On March 21, 2022, the mask mandate in Ontario will almost certainly be lifted, but you’ll see little change here at Central Ontario Psychology.
Many of our offices have big, bright windows which, unfortunately, don’t open. The typical psychotherapy session means two people will spend an hour together in one of these poorly ventilated spaces. Privacy demands that the door remains closed.
This is very different from the kind of brief encounter you might have while shopping. The clinician and the client will soon be breathing each other’s air, and they’ll be doing it for an hour.
We have equipped each office with a HEPA filter. This won’t hurt, and it should help—but how much protection will it really offer? We don’t really know.
Throughout the pandemic, we’ve enjoyed the legal right to provide our services to our clients face-to-face, provided everyone was masked (if they are capable of wearing one). But we made the choice, for the sake of the safety of both our staff and our clients, to offer as much of our work as we can through encrypted video services.
While the legal obligation to wear masks has changed, our ethical and moral obligations have not changed: We must offer our services in the manner which is safest, for both our clinician and our clients. [Update: As it turns out, our legal obligations haven't changed: In healthcare facilities, everyone still has to be masked, according to the Chief Medical Officer of Health.]
This is not fear—this is compassion.
COVID is proving to be a pernicious disease. While much of the focus has been on short-term outcomes, leading cases to be classified as “mild” if they don’t lead to hospitalization or death, the longer-term impact is only just beginning to emerge. It appears that even “mild” cases, including cases that were barely symptomatic, may be associated with severe consequences, such as increased risk of cardiovascular disease or cognitive impacts. There’s also the possibility that infections can lead to problems that won’t be apparent for many years, in the way that chicken pox can lead to shingles.
Vaccination has been terrifically helpful in reducing the severity of the symptoms, leading to reduced hospitalization and death. What is the impact of vaccination on these other severe consequences? To the best of our knowledge, those answers aren’t yet available. But if even mild symptomatic presentation is associated with these consequences, that could prove to be a major problem for society.
In addition, masks are our best defense against any new variant which might evade vaccination. Let’s not forget that Barrie was Ground Zero for the alpha “UK” variant in January 2021.
Therefore, for everyone’s safety, our policy will be to continue to require masks on both clinicians and clients in our facility (if they’re capable of wearing one).
In addition, we will continue to rely on video sessions, when the required service permits it (for example, some assessment procedures require masked face to face encounters, sometimes with brief removal of masks; and some psychotherapeutic procedures are best performed in the office). We will evaluate the need for face-to-face services in each case, with the goal of limiting the risks to our clients, clinicians and staff; and we continue to encourage the use of video services, whenever possible (which comes with the added benefit of making parking a heck of a lot easier!)
We look forward to being able to work with you, face to face and without masks. We want to be with you in your pain, and we want to see your smiles. But for now, we’ll be seeing them primarily through our video screens.
And speaking personally, I prefer seeing those smiles over video to having them hidden behind masks!
By the way, if you're going to wear masks, you might want to wear the best. Any mask will be better than none; surgical masks are decent at protecting the people around you; but a well-fitting N95 mask can dramatically improve the wearer's safety. And here's how they work:
--Dr Jonathan Douglas
Long before psychotherapy was defined as a controlled act, accessible by six different regulated professions (Psychologists, Physicians, Nurses, Social Workers, Occupational Therapists, and Psychotherapists), the Regulated Health Professions Act controlled who can perform which medical procedures in Ontario.
Of course, regulated health professionals are authorized by their colleges to perform certain controlled acts, within the scope of practice of their professions. Also, people in the course of joining a regulatory college can also perform them, under the supervision of a member of the profession.
But RHPA, written before psychotherapy was a controlled act, never foresaw that six different professions might perform the same act, and that they might commonly be involved in training each other.
Be that as it may, RHPA says that a person can perform controlled acts while in the process of becoming a member of a profession, if they are supervised by a member of “the profession.” “The profession” is interpreted as being a member of the profession the person is preparing to enter.
The practical implication of this: Psychologists can’t provide supervision of the controlled act of psychotherapy to students who are preparing to enter other professions.
