Episode 04 : Interview with Senator and Psychiatrist Stan Kutcher on Mental Health in Canada (Part 1)
In this episode, Dr. Sagar Parikh interviews Canadian Senator Stan Kutcher on his journey in becoming a psychiatrist, getting involved in teen mental health, and discussions on how the school system can take part in providing mental health care.
Dr. Wegdan Rashad: Hello and welcome! You are listening to the CAN-BIND podcast and I am your host, Dr. Wegdan Rashad. This is our 4rd podcast episode and it’s a very special one…it is part one of 2 where Dr. Sagar Parikh interviews our guest; Senator Stan Kutcher on becoming a psychiatrist, getting involved in teen mental health and how the school system can take part in providing mental health care. I’m sure you’ll enjoy this one…happy listening!
Dr. Sagar Parikh: Well, hello everyone and welcome. This is Dr. Sagar Parikh from the CAN-BIND Research Program and welcome to our CAN-BIND Podcast. I’m really honored today to have with us a very special guest and a friend, Dr. Stan Kutcher. He brings a wealth of information and background. He’s a psychiatrist but he’s, oh my god, he’s a senator too! Yes! He doesn’t play hockey so he’s not quite an Ottawa Senator but he is a senator who lives and works at least part of the time in Ottawa and yes, in that big fancy building known as the Canadian Parliament. Dr. Kutcher, welcome.
Sen. Stan Kutcher: Wow! Lovely to be here. Sagar, it’s so nice to see you again virtually. On that Ottawa Senators thing, when I was appointed to the senate, I told our grandkids that I was going to be a senator in Ottawa. And one of them said, “But you can hardly skate.”
Sagar: Well, you know what, he was really thinking about the Ottawa canals —
Stan: That’s right.
Sagar: And what you would do when you had to skate to work in the mornings on those canals, right?
Journey to Becoming a Psychiatrist
Sagar: You are a psychiatrist. And maybe you could share with us a little bit about where you trained in Psychiatry and some of your early career interests in Psychiatry.
Stan: Sure, sure. Well, I’m a Ph.D. dropout in History. I was studying, I did Political Theory and Geography and History and Political Philosophy in undergraduate and then went into postgraduate work in History. And partway through my Ph.D., I decided I wanted to go to medical school. And at that time, the only school that would take someone like me was called McMaster and they were an experimental medical school, so I was part of that experiment. And while I was there, I had some unbelievable mentors, people who really took an interest in me as a human being and who brought their curiosity and their depth of knowledge to that interest and they were many in different fields. But one of them was in Psychiatry. And there were two particular ones, one named Nahum Spinner who was basically a Talmudic scholar who needed a day job and hence became a psychiatrist. And there was Greg Brown who was a neuropsychopharmacologist. It was just when Neuropsychopharmacology was opening, and Joel Elkes who was also a pioneer in this whole area of brain and behavior. And those three people, I got to know them as a medical student for crying out loud.
Stan: And they took an interest. And so I realized that Psychiatry was a medical discipline that combined basic chemistry with the works of Shakespeare. And there was nothing else that actually in all of Medicine that was that broad. So that’s why I ended up taking Psychiatry.
Career Towards Teen Mental Health
Sagar: Well, you know, it’s interesting you mentioned Shakespeare and Psychiatry. And then, you know, what that brings to mind for me is Romeo and Juliet as troubled teens. Can you tell us how you got interested in teen mental health?
Stan: Well, maybe partly because I may have been a troubled teen myself. But all the way through university and the different places, I worked in recreation with young people, various recreation places in the summer and the winter. And one summer, I worked with Frontier College as a laborer-teacher where I was really exposed to indigenous cultures and the challenges indigenous people had just to become part of the accepted direction of Canadian society. And I worked in downtown mission areas, in Hamilton and in places where there were poverty and crime. And so those were sort of founding components. And I realized that young people had so much opportunity but they all didn’t have the same opportunity. And that was sort of a general realization. And then as I was working with young people, I realized that some of them actually had additional challenges. It is now in retrospect that I look back at them, there were challenges with their mental health. There were mental illnesses they were developing.
