:05] Lucy: So it's like, as a collective, I think we're getting misled. [00:08:09] Paul: It's definitely getting more and more as well, because I've obviously been around a long time. What used to be the focus with schizophrenia is there was a massive search. I think millions and millions of dollars have been spent looking for a genetic cause, or it's not quite the same as a chemical imbalance, but a belief that there's some genetic thing and none has ever been found. And because it's such a... I think the word extreme states is helpful because who would be looking for a genetic basis of an extreme state? That's what I mean by the language that's used. If you're calling schizophrenia, it leads to a whole pathway of thinking there must be some genetic or biological basis or chemical imbalance. Whereas if you call something extreme state, I don't think you'd be necessarily being so narrow to just look at DNA. [00:09:02] Lucy: Yeah, because it just sounds like it's a human experience rather than something that can be tracked. [00:09:07] Paul: Doesn't mean you can't have an extreme state. Not based on something that might come out of the blue, it might be unlucky, or there might be some unknown reason why you're experiencing that, and that's okay. But the whole labeling of things like that, I think, is too narrowing, and it reduces the chance of effective help. [00:09:30] Lucy: Is there anything else that you sort of see as an issue, the way we respond to people who are in those extreme states? [00:09:37] Paul: Yeah, there's lots. I mean, I just talking to a friend of mine, and her assumption was that people in extreme states are dangerous, and that's a common myth as well, I think. I'm not saying there might be a small percentage of people who are, but most people in extreme states are only a person they're in danger to of themselves. But there is, I think, a community perception that people in extreme states are dangerous to others because maybe a tiny percentage are. So that also comes to mind when you say that. [00:10:12] Rachel: What do you think those beliefs or those fears about people being dangerous leads to? [00:10:19] Paul: Well, it definitely obviously leads to fear in the rest of the community. And that fear is obviously the basis for stigma and wanting to have those people put away or out of sight or managed in some way to keep society safe. And I think that does lead to more coercive treatment, more marginalization of that group of people who suffer those things in the community. [00:10:48] Lucy: It almost sounds like just an insane response to lock up people who aren't traveling so well and makes it feel like they're punished. But I wonder if you could enlighten me or maybe some of the listeners, why that is a process to begin with. Why do people get taken to IPU settings? [00:11:08] Paul: It's generally based on fear and sometimes highly justified. So if you're talking to someone and they're threatening to kill themselves immediately. Obviously, you want to help them be safe, and so that's a normal reaction. And so often having some time out or some peace, obviously, a lot of extreme states pass on their own if somebody's being nurtured and looked after and cared for in a humane way. And so you don't want to not have people have that opportunity, because often this is not normally a rational or thought out thing. It's often someone's overwhelmed. And so having a place of safety for a chance for that to settle is great, I guess. Why are so many people being locked up? I think there's other things at play that contribute to that, like clinicians feeling blamed if something goes wrong or if someone chooses to end their life or something. So there's a lot of fear in clinicians that if someone harms themselves or does something, and I'm the last person to see them, they can be very defensive. And obviously, it's very easy to lock someone up to protect the clinicians from feeling blamed. So that is a massive problem. So I think that skews it. That's why sometimes I think there are not other alternatives sought to help that person in that extreme state because of the fear based practicing that's set up systemically for clinicians. So I think there is a place for people to be in a place of safety against their will when they're completely in extreme state and can't be rational about what they're doing or don't have capacity to make thoughtful decisions in a crisis situation. But locking someone up long term for that problem is not usually helpful either. But in the short term, if it's kind, compassionate and in a nice environment, it can be really helpful, I think. [00:13:17] Lucy: I don't know how much it works. Do you think it works? I mean, there's probably elements that do. [00:13:24] Paul: Yeah, I think. Well, in terms of, does it reduce people's chance of suicide? I don't think there's any evidence that's the case, in fact, but it's very hard to prove that. And I certainly, obviously have put people in hospital against their will, which I thought was justified at the time because of us so scared about their risk of suicide normally, not normally hurting someone else, normally their own risk