Does this make sense? Of course not. Psychologists have a great deal of insight into the process of psychotherapy, and in-depth knowledge of psychopathology. Any student who expects to practice psychotherapy could benefit from our supervision, regardless of the profession they plan to enter. And students of psychology could benefit from exposure to other professions, too. The people of Ontario would be better served if all the professions which practice psychotherapy had access to each other as part of their practical training. But, sadly, the RHPA is written in such a way that this is not possible.
As supervision in our practice is provided only by psychologists, this means that students seeking a practicum experience will be turned away, with our regret, if they are not in a program that gives them a reasonable expectation of joining the College of Psychologists of Ontario; and this may even include programs that include the word “Psychology” in them, as programs of “Counselling Psychology” often fail to provide sufficient training in psychopathology and psychological assessment to meet our CPO’s standards.
Unless your program and your plans will lead to registration with CPO, unfortunately, we can’t offer you a practicum experience.
Everybody’s current circumstances are very different, but one thing remains true: We are all in the middle of a world pandemic. The reality is that COVID-19 will impact all of us to some degree. Some of those reading this are front-line workers (thank you!). Some have lost their jobs. Others are attempting to work from home while also suddenly being their children’s teacher. Despite our different situations, we are all dealing with some identical factors: The unknown of what the future holds, the added stress of juggling work (or work-loss) and children who are now at home 24/7. Our current circumstances can cause anxiety even for those who would not typically consider themselves as anxious individuals.
The following tips are laid out in a fairly broad way, understanding that we all (to some degree) are facing uncertain times and added stress, but also realizing that no two situations are alike. As a parent, I know firsthand how unique each child is. What works for one, likely won’t work for another one. Be kind to yourself, and know that you are doing the best job you can. I believe that you were given your children as a gift and that YOU are the best parent (positive and negative attributes and all) for your unique child.
1. Be aware of your own anxieties and how you respond to them.
Children are like sponges. Being aware of our own anxieties is the first step to supporting our children’s anxiety. This is not an easy task, and will take time. A great resource is: Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle and Raise Courageous and Independent Children by Lynn Lyons and Reid Wilson. Even if you don’t identify as an anxious person, we all experience anxiety to some degree. This book will help you learn how to model healthy coping strategies to support your children’s own mental health development. It is important that as parents we try to be cognizant of our own response to anxiety, and model healthy coping strategies in front of our children. Our children look to us when trying to interpret ambiguous situations. If they see that their parents are fearful, the child will interpret that situation as something to be afraid of. If you struggle with anxious thinking, the best thing you can do is to try not to display an anxious thought pattern in front of your children.
2. Be present and available.
Our children are more aware than we may realize about the current situation. At the beginning of the isolation period I heard my four-year-old telling my two-year-old that EVERYONE was going to die. “Grandma’s going to die, Grandpa’s going to die, our cousins are going to die….” And the list went on. My husband and I had been talking in the car about the facts, but never used any language to suggest that those we loved were going to “die.” In fact, when my four-year-old asked, I thought our response was quite good: “some people are getting sick right now, and yes we may get it too, but we will get better from it, there’s nothing to worry about.” The reality is, somehow she had interpreted what she overheard as “everyone we love is going to die,” and she felt the need to share that with her younger sister. It was heartbreaking to hear, but also important that I overheard this conversation. As parents, the best thing we can do is be available to answer their questions and correct any misconceptions. We may not know the answers, and that’s okay, but we can help our children get the answers.
Right now our children need us more than ever. We can be a constant for them as we all face unchartered waters. Parents need to be the safe spot for their kids. They will follow our lead. If we are calm, they will be calm. If we freak out, they won’t feel safe. Do things with your children as much as you are able to. The memories you can make together will be more valuable than anything else you can provide for them. Have fun! Be creative! Build memories that will last a lifetime. Also, be mindful of actively treasuring these family times as much as possible (even though there are so many jokes circulating social media about our children driving us crazy… let’s be real, parenting is HARD!).
