An ode to depression

seuss-bw

I came across this reddit thread, Write a suicide note in a Dr. Seuss like fashion. The most upvoted post is a dark yet touching poem written by user, allbunsglazing. Like many commentators, I was really moved when I read this…somehow it’s an incredibly honest account of depression.

I cannot take credit for any of the above text allbunsglazing so carefully crafted. I did however crop his original work and ended it on an earlier note, before it reached the detail about the suicide plan. Perhaps it’s me being optimistic, but I felt that in itself, it’s the words above that resonated with me the most.

 

The Mental Health Strategy Canvas

canvas
My day job is to co-design mental health initiatives across two very unique organizations. When I explain this to others, I am often met with puzzled looks and quiet pause.

Then comes the follow up: “What does that mean?“…”What is a mental health strategy?“…”Can you give me some examples?”…

These are good questions.

When you’re working at the systems level in the way that I am, things can get pretty messy, complex and confusing. My mandate involves influencing and shaping the redesign of organizational policy and procedure; curriculum and pedagogy; services and programs; and training, education and awareness, all in the name of mental health promotion. Defining what “mental health” means through a holistic lens (e.g., not just illness focused) offers an added layer of ambiguity. What does mental health promotion mean in concrete/action focused terms? How does this connect with all the pieces of the strategy?

I have sketched out the diverse stakeholders and variables of the strategy into a number of visual configurations and maps. I have found this helpful in discovering new insights around relationships and influencers in this space. These maps, however, are difficult to condense down into a clear one-page document that can be used as a sharable communications tool. After all, I need to find a way to convey this information to others so that it is easy to understand but doesn’t undermine the depth and complexity of the work.

In order to make sense of all the layers of “the strategy” (stakeholders, groups, services, programs, policies, processes, politics, etc.) and contextualize it within its broader goals, ambitions, and value proposition, I found it incredibly helpful to create a strategy ‘canvas’. The canvas is something that I borrow from my days working more heavily in startups. I had met with some of the folks involved with Business Model Generation, a book written by Alexander Osterwalder and Yves Pigneur. Business Model Generation helps entrepreneurs develop a business model using a canvas, a strategic management tool that identifies and stitches together the elements of a business model into a unifying framework.

I see great utility in the canvas in helping make sense of a complex mental health strategy. It’s a birds eye view of something that has a lot of interrelated, moving parts. The canvas I have shared above is just an example, using general departments/programs/services that one would normally find in a postsecondary institution. The part I admittedly struggle to clearly articulate (without writing reams of text) is the value proposition. However, I modified a nice phrase that I am borrowing from one of the Managers I work with that I felt summed up at least one part of the value proposition quite nicely — at the end of the day, we wish to foster “healthy & happy graduates”.

I also wanted to add one final note about the canvas that I think is particularly helpful for non-profits and postsecondary institutions to consider: A business mentality. Based on my own experience in startups, here’s why:

  • Coordinated, campus-wide strategy work in postsecondary mental health is a relatively “new” concept. Because the intention behind this work is to (re)design initiatives that positively impact mental health, it helps to think like a business — how do we create new initiatives that are self-sustaining (and perhaps not reliant on institutional/government funding), nimble and testable within the organizational environment, actually responsive to the needs of users, and demonstrate meaningful impact that can be documented and shared? What initially attracted me to this space was the fact that, with a little creativity, my work could be treated like an internal startup of sorts.
  • lean startup mentality lends itself well to the postsecondary space given the resource constraints we face, day-to-day. We only have so many resources to work with and it’s important to experiment with initiatives, where possible, in order to test out the viability of new ideas so we can identify early successes and fail faster. All too often, I see under/un-tested ideas go through vast amounts of vetting, development and perfection before it ever reaches its intended user audience. I don’t think this is the best use of energy or time.
  • A value proposition is about conveying a company’s core offering/value add, and the reason why users should choose it over its competitors. In institutions, we tend not to frame our offerings this way, despite having strong leanings towards “customer service” language and philosophy. What I appreciate about the value proposition is that it needs to be communicated in plain language and makes sense to a layperson. At the same time, what I struggle the most about the value proposition is that it can be incredibly difficult to articulate…this is particularly true in mental health strategy, where the goals can be large, systemic and frankly, rather ambiguous (e.g., stigma reduction, healthier communities, etc.).