to themselves. So I think it is justifiable. But I think we do it too often, and I think that too often is because of the fear based practices that happen, because of the way, in particular way suicide is investigated it and in the fear that clinicians feel responsible. [00:14:12] Rachel: For the outcome makes me think about just the result of that is clinicians and services are often in a position of us against them. So there's this real kind of we're working against people rather than with. It made me think about earlier on, Paul, you said, you know, the medicalization leads to expert approaches, certainty around, or a false sense of certainty around the cause. If that's not happening, what do we do instead? [00:14:42] Paul: Yeah, well, I think that things are improving to some degree and I think the main issue is trying to involve as many people as possible in decisions like this. Obviously for us in a child and youth setting, it's family. So we're always trying to see if people can be supported in their own environment, at home with their family, but if you don't involve them, that can't happen. And there's often issues that are brought up about confidentiality and things like that. But I think, well, I personally believe we're getting better at having those sort of crisis responses be a social network or family response. And even if that does involve in someone being put in hospital against their will, at least it's done in a more transparent, open way, more.. There's no secrets, it's done with everybody's mindfulness and it also, I think, should lead to being able people to leave hospital quicker and some sort of plan and open. I think that in the past what happened to people was a much more secret, much more things against their will without them really understanding why. And also families felt very shut out of those decision making processes because the medicalization puts the problem in the person and the responsibility with the expert, whereas if it's more shared decision making with people that love the person and the person, I think that even though it doesn't sound that different, I think it makes a big difference. [00:16:19] Lucy: When we spoke in the lead up to this conversation, you were talking about the new Mental Health act calling for less involuntary treatment. Would you be able to talk about that? [00:16:31] Paul: Yeah, well, rightly, or wrong. I met with this guy, Terry Laidler, who's going to be the chair of the collaborative Centre, which is supposed to be the heart and mind of the Royal Commission. And the two priorities. One of the priorities he's has is reducing the number of community treatment orders and that's what society wants and where really psychiatrists or mental health professionals need to be in keeping with society's views. I think they're laws for the society. It's not just up to us. And I personally agree with anyway. Obviously I have supported some people being on a community treatment order. So it'd be very hypocritical of me to say never. But we do have a high number in Victoria. I've heard it's the highest in the world. [00:17:26] Lucy: Why? Why, Victoria? [00:17:27] Paul: Firstly, I think sometimes I've personally been involved in situations where I feel it's been helpful. So I'm not going to say it's completely unhelpful. I think though, this fear based practice and this idea that experts and clinicians are responsible for someone's life, and if something goes wrong, it's their fault, that my opinion definitely leads to a high number of community treatment orders, because it's taking risks and allowing people to make decisions about their own life when they may not be always in the best frame of mind, which is a difficult thing. But if you've also add the other layer, that you're going to be criticized or blamed if they choose something that's like suicide or self harm or something. I think there's a higher tendency to have people on involuntary orders. That's my opinion. [00:18:22] Rachel: What are some of the things that happen that perpetuate fear based practices? [00:18:28] Paul: I think there's many, many things, but I think the first thing that's happened in Victoria is the use of root cause analysis to investigate suicide, which even though it says it's looking to find the fault in the system about why someone chose to end their life, the system is people. And so people that I've experienced when they have to front up, if in a very rare but tragic situation where someone's taken their life, they have to go through some grueling investigation process where there's incredible scrutiny on the notes that they write on exactly minute by minute, what happened in the few days before that person died, I think that seeps through the system in a really toxic way. That's the first thing that needs to change, in my opinion. Because if you're going to do those root cause analyses, you can't deliver on a just culture, which is another whole topic, but the culture where clinicians are compassionate, kind and free to work in a meaningful way with people. If you're going to always going to feel that the organization doesn't have their back or someone's going to blame