3. Acknowledge their emotions.
Children do not know how to process their emotions well, especially the younger they are. They are experiencing loses that they don’t fully understand. They miss their friends and family. They may not be able to have a birthday party right now. Some are even missing out on graduation parties. Their feelings may be coming out in ways that you don’t fully understand. For example, their anxieties may be displayed by “acting out” behaviours, tantrums, and irritability. We can help them process these emotions by giving them the words to describe how they are feeling. For example, “I see you are upset. Is it because you are sad that you cannot hug grandma right now?” Instead of telling them to “stop crying,” let them know you “see them” and that you recognize that they are “upset/sad/mad.” This not only helps give them some language to use, but also makes them feel understood. Then, when they are calm, help them work on ways they could express those same emotions in more appropriate ways.
4. Implement routine as much as possible.
Depending on the age of your children, and your personal circumstances, this won’t always be possible. But, whenever possible, try to provide some structure to your children’s day. For instance, as much as possible, keep bedtimes and wake times consistent, and set aside time for school. Children thrive on routine, and during uncertain times they need structure more than ever. It’s also okay to be flexible and break routine from time to time. If school work doesn’t get done today, that’s okay! We want to try to lessen the stress, not increase it. This is also a great time to introduce new routines or family traditions. Maybe life was so busy before that it was hard to sit down as a family to have dinner. Schedule family dinner time now!
5. Limit exposure to the news.
This is a hard one. My inbox is flooded with COVID-19 updates and every other post on social media relates to COVID-19. We often expose ourselves too much to the news; we don’t want to miss that “positive” announcement. This behaviour is similar to someone who has a gambling addiction. They sit at the slot machine for hours (or days) in hopes that their next pull will be the “one” that makes them lots of money. Similarly, because of the random pattern of the “rewards” we are provided, we don’t want to miss anything. Maybe that “reward” is news that we are flatting the curve, or that more funding is being provided to those who are unemployed or for families, or maybe it has to do with businesses now being allowed to open.
The problem with flooding ourselves with the news is it usually increases anxiety. This doesn’t mean you shouldn’t listen to the news. It just means we need to limit it. Not only is this healthy for you, but also for those little ears that may be overhearing. So set a scheduled time(s) in your day to review the latest updates. Try to limit these times to no less than two hours before bedtime. And, engage in some sort of activity to “clear your mind” afterwards. Just like you would “cleanse your palate” between wine samplings, do the same between news updates. This could be something as simple as watching a TV show, doing an activity with your children, reading a good book, etc. It is important to try not to have the news on in front of our children, especially young children. Some kids are getting way too much information.
6. Get active.
With gyms, recreation centers and parks closed it can be hard to get physical activity in. Sometimes it’s also hard to muster up the motivation to be active. Physical activity is VERY important for your mental well-being. Encourage your children to get active in fun ways. Add this into your schedule and whenever possible make it fun.
7. Model self-care for your children.
Get active yourself. Set time to do things for yourself and let your children see this. Not only will this benefit you, but it also will help to model the importance of self-care for your children. Remember, you cannot take care of your children if you are not first taking care of yourself. This is a hard one to find time for, but it is so important.
8. Practice physical distancing, NOT social distancing.
The term “social distancing” is understood by everyone to mean physically distancing yourself from others. We must practice physical distancing, but more than ever we need social interactions. Connect with family and friends as much as possible, (while following the rules of physical distancing). Be intentional and creative with how you stay connected. Many organizations (churches, daycares, schools, clubs, gyms etc.) are moving towards social platforms to stay connected. There are endless ways to stay socially connected while physically distancing yourself from others.
As a family, identify people who may need to be “adopted” by your family right now; for example, those who live alone might need some extra support. This might not even be someone you know very well, but a neighbor who you have noticed lives by themselves. This will not only bless the “adopted” individual’s life, but, you will be modelling selflessness and empathy to your kids. A basic distress tolerance tool in dialectical behavior therapy (DBT) is to “contribute” (part of the A.C.C.E.P.T.S. strategy from DBT). By contributing (i.e., doing something for someone else or for the community as a whole) is rewarding and helps distract us from our own current distress (until we can better process it). Do something for someone else. Send “happy mail” to someone. Leave something at someone’s doorstep. Offer to go to the store for the elderly couple down the road. Be creative!
9. Seek professional support.
Believe it or not, many mental health professionals (e.g., psychologists / psychological associates, social workers, psychiatrists, psychotherapists, etc.) have more availability right now. If you are comfortable with seeking services through virtual platforms, now is the time to seek support for you or your children.