Have you seen other uses of the business model generation canvas and do you think it applies to organizations/strategy in the way I have suggested here?

 

Positively, Mental Health

positiveMy job title comes with a lot of assumptions.

I tell people that my day job involves designing and implementing mental health initiatives across two Universities in Ontario. While this may be a rather broad description, I notice that people tend to take pause when they learn what I do. This is often met with an unsettled or serious look, followed by a story or mention of how mental health has impacted their lives or the lives of those around them.

I can understand this response. People relate to “mental health”, often in very personal ways. It can evoke a range of deep seated stories, experiences and emotions, many of which touch on challenges related to mental illness and/or difficult times in one’s life. What I find most interesting is that this response tends to come about because “mental health” holds such negative connotations to people — it is something one must work through, manage, or “overcome”. When I sit at different tables, this is a common underlying sentiment.

I have come into a role that has arisen out of a very valid and real need to promote awareness, education and supports around mental health…however, there is a disproportionate focus on the relative burden of mental health and mental illness. There is also a heavy focus on using a certain type of evidence (no. of mental health diagnoses, overwhelmed services, etc.) that is suggestive of growing “problems” and “deficits” within the organization. From this problem oriented perspective, it can almost seem “easier” to justify the need for change.

While I can appreciate that mental health affects us all in different ways, I wish that the term evoked a more positive response in people. I now find myself actively creating a different conversation around mental health when I describe my role: that it encompasses positive and negative states of being, and that particularly within the context of art and design, mental health is often understood as fuelling imagination and creativity. I realize that my own conception and explanation of my role impacts the responses I evoke in others too, and this has made me more aware of how I communicate my work.

I stumbled upon this CIHI report on “Exploring positive mental health“. Here’s an overview of the five components of positive mental health they have identified that I think help us keep focus on a very positive and constructive understanding of mental health promotion:

  1.  The Ability to enjoy life: This refers to happiness, life satisfaction, subjective well being, partly a result of personality but can change due to life circumstances and environments;
  2. Dealing with life’s challenges: The ability to cope and grow with daily challenges by engaging or disengaging with issues we face;
  3. Emotional well being: Experiencing and regulating positive emotions in a manner that maximizes their benefits and minimizes negative aspects;
  4. Spiritual well being: Feeling connected to something larger than oneself (e.g., religion, values, principles, etc.) and having a sense of meaning in life; and
  5. Social connectedness and respect for culture, equity, social justice and personal dignity: Creating an environment where mental health can flourish.

I’d like to explore how these areas can help serve as a starting point for benchmarking “success” with mental health initiatives. Generally, the evidence base around mental health initiatives has not been well documented, particularly when it comes to these more “positive” metrics. At the very least, it’s a good reminder of how I can describe and convey my own goals.

stödja – to support someone in distress

ikea_health1

ikea_health2

 

 

 

 

 

 

 

 

In brief: Mental health training is a popular tool for addressing mental health issues within organizations. This often involves teaching people how to identify signs exhibited by a person in distress and address them (often) through an appropriate referral. I make some observations about the content and approach of existing trainings, and make an attempt to simplify what training can literally look like by borrowing from the instruction manual design used by furniture giant, IKEA.

Mental health “training” is a popular way for organizations to address mental health issues by teaching people how to better “refer”, “assist”, “support”, “help”, and/or “address” those who are in distress to mental health services and resources. These training programs come in different shapes and sizes and tend to focus on knowledge and/or skill development that, at a very basic level, enables trainees to understand how to identify the signs of distress, engage with a person who exhibits these signs, and make a referral to an appropriate support.