them, and it's just natural human thing is to practice defensively. So I think that's the biggest barrier. There are other barriers, though. I think the tendency to be medicalized and not involving families as much or really focusing on individuals is a problem as well. But there's a lot of things at play and it's definitely changed in my career. So when I started, all of the psychiatric wards in Victoria were open, apart from a small high dependency unit in each ward. And certainly I started my career at Larundel, which was on a massive block land. And the vast majority of people that were there were free to go around totally freely. Isn't. I don't think there is any ward, including wards for teenagers and children that is not locked in Victoria now. I don't believe there is. So that's a massive shift. [00:20:43] Lucy: Yeah. What happened in that time? [00:20:47] Paul: Well, I think it's not just suicide, although I think that's the main reason. So if someone kills themselves, either on leave or from a ward, it triggers what's called a sentinel event. And that's when this root cause analysis kicks in. I think there's other issues too. I mean, people would say it's difficult to control things like drug use and other things. Visitors doing things that's less secure and things. So it is a complex issue, but I think it would be better. Everyone, I think, has the desire that psychiatric wards could be opened more open. But it does seem a difficult one to change. [00:21:33] Lucy: Yeah. What are the things that you think that we can be doing better? [00:21:36] Paul: Yeah. So I was quite involved with the Royal Commission process in Victoria, which I think was an incredibly. It was a great process. And there are many things in that which I think will, should and could make Victoria having the best mental health service in the world, actually. So one of the things that was a massive focus was the embedding of lived experience within clinics and within teams. And I think we've noticed a massive improvement in the quality of our care through doing that. But we're nowhere near complete with that. Or we've just started on that, really. And that's a massive focus of the Royal commission. The Royal Commission paid, as my understanding, weighs 15 kilos. So it's very difficult for me to summarize some of the positive changes in that. But there's many, many positive changes. There's many sort of structural things or resource things. But I think I would recommend people looking at the cultural shift that's asked for in that, which is, again, a bit like what you're talking about. To me, it's trying to put in practice more humanistic, less medicalized, more recovery orientated practice within mental health services. Honestly, I think that is pretty well spelt out in that royal commission and people. What is also well spelt out is things that were not right before. One example I can give is some stories and it was in the first iteration of the hearings. It was in person. And I had the privilege, I suppose, of following somebody. And they talked a bit about the trauma that they experienced when they read their file, because there was a lot of things said about them that they didn't know people thought about them, and a lot of stuff there that they were is highly traumatizing to read. So the whole idea of making files or available for people to read in time, or that notes are not secret biographies, but are transparent records of what's happening with the person's involvement and knowledge about what's in their file. That's, for example, I think can make a big difference because it changes that sort of us against them that Rachel talked about. And look, we're in it together. We may not always agree, but at least we know what we're not agreeing. [00:23:59] Paul: Rather than when some of these people read their files, they had no idea that's what people thought of them, and that was very traumatic. [00:24:07] Lucy: I can imagine. [00:24:08] Paul: And now I could go on about it, but there's lots of things in the royal Commission report which talk to that idea of people feeling not heard and not respected and not treated well. [00:24:21] Rachel: If you have a humanistic mental health system that is focused on non pathologizing or non medicalizing of people's distress, what's the role of medication or drugs? [00:24:33] Paul: Yeah. So lots of people describe drugs being helpful to them. And so I think it's the way you prescribe. So if you are prescribing as like providing an antidote to some medicalized chemical imbalance, I think that's not the way to do it. But if you've got drugs that can help provide relief from very distressing symptoms, and the person who's prescribing them has a very high level of knowledge about the effect of the drugs on people's brains, like both positive and negative, and then you come to some informed. The person who's taking the drugs comes to some informed decision about why the pros and cons of doing it and why they're taking it and what the outcome might be. And there's an open mindedness about the effect of that, either good or bad. And there's an ongoing conversation around whether the drug is