Most importantly, remember that parenting is hard. Be kind to yourself. Recognize that none of us have it “all together.” We are bombarded with “perfect family life” posts on social media. People don’t post the bad, only the good times. What we see on social media is not the realities of everyday life. We are all experiencing the ups and downs of the current situation. We will have good days and we will have bad days. Try and be kind to yourself, remembering that you are not alone. Stop and remind yourself what you have to be thankful for, even during the chaos of parenting. You got this!
--Laura Stevens, MSc, CPsychAssoc (Supervised Practice)
After many years of providing support and treatment to those who have suffered from motor vehicle accidents, we have made a difficult decision: It's just no longer worth it.
The payment is poor (and often slow and unreliable), the work is demanding, the administrative demands are overwhelming--and it's become demoralizing to know that our conclusions and recommendations will often be denied by a system that prefers to assess than to treat.
The sad thing is, we're not alone. It's not easy to find psychologists with the experience, knowledge, and willingness to put up with the auto insurance system, because the system, which is so heavily designed in the favour of the insurer, is so hard not only for the injured party, but for the provider.
When the reaction to an MVA referral is to groan out loud, it's time to walk away--we're not going to do anyone any good by taking part in a system which saps our energy and enthusiasm.
We'll continue with all those clients currently under our care, of course. But we regret that we'll be turning people away in the future.
Mesdames et messieurs, thank you for giving me this opportunity today. It’s quite humbling, as I do not consider myself an expert in quinism. Instead, I’m an expert in operational stress injuries, or OSIs: those diagnoses that arise from the stress of military training and operations, including PTSD, depression, adjustment reactions, and any of the myriad other problems that arise as a result of being thrust into extremely demanding situations.
I’m very pleased that the committee will be hearing from the real experts on quinism. In particular, I have learned much from Dr. Remington Nevin, who has studied quinism extensively, and will be able to teach you much more than I can about the neurological damage that it causes.
I’m here today primarily because I have listened to Veterans. Through doing so, I have learned about the challenges associated with mefloquine, including the difficulty that diagnosing it can represent.
I have worked with Veterans for about 15 years now, and as part of my work, I have completed many psychological disability assessments. For most of these, the issues associated with quinism have not been on my radar. It’s simply not something there’s much awareness of in my field.
To diagnose an operational stress injury, I begin with a clinical interview. I need to understand the Veteran’s presenting symptoms, and I gather a history, so that I can understand how they were functioning before and after the exposure to the military.
I look at the operational history of the Veteran, including what tours they went on, and what traumatic events occurred. We look at physical injuries, including exposure to blasts, as well as any other physical issues which might arise from the rigors of training and deployment.
I review what documentation I might have available (which is often pretty scant), and I administer psychological tests. From these, I’m able to identify the Veteran’s symptoms, and in combination with the history, I can draw conclusions about the diagnosis, and its probable link to military service.
I’d like to take a moment to review the diagnostic criteria for PTSD. You may already be reasonably familiar with these, but please bear with me, as I think it’s worth reviewing them in this context.
The diagnosis of PTSD is rather unique among psychiatric diagnoses. That’s because diagnosis begins not with the symptoms presented by the patient, but with an examination of the event.
Criterion A is directly experiencing, or witnessing, actual or threatened death, serious injury, or violence.
In the course of their careers, many, if not most, Veterans will experience an event which meets Criterion A. However, they don’t all end up with PTSD. They must experience symptoms which arise following the event:
Criterion B requires one intrusion symptom:
• Intrusive memories of the event
• Recurring dreams in which the content or mood of the dream reflects the trauma
• Dissociative reactions, such as flashbacks in which the person feels or acts as if it’s happening
• Intense or prolonged psychological distress at exposure to reminders of the event
• Physiological reactions to reminders of the event
Criterion C requires one avoidance symptom:
• Efforts to avoid distressing memories, thoughts, or feelings associated with the event
• Efforts to avoid external reminders of the event, such as people, places, conversations, activities, or situations
Criterion D references two symptoms of negative alteration in cognition or mood:
• Inability to remember some aspect of the event
• Exaggerated negative beliefs about oneself, others, or the world: “I’m broken,” “No one can be trusted”
• Distorted beliefs about the cause of the event, leading to blame of self or others
• Persistent negative emotional state (fear, anger, guilt, shame)
• Withdrawal from activities
• Feeling detached or estranged from others
• Inability to experience positive emotions
Criterion E references two symptoms of alteration in arousal and reactivity
• Irritability or angry outbursts
• Reckless or self-destructive behaviour
• Exaggerated startle response
• Problems with concentration
• Sleep disturbance
Criteria B through E represent the symptoms of PTSD, and in each case, there should be evidence that the symptom began or worsened following the trauma. In these symptoms, you’ll find the echoes of other OSIs, including depression, or anxiety disorders. Substance abuse can be used to self-medicate and mask many of these symptoms; those who have strong reactions to events that don’t meet Criterion A might be diagnosed as having an adjustment disorder. All of these are common OSIs.