And when I went into Psychiatry, I can still remember in my first year starting to take histories of patients that were on inpatient. Michael Rosenbluth an outstanding psychiatrist in Toronto was my first supervisor on inpatient. And he told me, so you go in there with the patients and you take their entire life history and don’t come out until you got it. And he was so right. And over and over again, I kept hearing that this happened in adolescence. These things started in adolescence. And at that time, we hadn’t realized that the majority of mental illnesses could be diagnosed in adolescence. But it was that realization. I can still remember getting that realization that if I really wanted to make a difference, I had to try to start where the disorders actually were being manifested that we could identify, we could diagnose and we could treat.
Sagar: So Medicine is very much an art and a science. And you were interested in History. And it’s fascinating to hear how you were able to use your humanistic ear and get the history and then make what I would say is a scientific observation which is that troubles, mental health troubles may arise in adolescence. And so the turbulence that teenagers may experience may be part of a universal developmental phase but there’s also the opportunity for things to go wrong or things to evolve or arise for the first time. And these could be mood problems, anxiety problems, substance use problems. You chose to pursue that and I think more focused on mood although anxiety overlaps with mood in teenagers so much. Can you tell us a little bit more about your interest in mood disorders in teenagers?
Stan: Well, you’re right. Both mood and psychotic illnesses, so those are the two disorders. And I came to that sort of backended because during my training I was lucky enough to do a fellowship in Child and Adolescent Psychiatry at the Hospital for Sick Children with outstanding, outstanding clinicians, Paul Steinhauer being one, Quentin Rae-Grant being another. And then I actually did Geriatrics. I did a fellowship in Geriatric Psychiatry and Ken Shulman was my mentor there. And I began to see through that. And Sagar, there was no forethought into this. It was complete serendipitously. I began to see the trajectories from early childhood, adolescence, into adulthood and then on into the geriatric years. In fact, Ken Shulman and I did a book together called Mood Disorders through the Life Cycle. Mauricio Tohen was one of the editors as well. It was the first one. It was a life span approach.
Sagar: I remember that book. Yes.
Stan: Thinking of these things throughout the life span and then trying to understand what were the things that occurred that took this normal turbulence of mood and pushed it into a disorder of the control of mood. What took the normal wonderful creativity where you could stand outside, dissociation in the service of the ego, I think the analyst used to call it at that time, and turn it into a psychosis? Like what was the difference? Because in one hand, it was part of a normative developmental process and sometimes they were healthy developmental process. On the other hand, it leads to substantive difficulties in the functioning of everyday life. So that was the question.
Sagar: Right. So again, you know, the art and science. Seeing the trajectory. Seeing how somebody’s life unfolds and then looking for roots there of what might in the future might be disorders or problems of some kind. So you did your training in Central Ontario, in Hamilton and in Toronto. But somehow, you got on a plane and you ended up in Halifax. Tell us about that.
Stan: Well, there was a little bit of time before that. I went to Edinburgh and I did a post doc in Edinburgh. Then I came back to Toronto and I had the opportunity to really take on the adolescent unit at Sunnybrook and to move it from a clinical unit to an integrated clinical research and community-linked service. And then I went to Halifax to become chair of the department and that was a whole other thing because I learned how to do administration. I learned the importance of policy. I learned the necessity to be able to take best available evidence and try to put into policy so it actually could make a difference in people’s lives. It was at that time that I got involved with the Pan American Health Organization and the WHO and I was asked to develop a WHO collaborating center at Dalhousie which I did. And that opened the door for me to work in Sub-Saharan Africa, I worked there for over 20 years, in China, other parts of Asia, in the Middle East, in South America, the Caribbean regions, Latin America. So those were all very formative components so that I was able to understand that although the disorders were very similar, it doesn’t matter where you went. How they manifest themselves could be slightly different depending on the culture and other components. But the way that societies or governments or nations or communities reacted to those needs was vastly, vastly different.
Observations on Culture and Perception of Mental Health
Sagar: That’s a fascinating trajectory with the intense attention to individual stories, to careful history taking across the life span. And then you had to deal with systems and you initially started as you said as a chair of Psychiatry at Dalhousie University, you know, managing the local healthcare system, managing the training needs and getting perhaps a small province’s perspective on dealing with mental health. But then you followed that with an extensive involvement in many different international sites. And so you know, are teenagers the same in different countries? Do teenagers in other countries go through the period of turbulence that is such a dominant theme of our Western society?