being helpful or unhelpful, I think it can be great. But the idea that you come in, get labeled with something, and then get an expert tells you what's wrong with your brain, and this is going to correct it. Firstly, that's not based on science. And secondly, I think that can lead to more harm than good, because people can walk out feeling like they've got something wrong with them. They got a broken brain, or they got some chemical imbalance, which is actually simply incorrect. It's like just changing the way drugs are prescribed or I think that's the key. Not that drugs are good or bad. They can be helpful or unhelpful, but if they are provided as if you got a broken brain, I think mostly they're unhelpful. [00:26:23] Rachel: Is that why you don't use the word medication? [00:26:26]Paul: Yeah, that is why. It’s deliberate. They are drugs. There's lots of drugs that we take. In Australia, we're the highest users of cocaine per capita. We're the highest users of methamphetamine per capita. We're the second highest use of antidepressants per capita. We're about to be, I think, the second highest or the highest user of prescribed amphetamines. So our culture is based on taking a lot of drugs. [00:27:00] Rachel: I'm even noticing a reaction to the word antidepressant or antipsychotic. It's sort of perpetuated by the way we even label medications or drugs, isn't it? [00:27:10] Paul: It is. I think when they tested the SSRIs, they're called on people. What they found, I think, in supposedly normal people, whatever they are, is that they do have the capacity to numb feelings. Now, that could be good. If you're really distressed, it might be nice to have your feelings numb, but it also might numb good feelings. So as long as you know that and you're taking it with informed consent, not like that. You've got low serotonin. This is going to correct your broken brain. Then I think it's okay. But the naming is all for me. It's marketing. So it's a marketing strategy. [00:27:54] Lucy: You make everything seem so clear. [00:27:58] Paul: Well, let me assure you what is very surprising. Being someone like me. And as a group of us, we are seen as the radicals, which I feel like is really bizarre to me, that it's a radical thought not to give children amphetamines. It doesn't seem radical to me. [00:28:15] Rachel: I'm wondering if you've got a bit of an example of a time where you think someone has been well supported in an extreme state. [00:28:24] Paul: I just know that when we meet the whole family straight away after they've called in and the whole family comes, and we spend the whole session trying to help a young person with suicidal thinking, which is a really common presentation. It's very emotional. And it's hard work and it's very raw. There's tears. It feels like everyone's in there working on the same thing. And even though the young person, obviously their wish is to not be there and also potentially to die, it's difficult. But to me, it's sitting with those going deeper into the underlying reasons, exploring the connections between family members, being open and raw yourself, and being able to sit with distress forever, how long it takes. I think those moments, that's good practice to me, rather than jumping in and trying to work out exactly what the label is or what drug to prescribe, actually trying to spend time helping the whole family system help cope with an absolute nightmare situation. [00:29:31] Lucy: Well, thank you so much, Paul. I want to thank you especially for not using heaps of jargon and complicated words so plebs like me can understand and follow. And honest as always, which I really appreciate. [00:29:45] Paul: Thanks, Lucy. [00:29:46] Lucy: Thank you. [00:29:47] Rachel: Thanks, Paul. [00:29:48] Paul: Thanks, Rachel. [00:29:56] Rachel: This conversation with Paul, Lucy, left me feeling really hopeful because it was sort of know. I was left thinking, how good is it that there's leaders in our mental health field who think this way and who are really working really hard to create a culture in mental health care that is de-medicalizing and is cautious about the pathologizing and how that leads to really limited ways that people can be helped? [00:30:28] Lucy: And so refreshing to hear that because it's actually quite brave for a psychiatrist to come out and say, speak so candidly in the way Paul does and always breaks things down for people in a way that everyone can understand. Rather than using all this jargon and sort of losing people along the way. Paul really simplifies and helps you understand the truth of what can go on in the medical world. I find that so refreshing and uncommon. [00:30:59] Rachel: Yeah, it is. I feel like I've learned a lot from Paul, both in this conversation, but also in lots of different ways that I've been able to learn from him. And I'm very grateful. [00:31:12] Speaker A: He gives a gold nugget every time I speak to him. A new gold nugget every day. Thank you, Paul. Thanks for coming on. [00:31:34] Lucy: Thank you for listening to our podcast. If you wanted to stay in touch or learn more about discovery college, please head to our website, discovery.college.