For our purposes, there’s one more important criterion for PTSD: Criterion H says these symptoms must not be attributable to the physiological effects of a substance—such as mefloquine.
That final criterion is pretty close to universal in DSM-5, as it’s found in the diagnostic criteria for most disorders. It’s so common, it’s actually easily overlooked; when you’re dealing with psychological trauma, it’s rare to see someone in clinical practice whose symptoms can be attributable solely to the effects of a substance. In fact, before I’d heard of mefloquine, I was not aware of any substance which could mimic PTSD. And this substance was often prescribed in proximity to a traumatic event.
When we look at the symptoms of quinism, we’re going to see that they mimic many of the symptoms of PTSD and other OSIs.
According to the work of Dr Nevin, the adverse effects of mefloquine can include the following psychiatric symptoms:
• Panic attacks
• Severe mood swings
• Mania (racing thoughts, irritability, paranoia, excessive goal-driven behaviour, euphoria)
• Dissociative symptoms such as derealization and depersonalization
• Sleep disturbance, including terrifying, intense nightmares, or sleep paralysis (an experience like being awake in a body that will not move, often with a terrifying hallucination)
With varying degrees of frequency, all of these symptoms can, and do, present as sequelae to exposure to psychological trauma.
I’m thinking of two Veterans I’ve worked with. Both meet Criterion A for PTSD. Both present with an unusual feature, which I rarely see in OSIs: Hallucinations. Only one was exposed to mefloquine, and he experienced the full prodromal reaction: nights of severe terror, punctuated with what seemed to be auditory hallucinations of animals screaming in the forest surrounding him. Today, he suffers from tinnitus and a persistent auditory hallucination, consisting of mumbling voices, along with other more typical symptoms such as irritability, anxiety, and mood disturbance.
It was years after his initial diagnosis of PTSD that the issue of mefloquine came up—and that was the first time I’d ever heard of the word. I only heard about it because he brought it to my attention.
As we’ve seen, PTSD should not be diagnosed when the symptoms can be explained by the impact of a substance, such as mefloquine. Does this mean that his diagnosis is not accurate? Frankly, it’s possible. But I think the question may be more complex than a simple “yes or no” answer.
One of the challenges in clarifying the diagnostic conundrum is that Veterans may not always be able to accurately reconstruct the order in which events occurred, particularly vague events such as the emergence of a symptom.
Let’s consider a possible timeline: A soldier is deployed overseas, on his first tour of duty; there are no prior exposures to traumas. To prevent malaria, the soldier receives a course of mefloquine; he and his buddies joke about how rough their Friday nights are, after they’ve received the weekly dose of the drug, but they’re either not aware of the risks of continuing to take it, or they dutifully push through. Almost immediately after treatment, the soldier is exposed to a war zone, with all the horrors that entails.
When the subsequent symptoms arise and persist, are they solely due to the mefloquine? Are they solely due to the exposure to trauma?
Soldiers are not always the greatest historians. After years of pushing their emotions to the side, and ignoring discomfort, it can be difficult for them to remember precisely when a symptom arose. In the midst of a war zone, it’s only natural to be anxious, vigilant, and irritable. Years may pass before the psychological injury is assessed. How are we to say whether the symptoms are due to quinism or trauma?
There are some symptoms, more neurological in nature, that might be helpful—things such as difficulty with balance, vision, vertigo, or tinnitus, which do not typically present solely as the result of PTSD. Again, though, these have their own confounding variables—including the impact of blast injuries and concussions.
