Practice comings and goings

Some recent changes in our group practice:

We were sad to say goodbye to Dr. Roger Covin, who moved recently with his family to Ottawa. While we wish him well in his new city, we are sorry to see him go. He was a valued member of our practice.

We also have exciting news about additions our practice! While Dr. Jessica Franks has been working with us for a few years now, at the end of October she is increasing her availability at Hamilton Psychological Services to full time. In addition, she will be offering services in assessment and treatment to clients regarding Autism Spectrum Disorders. A further blog post about this is coming soon.

Finally, we’re pleased to announce that Ms. Getee Naeem has joined us part time. Ms. Naeem offers assessment and treatment to children and adolescents. In addition, she is able to practice in both English and Urdu.

Please join us in wishing Roger well in Ottawa, and in welcoming Jessica and Getee.

Information Sheets available from the Canadian Psychological Association

At this link you can find many fact sheets that have been prepared by members of the Canadian Psychological Association (CPA).

These fact sheets are called "Psychology Works," because they detail many areas (e.g., diabetes, phobias, parenting challenges) where psychology can be of assistance.

Have a look through them. We're sure you'll find something useful, and probably also something you'll want to pass along.

Ontario June 2014 Elections and Mental Health

You may be interested in reading this in preparation for our provincial elections. A group asked about the mental health policies of parties running in the election, and has posted their replies.

The Pain of Cyberbullying is More Real Than We Think

I recently noticed a somber coincidence while reading the news online. In the left column of the page was the story of MP Steven Fletcher, whose advocacy of assisted suicide was accompanied by this sobering quote: "When you're in real pain, you would do anything to stop it. You just want it to end -- death is better than the pain."

The article immediately to the right of this story was about a 15 year-old Saskatchewan teen (Todd Loik) who committed suicide after being the victim of cyber bullying.

That these articles happened to appear together was noteworthy because despite being different in many ways, they both shared a central topic - the use of death to escape pain.

I would venture to guess that while many people might have noticed this shared similarity, they would  draw a distinction between the types of pain. One is emotional pain and the other is physical pain. They are different, right?

This is where I believe the public needs to be educated about the potential effects of bullying and about pain. Specifically, the pain caused by bullying could be more similar to physical pain than most people realize.

Pain

All pain gets processed in the brain. If you burn your hand, the pain you feel is not in your hand. Receptors and neurons have been activated and they carry a signal through the spinal cord to different regions in the brain. It is in the brain that pain exists.

Two areas of the brain known to process physical pain are the Anterior Cingulate Cortex (ACC) and the Pariaqueductal Gray (PAG) (1). Interestingly, scientists have learned that these areas of the brain also process social pain. Social pain occurs when we are hurt through our relationships, or lack thereof, with other people. Rejection and social isolation are two examples of events that can cause social pain.

With the assistance of MRI scans, researchers have seen the ACC in people's brains "light up" when they are rejected. Research evidence from various fields, such as neuroscience and psychology, has been accumulating over the years supporting the claim that social pain and physical pain are closely related. Our bodies and brains seem to be designed to treat social threats in a similar manner to physical threats. In fact, when you look at how we describe rejection and social exclusion, the language is almost always pain-based:

"Her words stung."
"I was crushed after the break-up."
"When they said those things on Facebook, it really hurt."

A Need to Rethink Bullying

It is with this research in mind that we all must start to rethink how we conceptualize bullying. At present, most people seem to think of physical assault and cyber bullying as being different experiences. However, whether you are punched in the face or humiliated online, if the end result is pain caused by the activation of the same brain regions, then the experiences are not that different. Furthermore, the pain caused by both can lead to problems with anxiety, depression and suicide.

Children, adolescents, parents and adults in general should rethink how words affect people. We are no longer justified in saying that these are simply feelings and emotions that are being affected. It is actual pain.

This kind of education about bullying might have a few notable benefits.