Stan: One thing that I have learned from the privilege of just being in different places, working and getting to know people in different cultures and different locations is that humans are more similar than they are different. And yes, there are cultural differences in how people express themselves but basically, you know, we’re all human beings. We all have the same emotions. We have the same cognitions. We have the same worries, fears, aspirations. And cultural frameworks can facilitate or can repress specific types of behavior. They can change the way emotions are manifested but they don’t change the fact that those emotions occur and they don’t change the fact that creativity occurs and all those different things. So what I would say to that is yes, we are more alike or the same. How we express that thing can differ from place to place.
Sagar: Well, that gives us another angle to think about and that’s the public health angle and the epidemiologic angle. One of the dominant worries of our civilization is the fact that it appears that rooted anxiety disorders and all kinds of distress in teenagers are much more prevalent now than say 20 years ago. Do you really believe that? Or is it just that we’re detecting more things? Or are today’s teens just wimps and they just don’t know how to handle things? I mean, what’s going on here?
Stan: Well, I think a couple of things. From my reading of the literature and I’ll be interested on your perspective on this is that when we use similar diagnostic criteria including functional impairments, the prevalence of major mental disorders has not changed all that substantively. What we have seen is an increase in accessing care, part of which can be I think explained by greater awareness that these mental disorders exist and that care should exist. That’s a whole other conversation. However, I think we’re also seeing certainly in the last decade and a half, maybe a little bit longer a degree of distress intolerance that is being confused with the negative emotions that require treatment. And I think that there are multiple and complex social factors at play. And I’m no sociologist. I don’t want to pretend to be. But I do notice that the public’s tolerance for distress, particularly in young people has changed dramatically from the 1950s to early ’60s to today. And young people themselves rate their distress for the same stimulus way greater now than they did in the past.
And I think expectations, I think that we’ve been living in the Western world, not everybody — I want to come back to this because this is so important. But generally, we’ve been living in an era of superfluous abundance. And that superfluous abundance has its health toll. And the physical health toll of superfluous abundance in my opinion is obesity. And the mental health toll for superfluous abundance is this idea that we are distress intolerant so that if I’m unhappy, it means I’m depressed. If I feel worried, that means I’m anxious. And it’s this modulation of the normative stress response when we’re faced with stressors in our lives which 30 or 40 years ago would’ve been thought to be minor but now they’re major because the major ones haven’t been there.
And that’s a problem for a number of reasons. But one of the big problems is that there are groups in our society who are still going through substantive challenges. Aboriginal, First Nations, Inuit peoples, marginalized peoples, racialized peoples, intersections of poverty and all those other components. And that when we start to focus our attention on I feel unhappy as being a legitimate need for access to mental health care, we forget the bigger needs that are in our society. It’s too easy to turn our attention away from where the needs are greatest to the place where we can intervene the easiest.
Sagar: You introduced a new term here, superfluous abundance. And I think that’s a new term. What do you exactly mean by that?
Stan: By that I mean is if you go to the grocery store in the middle of February and you don’t have ripe avocados, you get pissed off.
Sagar: We really enjoy all the advantages and the luxuries of everyday life now. And if we’re somehow disappointed or challenged, that becomes an issue.
Stan: Yeah. And the same thing for emotional frameworks. Over and over again when I have talked with young people in the school because I’ve been spending two decades now working in school systems, the message that I get from them is being mentally healthy means I’m happy. Mental health isn’t about being happy. It’s about having normative emotional responses to the existential events in our lives be they challenges or opportunities. And the fact that an existential event elicits negative emotions is not necessarily a bad thing. It doesn’t mean you have poor mental health. So I think that we’ve created a superfluous abundance, this level of expectation that life is supposed to be pleasant and always with little tiny blips. And then when we face real challenges like we’re facing in COVID, we are not as well prepared to deal with them as previous generations that had more of these substantive challenges in their lives and had to deal with. So I think that — And again, I said I’m not a sociologist.
Sagar: Right. But you’ve made some very I think important observations here. And really, when we think about the public health trends about an explosion in rates or cases of this disorder and that disorder, I think what you’re telling us is we need to be careful. We need to remind ourselves that the prevalence of the severe mental illnesses really has not shifted all that much. What has happened is that we are much quicker to recognize distress and unhappiness. We’re much quicker to label that distress and unhappiness as possibly a problem that is maybe, well medicalized might be too strong a word but maybe as severe in some ways as a severe mental illness. And then we act as though the healthcare system or society at large is responsible for managing that distress when we as human beings need to be able to handle the full range of challenges and emotions of everyday life.