And of course, if the mefloquine was taken not on the first tour, but after the soldier has already been exposed to chronic trauma, then exposure to mefloquine may or may not account for subsequent symptoms.
The interaction between quinism and OSI may prove to be quite complex. Consider, for example, research on how MDMA, or ecstasy, can help Veterans overcome traumatic memories—in a nutshell, a drug which induces feelings of warmth and compassion, when paired with a traumatic memory, helps to settle the anxiety provoked by that memory, with lasting effects.
Is it not likely that quinism does the opposite—a drug which provokes a chronic state of anxiety, when paired with a trauma, leads to a greater likelihood of PTSD?
In some tragic circumstances, there may be another source of trauma—actions taken while under the influence of the drug could lead to horrific moral injuries. I understand that soldiers in the Airborne Regiment in Somalia were given mefloquine. Imagine being such a soldier. You might find yourself asking how you came to violate your values and your duty by acting violently and illegally. Though it may not meet Criterion A, perhaps the reaction to the drug is a kind of trauma in itself—is there anything more traumatic than having your very self, including your values and your sense of reality, stripped away?
Our understanding of quinism is in its infancy. We have yet to grapple with its impact on the diagnosis, misdiagnosis, overlapping diagnosis, or exacerbation of Operational Stress Injuries, in part because too few of us are sufficiently aware of the need to screen for mefloquine exposure, and subsequent reactions to that exposure.
In our ignorance, we’re also at risk of creating Sanctuary Traumas. A Sanctuary Trauma occurs when someone expects to find help and support, but instead, experiences invalidation and rejection. Research shows that the experience of such injustice can have a severe impact on recovery from physical and psychological injuries.
Therefore, it’s imperative that the Veterans coming forward with stories of quinism have access to well informed case managers and clinicians; and that means we must disseminate what we know, and do the research necessary to learn more, so that we know best how to assess and treat this complex condition.
Certainly, we need to start asking the questions, both as clinicians and researchers. I am grateful that the Ministry is asking the questions that need to be asked. I hope I’ve been of some help to you in that quest. Thank you for your time. Merci.
--Dr Jonathan Douglas
The "RTW" process is a pretty individualized process for me. Question one is always about what the worker feels ready to do—it’s rare for me to be convinced the worker is ready when they don’t think so, and probably rarer still for a resistant worker to make a successful RTW. If the worker is resistant, it's important for the psychologist to understand why, and if appropriate, address the underlying issue. Getting the worker on board is very helpful, if it’s at all possible. RTW should be a cooperative process, and everyone involved needs to recognize that.
On the other hand, we have to struggle with the process of avoidance, and make sure that the worker isn’t giving into an avoidant strategy when they could and should take on more. I think this is a matter of testing the ground prior to RTW—you can get a lot of sense of their readiness from how they handle tasks outside of work, such as shopping, yard work, exercise, social interaction, etc. If I can’t get them going in the community, chances are they're not ready to get going at work. This will also let me know how they are handling any provoked symptoms, and give me a chance to help them to practice coping strategies.
Next we have to consider what they’re ready to take on in comparison to the job demands. A good understanding of what the job entails, and what accommodations are available, is necessary. Personally, I like to leave WSIB up to the task of interacting with the employer as much as I can—the RTW Specialist is a wonderful resource. Workers are often highly anxious around WSIB interaction, so getting the RTWS involved early is important. It can take an incredibly long time to move from “I think we’re ready” to the client walking through the door at work.
Finally, we need to consider restrictions vs. accommodations. A restriction should be that which the worker clearly cannot do. Physical safety to self and others is the top priority here. For example, someone with significant deficits in focus and concentration shouldn't be in a position where a momentary lapse can put someone in danger.
Psychological safety is a more nebulous concept (and more controversial—cf. the concept of “trigger warnings.” How much discomfort is reasonable as we navigate an unpredictable world? How much should the world adjust to our emotional distress? That's a whole other blog post!)