First, for those people who consider physical assault as always being more harmful than the use of hurtful words, knowing that such a distinction is somewhat arbitrary could change their attitude and behaviour in fundamentally important ways. For example, I am willing to guess that many parents would react more swiftly and purposefully if they learned that their child was biting or hitting another person, than if they learned their child was mocking another person. Knowing that both acts lead to a pain experience that can approximate each other in strength and harm might motivate them to intervene more appropriately in both instances. 

Similarly, if children and adolescents were aware that words can literally be as harmful and painful as physically hitting someone, it too might alter their behaviour.

Second, just as physical assault can leave scars, so too can social pain. Social scars can actually be worse because no one can see them. Feedback can lead to empathy. If you punch someone, seeing their bruise gives feedback that your actions have caused real damage. This feedback can produce guilt, shame, self-criticism and hopefully empathy for the person you attacked. With cyber bullying, you don't always get this useful feedback.

Well, here's a message for those who use hurtful words against others -- you might not see it, but it is there, and I (a psychologist) eventually get to see it many years later. Learning to avoid physical pain is a simple concept that everyone can grasp. If you touch a hot stove, you learn to never touch the stove again. People need to know that social pain leads to learning as well -- a form of learning that is not always obvious.

The scars from painful social experiences in childhood and adolescence can last a long time -- even a lifetime. These scars exist emotionally, cognitively and behaviourally. It is not unusual for psychologists to see social anxiety, substance abuse, extreme fear of rejection, clinging in relationships, avoidance of intimacy (to name several) - all in adults who learned a long time ago that these behaviours can be used as protection from social pain. Indeed, it tends to be people's efforts to numb (e.g. drugs and alcohol) and avoid (e.g. self isolation) social pain that cause many of their problems.

Finally, knowing how the brain is affected by bullying can assist in treating the problem. Whereas MRI scans show the brain's pain regions becoming activated in response to rejection, similar research has also found that these pain regions can be deactivated with social support (2). Therapy can be very helpful for those currently being bullied and those still living with the scars of past abuse.

As stories like those of Todd Loik and Rehtaeh Parsons raise our collective awareness of how severe the consequence of bullying can be, it is imperative that we improve upon our understanding of exactly how the psychological and neurological processes governing the response to these events affect the individual. It is with the knowledge of just how painful social exclusion can be that we can start to understand how something like assisted suicide for a terminal illness and suicide from bullying can be related.

References

1. MacDonald and Leary (2005). Why does social exclusion hurt? The relationship between social and physical pain. Psychological Bulletin, 131, 202-223.
2. Keiichi, O. et al. (2009). Decreased ventral anterior cingulated cortex activity is associated with reduced social pain during emotional support. Social Neuroscience, 4, 443-454.

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1 in 5? Mental Illness Underestimated in Canada

Canadians recently learned the results of the Canadian Community Health Survey on Mental Health (2012), which revealed that 1 in 6 Canadians were in need of mental heath care. This is a large portion of the population and so the findings are not only significant, but they have garnered media attention and should assist in advocacy for mental health issues in Canada.

The problem is that the statistic is flawed.

The researchers excluded three critical groups:

1. "persons living on reserves and other Aboriginal settlements"
2. "full time members of the Canadian Forces"
3. "institutionalized populations"

The problem here is obvious -- the exclusion of these populations significantly lowers the number of people identified as having a mental health need. Native Canadians are known to suffer from problems with substance abuse, depression and high suicide rates, and the Canadian Armed Forces tend to have higher rates of PTSD and depression than the general population.

Furthermore, the researchers only assessed a small portion of mental illnesses -- depression, bipolar, generalized anxiety, and substance abuse/ dependence. Using a reduced number of disorders in the calculation and understanding of need biases the results.

So, the 1 in 6 figure significantly underestimates the mental health needs of Canadians.

There were other methodologcal issues that are also worth mentioning here, but my goal is not to tear down the methodological flaws of the research. Rather, I believe there is a larger and more important message to be delivered by examining the mental health statistics disseminated in Canada. Before making my broader point, let's look at a more popular mental health statistic that many readers would be familiar with.