I have been contemplating ways that mental health training is designed and implemented, and taking a look at what is out there. In considering what it means to offer “mental health training” on campus for students, staff and faculty, I have been carefully assessing the guiding values, messaging and practicality of training content. There are benefits and disadvantages of existing trainings and while I am still early in the process, I’ve noticed a few trends:

  • Personal Boundaries: Most trainings fail to consider the boundaries, assumptions and expectations of the person offering support. At a baseline level, I think there is something we can all do to provide some level of support to someone in distress, but at the same time, it takes a careful understanding of oneself and her/his concept of mental health, personal values, and comfortability to ascertain how this actually looks in practice. In order to “do no harm” (borrowing from primum non nocere) and not escalate a situation, it’s important to know to what extent one is expected and able to intervene.
  • Symptom Focus: While the aim of trainings aren’t to equip people to act as “pseudo-professionals” who can diagnose mental illness, there appears to be a lot of emphasis on identifying the symptoms of various illnesses and problematic behaviour changes. I agree that there is great value in recognizing these signs, but the emphasis placed on symptoms (by illness) can be overwhelming to remember and may encourage people to diagnose others. Coupled with a lack of understanding around personal boundaries and without coaching on how to incorporate ‘illness’ signs/symptoms into a conversation, the symptom focus may lose its effectiveness, in my opinion.
  • Social Construction of Illness: A lot of content doesn’t take a look at mental health in context including its various histories, perspectives, and determining factors. I find this most interesting as I imagine it would be challenging to appreciate and begin to address mental health without a better understanding of it, particularly since it can be a highly stigmatized and contentious issue to raise.
  • Memorable Messaging: Trainings tend to describe “steps” to follow in a help scenario. While useful, in the moment it may be difficult to recall what one has been trained to do if the messaging is too long, highly specific to a disease or host of symptoms, and not memorable. More often than not, reams of training text are compiled into a guide or book of sorts for people to read through, but I find this is personally more helpful as a reference than a practical, front-line tool. I think that people could greatly benefit and remember more if a condensed aid is available, particularly if it is visual.

From my perspective, I think one of the most interesting things about “training” is that it relies on exercising something that is innately human: our interpersonal skills.  This includes conflict resolution, validation, de-escalation, talking, observation, physical language, active listening, personal boundaries, values, empathy, and guidance. While these might seem like natural qualities, they are skills that we do not make time to practice or teach each other in formal contexts…and it is interesting to see this as such a massive need when it comes to health and wellbeing. Consequently, a lot of practical skills related to training comes down to having a conversation with one another in order to reach an understanding of what’s going on and what we can do about it.

In considering ways to ‘simplify’ training skills and step and make them more memorable and accessible to a general audience, I thought about how to convey training content in a minimalistic yet still informative manner. I also wanted to place focus around interpersonal skill development and interaction than disease states, which I think is a helpful shift to make.

One of the first examples I thought of was IKEA instruction manuals. IKEA is well known for its focus on its modern, simplistic, accessible and easy-to-assemble design. It was only a few years ago that IKEA’s change in typography caused a massive backlash from designers, demonstrating how a change in IKEA’s design standards could have a huge impact on the design world. In any case, over the years I have come to appreciate how visual IKEA’s instruction manuals are as they illustrate the tools, parts, and process required to assemble furniture. I thought this was an accessible way of conveying information…and as an ode to simplicity and more visual responses to distress, I created the above “manual”. Without text, I think it communicates a lot about the interpersonal nature of the skills needed for ‘intervening’ in a situation, placing emphasis on a collection of encouraged interactions and responses. It doesn’t get into the details, but I think is a helpful visual starting point.

If you’re unfamiliar with IKEA’s naming scheme, here’s a little bit of context. I chose “stödja” as the name of this manual because, in Swedish, stödja is described as meaning: “to support”, “to be helpful”, and “to be attentive.” I think is a relevant term that communicates the intention of manual. Also, please forgive me if I am using this word out of context…my Swedish is only as good as Google translate 😉

An aside: I just came across this NY Times Opinion piece and thought it was completely relevant to the discussion above: How Not to be Lonely by Jonathan Safran Foer. While it focuses on loneliness, I think it still applies. Here are a couple of helpful quotes from the article:

Most of the time, most people are not crying in public, but everyone is always in need of something that another person can give, be it undivided attention, a kind word or deep empathy. There is no better use of a life than to be attentive to such needs. There are as many ways to do this as there are kinds of loneliness, but all of them require attentiveness, all of them require the hard work of emotional computation and corporeal compassion. All of them require the human processing of the only animal who risks “getting it wrong” and whose dreams provide shelters and vaccines and words to crying strangers.