An accommodation is that which the client can do with modification to the task. We need to push workers to experience some discomfort—to the extent that they can handle it. There’s a lot of judgment in that. Some anxiety may be reasonable; a panic attack may cross the line. How is their impulse control when under stress? Will sleep be disrupted by anxiety, pain, or shiftwork, , and if so, how will that impact on their emotional regulation? Will the worker lash out verbally at coworkers or customers? Can adjustments to work demands or schedules be made to mitigate that risk while the worker re-adjusts and continues healing?
Then there's the issue of bias. Underlying the whole thing is the role of the health care professional in an economic system: As we push our client back to work, is that because getting referrals depends on returning workers to work quickly, or because (as I’ve seen) the referral letter specified an arbitrary, a priori expectation of a RTW date? Is it our job to treat our patients, or to ensure that insurers don’t lose money on a claim? Is it our job to get people back to work because work is best for them, or because work is best for the employer, the insurer, our reputations, and our economy? Do we resent those who have access to benefits while others have to work? Does the concept of “milking the system” whisper in our ears, poisoning our perceptions of the disabled worker? Are we just acting as the pawns of The System, believing we’re acting for our client’s best interests when in fact The System is so deeply entrenched we don't see how its influence affects us?
Or, alternatively, are we advocating for our assessment of our client's needs...or for our client’s preferences? Are we afraid of losing the relationship with the client if we push them outside of their comfort zone? Do our hearts bleed in the face of our client’s pain and distress, causing us to want to protect them—but keeping ourselves from pushing them to be all that they can be? (And is all that they can be just another cog in the machine? Aren't other ways of being in the world just as valuable as being a "productive worker"? Is it moral to return a worker, injured in a good job, to work which is less satsifying?)
There may not be a clear answer for many of these variables--the RTW process demands careful assessment, not only of the client, but of my own political and economic biases. The best I can do is communicate as openly and honestly as I can with my client, while standing up not for the client's preferences but for my assessment of their actual restrictions and need for accommodations, and working as co-operatively as I can with all the players--but always with the client's best interests at heart.
Dr Jonathan Douglas
It's so important in the face of these tragedies that we remember: The tragedy of the suicides hits us in the gut, leading to headlines and shock. And they get communicated, quickly and powerfully. This is good, because without the talk of suicide, it's likely that PTSD wouldn't be recognized for the serious injury that it is.
However, it's also true that suicide is still a comparatively rare outcome of PTSD. Far more people survive PTSD than succumb. Some people even grow through the experience of it, even if they're forever changed.
The stories of survival don't sock us in the gut the way the stories of suicide do, and they don't get shared as readily. And our brains aren't wired for statistics--they're wired for experience and narrative. So we tend to think that the thing we hear about more often is more common than it really is.
That can be dangerous, because we can develop a schema about PTSD that says "this diagnosis is fatal." And that can be a self-fulfilling prophesy.
We need to honour this life and mourn this loss, but we must never given in to fatalism. Suicide is the exception, not the rule. Far more people survive PTSD than die from it. And those stories of survival aren't so easy to find.
Take care of yourselves, and keep surviving until you're thriving.
There may be nothing quite so stigmatizing about PTSD as the belief that it's easily faked. People are routinely accused of "milking the system." They assume that faking PTSD is as simple as memorizing the symptoms and reporting them. So how easy is it, really?
I took one of our commonly used psychological tests. This is a measure I know very well. And I set out to fake PTSD, a disorder I know very well. I imagined that I'm trying to present as someone wanting time off work because of PTSD and depression. What would show that I'm really struggling? How would such a person present?
The test I used is designed to not only record people's reported symptoms, but to examine how they approached the test. Were they exaggerating, or minimizing? Do they view themselves especially negatively? How similar are their responses to those of people who are setting out to falsify their results?
I use this test at least once a week. Let's see if I know it well enough to beat the test.
Big T, little t: What begins PTSD?
PTSD is unique in psychological diagnosis. Usually when we diagnose somebody, that’s what we’re doing—diagnosing SOMEBODY. But Step One in assigning a diagnosis of PTSD isn’t about the person. We start with the event they were confronted with.
The current version of DSM, the diagnostic manual published by the American Psychiatric Association and most commonly used in North America, defines a traumatic event in this way:
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. directly experiencing the traumatic event
2. witnessing, in person, the event as it occurred to others
3. learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental
4. experiencing repeated or extreme exposure to aversive details of the traumatic event (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion 4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related.