Stan: Yeah. I think you said it way better than I did. And that is what I was trying to get at. But there is also another piece to this that I just like to raise for your consideration and that is as our society has become more and more secular, the frameworks and structures that had been there 30, 40 years ago for people who were feeling this substantive distress no longer are there. So when we had faith-based organizations that people create communities around, that if you were having difficulties in travestying your life challenge, you went to the faith-based leader whether it was an imam, whether it was a priest or a rabbi, a minister, a clergyman, whatever. That’s who you went to. And so you got a lot of the support from that group of people who were trained actually. As we become more and more secular, that is no longer there for many people but human beings still need that. They need that ability.
Stan: So now, we go to the healthcare system for it, right? Because that’s where it is.
Mental Health in the School System
Sagar: Now, I know working with teenagers in school settings has been a particular passion of yours. So how did you get into the schools? And what have you done in schools for teen mental health?
Stan: I took a chair in Adolescent Mental Health. And when I took that chair, I was trying to figure out what area I wanted to go in. So I gave myself a little bit of time to try to sort this out. I was looking for something that had probably greater, wider public health impact. And so I looked into the school system and I found to my chagrin that there has been years of mental health awareness building. But when you went and you ask kids, “what is mental health?” they didn’t have a clue.
Stan: And I became very interested when I was with the WHO in this area of health literacy being a very important social determinant of health. You know, it’s hard to fix poverty but you can teach people literacy. So I came to it to try to understand mental health literacy as a subset of health literacy. And I said, gosh, the best place to do literacy is in the school system because that’s what they do.
Actually, that’s what they do. Period. They know how to do that. And that’s where the kids are. It took seven years, Sagar, seven years before I actually had a curriculum-based intervention that we could train the teachers and that we could say we have comfort that when you do these curricula, these are the outcomes you’re actually going to get.
Mental Health Awareness Vs Intervention in School Systems
Sagar: So can you clarify? You know, you talked about building awareness and now you used the word intervention. So should school-based programs be about awareness of mental health or are they actually delivering treatments like cognitive behavioral therapy or other forms of psychotherapy? Or is it somewhere in between?
Stan: So schools can do awareness but awareness is not enough. In fact, awareness can get you down the wrong track. It’s still common. People talk about stigma against mental health. There’s no stigma against mental health. There’s stigma against mental illness, with an illness. But people keep confusing those terms constantly. So schools have to do more than that. They have to be able and they can teach mental health literacy as part of the work that the school does.
And when I say that, there are four parts to it. Understanding how to obtain and maintain good mental health. That means really understanding the stress response, not just so you can diminish it but you can use it for adaptation and resilience building. Understanding mental disorders and their treatments. Decreasing stigma. And then increasing help-seeking efficacy. It’s a competency-based model. Then the other thing is: Can schools actually deliver mental health care? And there are lots of different models that they can and there are different ways that they can do that ranging from the kind of work that you’ve been doing in schools to school-based health centers in which actual physicians and psychologists and counselors and nurses actually work, not just on the mental health of kids but on all healthcare delivery.
So the schools are a place and they’re also a very important institution. They’re an institution which not only helps young people learn and get literacy, education but also a culturation, also access to services and care, food. You know, they can help meet the needs of kids that aren’t being met in their families or aren’t being met in their communities. They’re not substitutes for families or something like these but they’re certainly part of the mosaic that kids interact with. And kids spend a lot of their time in schools, most kids, not all kids. I see the schools as being a vehicle that permits, that enhances the growth and development of young people. And that growth and development I think really needs to include mental health literacy and might provide access to care.
Sagar: Right. So you’ve taken us on quite a journey. You’ve identified the many practical issues about well, schools are where the kids are. They have many needs. And as a society, we have to provide for many different needs that our kids have. And one of those is of course normative development. And mental health literacy is important for normative development and tolerance of different emotions. But then they should also have the chance to learn what is a mental disorder and what can be done for it and perhaps even, you know, get some treatment for it perhaps in the school setting or at least be facilitated by the school setting to get treatment in more traditional healthcare setting.
Wegdan: And that’s about it for today’s episode. It was a very engaging conversation that took us through Stan Kutcher’s journey in becoming a psychiatrist, teen mental health specialist and policy maker. We hope you enjoyed this episode, because next episode we continue the conversation with Senator Stan Kutcher, where we explore the social determinants in depression care, the role of policy in enhancing teen mental health, technology and some great tips for parents and teens.
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