“Attention is the rarest and purest form of generosity” – Simone Weil

Mental Health Tetris

tetris_cop

In brief: Visual experimentation of mental health concepts using Tetris blocks.

I have been thinking about ways to represent various concepts in mental health using basic shapes. I started to play around with squares to see what I could come up with, but ran out of creative juice quickly. Recently, I stumbled upon the work of Graphic Patrick who created some clever posters about mental health terms which inspired me to return to my square experiment. What I came up with were Tetris-inspired visuals, as you can see above and below.

I was a big fan of Lego and Tetris when I was a kid, so I’m not surprised that my experiment led me to create some visual concepts inspired the very building blocks that kept me creative and busy during my childhood. I received a Game Boy for my birthday (way back when it was first released) and was absolutely thrilled that it came with my very first portable video game: Tetris. Really, this was the best tech toy a kid my age could get for her birthday in the early 90s <<YouTube video: 3mins of pure Tetris nostalgia here>>

Tetris aside, I decided to experiment to see if the notion of adding/removing building blocks (perhaps representing positive and negative events/stressors?) could help describe some topics in mental health. My intent here is to find alternative/complementary ways to explain complex mental health issues. I realize Tetris may not be the best analogy, as I don’t consider mental health a “game” of sorts nor something you can really “win” or “lose” at. But for the sake of trying something different, I selected a few issues that I thought would be worth exploring. And yes, this is an exploration that aims to challenge me and my own understandings of mental health and hopefully encourage others to think differently too. Using Tetris as a back drop is meant to describe terms in a playful and accessible way but is not intended to minimize their seriousness or depth. The decision to position the blocks the way I did here comes from both the way the game is constructed as well as the player experience.

Illustrated are the concepts of recovery, depression, bipolar, ocd, coping, and determinants of mental health. I’d rather not provide an extensive explanation of each image, rather, I’ll let you interpret it for yourself. I’ve included a definition of each term below each diagram for your consideration. As always, feedback and ideas are welcome.

An aside: When I googled “Tetris” and “mental health” to see if there were some existing work in this area, I came across articles referencing an Oxford study suggesting that playing the game could possibly prevent PTSD flashbacks. Some food for thought.

tetris_rec“Recovery is understood as a process in which people living with mental health problems and illnesses are empowered and supported to be actively engaged in their own journey of well-being. The recovery process builds on individual, family, cultural and community strengths and enables people to enjoy a meaningful life in their community while striving to achieve their full potential.” (Toward Recovery & Wellbeing, MHCC)

tetris_dep1

“Depression is a medical illness that causes a persistent feeling of sadness and loss of interest. Depression can cause physical symptoms, too.” (Mayo Clinic)

tetris_bp

“Bipolar disorder — sometimes called manic-depressive disorder — is associated with mood swings that range from the lows of depression to the highs of mania. When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts in the other direction, you may feel euphoric and full of energy. Mood shifts may occur only a few times a year, or as often as several times a day. In some cases, bipolar disorder causes symptoms of depression and mania at the same time.” (Mayo Clinic)

tetris_ocd

“Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by unreasonable thoughts and fears (obsessions) that lead you to do repetitive behaviors (compulsions). With obsessive-compulsive disorder, you may realize that your obsessions aren’t reasonable, and you may try to ignore them or stop them. But that only increases your distress and anxiety. Ultimately, you feel driven to perform compulsive acts in an effort to ease your stressful feelings.” (Mayo Clinic)

tetris_cop

“Coping is the process of attempting to manage the demands created by stressful events that are appraised as taxing or exceeding a person’s resources” (Taylor & Stanton)

tetris_det

“Multiple social, psychological, and biological factors determine the level of mental health of a person at any point of time. For example, persistent socio-economic pressures are recognized risks to mental health for individuals and communities. The clearest evidence is associated with indicators of poverty, including low levels of education.” (WHO Fact Sheet)