Does this mean that events that do not meet these criteria cannot produce posttraumatic reactions? Absolutely not. People have a wide variety of reactions, both to events that meet the criterion for what we might consider to be the “Big T” Traumas that meet the definition above, and to events that do not meet this definition – those things that I like to call “small t” traumas. However, for a person to be diagnosed with PTSD, the event to which they were exposed must meet this description.
It is important to realize, too, that PTSD is not the only psychological injury that can arise from trauma (whether Big T or small t). Mood disorders, anxiety disorders, adjustment disorders, substance use disorders, and even psychotic disorders can arise as a consequence of events. Where there is a diagnosable condition and significant impairment, which arose as a consequence of an event, we would consider this to be a psychological injury—and PTSD is only one example of such an injury.
Consider, for example, a reaction to the break up of a relationship. Maybe this breakup came suddenly, with no warning. You might respond with numerous reactions to that event, including disruption in sleep, withdrawal, depressed mood, irritability, and anxiety. I do not think anyone could blame you for describing it as a “traumatic” event in your life if, say, you came home to find your partner in bed with your best friend. However, this event would not meet the definition for PTSD. A more likely diagnosis would be an Adjustment Disorder, a reaction to an identifiable stressor which includes one or both of:
· a level of distress which is out of proportion to the severity of the stressor, or
· significant impairment in social, occupational, or other areas of functioning.
Without question, some of the criteria for diagnosing a Big T Trauma involves the use of judgement (for example, what constitutes a “serious” injury?), and lines that may be considered to be somewhat arbitrary: Repeated exposure to traumatic material can produce PTSD. Repeated exposure to traumatic material through electronic media cannot produce PTSD. Repeated exposure to traumatic material through electronic media which is part of a person’s work can produce PTSD.
One gets the impression that some of the lines that get drawn here are based not so much on what we know about people’s clinical reactions to traumatic material as on a concern for how the diagnosis of PTSD can have an impact on extraneous concerns such as employment law and compensation for injuries.
In fact, it’s often important that a trauma therapist be able to interact effectively with the legal system, as so often, psychological injuries end up before the courts or need to be adjudicated by some other third party. If you’re dealing with psychological trauma in the context of such a system, be sure your therapist is comfortable with writing reports, can defend the diagnosis, and will be able to provide convincing testimony in court.
The Disability Tax Credit
It’s the time of year when our clients are told by their accountants that they should ask us about the Disability Tax Credit.
The concept of disability is easily misunderstood. There’s no universal definition of disability. You might be off on “disability” due to an inability to work; however, that does not mean that the definition of disability used by the DTC would apply.
Psychologists are commonly asked to rate the disability in the Mental Functions Necessary for Everyday Life category. This is defined in this way:
A person is considered markedly restricted in performing the mental functions necessary for everyday life (described below) if, even with appropriate therapy, medication, and devices (for example, memory aids and adaptive aids):
It is important to address what occurs at home or out in the community, not only what occurs in a work or school environment.
An “inordinate amount of time” is defined as taking three times longer than the typical individual to perform the task; and this would have to be true 90% of the time.
As an example, difficulties in memory and concentration, which are common in many of the conditions we treat, could meet the definition. However, most of the people we treat could not meet the definition of “markedly restricted” in spite of having difficulties with memory and concentration. Someone with such a marked restriction could probably not successfully follow through with appointment times and navigating to our office without substantial support from a third party.
Unless you are substantially unable to care for yourself, pose a risk to your own safety without supervision, or are unable to manage your own affairs, it is unlikely that you will meet the bar set by the Disability Tax Credit from a psychological perspective. These conditions must impair your functioning 90% of the time, and be expected to last 12 months or longer, to qualify.
Also, beware of companies that offer to help you receive the DTC. These companies make their money by taking a percentage of what you are awarded, while claiming to help your doctor complete the forms. In reality, such companies are often predatory, and in fact, their practices have forced the government to take a much harder line on the DTC. If you qualify, your health care practitioners can complete the form on your behalf without any input from such companies. You can read about such companies here.
--Dr Jonathan Douglas