Many Canadians have heard over the years that 1 in 5 Canadians will suffer from a mental illness in their lifetime. They were exposed to this statistic through the Bell Canada "Let's Talk" campaign or through the various health agencies in Canada, such as the Public Health Agency of Canada, the Canadian Mental Health Association (CMHA), and the Canadian Institute of Health Research.

These groups' websites are not the best at clearly citing their sources, but with a little bit research, one finds that the statistic usually comes from one of two reports:

1. The Report on Mental Illness in Canada by the Public Health Agency of Canada.
2. The Canadian Community Health Survey on Mental Health and Well-Being (2003).

The first report summarizes existing data and was used to paint a picture of mental illness in Canada.

The odd thing about this report is its clear problem with internal consistency.

The authors of the report assert on page 15 that 20% (1 in 5) of Canadians will experience a mental illness in their lifetime. Two pages later (p. 17) they write that "Canadian studies have estimated that nearly one in five Canadian adults will experience a mental illnessduring a one year period (my italics)." This appears to be a baffling mistake that confuses the reader about which statistic is correct.

The second report presents the findings of a national survey. Both one year and lifetime prevalence of various mental illnesses are presented. Results from this study found that 1 in 10 Canadians had at least one mental illness over a one year period, and 1 in 5 experienced one of these disorders in their lifetime.

These data are a significant improvement over the The Report on Mental Illness in Canada, which derived their data from smaller Canadian studies.

However, the problem with the CCHS survey is that only a portion of mental illnesses were examined. The researchers did not assess the prevalence of many disorders. To give an idea of the degree to which this exclusion of illnesses would bias the prevalence results, I have listed here the illnesses not included in the survey and the lifetime prevalence of each disorder based on U.S. estimates (1):

- Specific Phobia (12.5 per cent)
- Generalized Anxiety Disorder (5.7 per cent)
- PTSD (6.8 per cent)
- OCD (1.6 per cent)
- Dysthymia (2.5 per cent)
- ADHD (8.1 per cent)
- Oppositional Defiant Disorder (8.5 per cent)
- Conduct Disorder (9.5 per cent)
- Intermittent Explosive Disorder (5.2 per cent )
- Schizophrenia (one per cent)
- Personality Disorders (14.8 per cent)

As you can see, there were a large number of disorders not included in this Canadian survey. However, this is not the only problem. Similar to the more recent CCHS survey, the following groups were omitted from the study:

- those living in the three Canadian territories and resident of remote areas
- those living on Indian Reserves and Crown lands
- residents of institutions, and
- full-time members of the Canadian Armed Forces

When one considers that these groups were not included, in addition to the large swath of mental illnesses that were not evaluated, it becomes very clear that 1 in 5 Canadians is not even close.

Large scale American studies on prevalence of mental illness have found that 1 in 2 Americans will experience a mental illness in their lifetime.

While I certainly applaud these various health organizations for their efforts and hard work, I am quite dissatisfied with not only the biased statistics that have been formulated and disseminated, but also how no one has even noticed.

To help put into perspective the injustice of this problem, one only needs to surmise the reaction of politicians, health officials, advocates and indeed the general population if this same approach was used with a physical health problem like cancer.

Imagine if the true prevalence of cancer in Canada was somewhere around 50 per cent, but the government of Canada estimated the prevalence to be approximately 20 per cent because they included in their estimate only a portion of all possible cancers. The medical community would be in an uproar because there are important implications drawn from such data.

Health awareness in the community and funding for research and treatment are all affected by the estimated severity of a problem. And if you vastly underestimated cancer rates, the realistic danger is that cancer research and treatment would not receive the necessary attention and funding that it deserves, and the community at large would suffer. Thus, it is important to always have an accurate understanding of the severity of a particular health problem.

Well, guess what happens if mental illness is underestimated?

It is often said that mental health is the orphan of the Canadian health care system. Sadly, the lack of awareness in just how prevalent mental illness is in Canada only serves to further validate this conclusion.

References

1. Kessler et al. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.