 

Toward a Visual Understanding of Mental Health

Mental_Health_3D

In brief: Achieving buy-in and support for a mental health agenda within an organization starts with clearly defining the concept of “mental health” in a manner that is succinct, memorable and easy to share. Without a cohesive understanding around mental health, it is challenging to mobilize people in favor of the cause. There are many definitions of mental health that exist but I find that one of the most accessible, personally relevant and understandable explanations is conveyed in a diagram based on Corey Keye’s work around the notion of flourishing. Here I adapt Keyes’s work in order to create a new visual piece (above) for your consideration that takes into account the environmental determinants of mental health.

Note: I talk about mental health strategy development here within the context of my work as mental health coordinator for two major post-secondary institutions in Ontario.

How do you design conditions that shift the thinking, actions, and attitudes of a group of people organized around a particular mission or goal?

It’s tough. I would never assume organizational change to be a trivial task, particularly when one is looking to produce a system-wide cultural shift around mental health. Mental health is often a challenging, interrelated and ambiguous concept as it captures a large slice of the “health and wellness” pie, and is influenced and constructed in multiple ways. Accordingly, it is difficult to find a way to fully capture the social, historical and cultural complexity embedded within the term “mental health” in a few words. Generally speaking, people also tend not to identify with mental health as being a core aspect of their livelihood as it is commonly assumed that “mental health = mental illness, so it doesn’t affect me.” However, unless “mental health” itself is well understood within an organization, rolling out a mental health strategy is tough to achieve. Fertile ground for change starts with a clear definition. Here are some I have been working with that are widely used in public health:

The capacities of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections, and personal dignity (Public Health Agency of Canada)

Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community. (WHO)

These definitions are helpful for the most part, but are arguably challenging to remember, rather intangible and aren’t necessarily worded in a way that is memorable. They also do not explain the relationship between mental health and mental illness, the latter of which is commonly understood as being synonymous with mental health and helpful to differentiate. This is not to say these definitions aren’t easy to understand per se, more that it can be difficult to personally relate to them. Expecting someone, particularly one who does not have a public health background, to relay this language/wording to someone else may not be an easy task…at least that’s what I’ve found from my experience.

There is however one explanation of mental health from Corey Keyes that I have found most helpful. Keyes introduces the notion of the Mental Health Continuum, an understanding of mental health that is grounded in positive psychology, happiness and the concept of flourishing. He describes the “…operationalization of mental health as a syndrome of symptoms of positive feelings and positive functioning in life. It summarizes the scales and dimensions of subjective well-being, which are symptoms of mental health. Whereas the presence of mental health is described as flourishing, the absence of mental health is characterized as languishing in life.

Unlike the other definitions offered, it is the visual representation of Keyes’s concept of mental health that is most powerful. Figure 1 (below) is adapted from Mental Health for Canadians: Striking a Balance (the original diagram available at CMHA Ontario) and visualizes the continuum of mental health:

  • Y-axis: Optimal mental health (aka Flourishing) at one end vs poor mental health (aka Languishing) at the other
  • X-axis: Serious mental illness at one end and no symptoms of mental illness at the other

As such, a person can be flourishing with or without symptoms of a serious mental illness. At the same time, one can be in poor mental health and yet living without mental illness symptoms.


MentalHealthx3Grids

All of the explanations above have their strengths and weaknesses, but there is something in particular I like about the visual as a starting point: It embodies the simplicity and complexity of the concept of mental health, all at once. I have found this to be one of the best ways to describe mental health because I am not limited by my own words, rather, I have a tangible map of mental health that is applicable to everyone: We all fit along these continuums and can locate ourselves with respect to where we are at now and where we might want to be. For me, this has been an excellent health communications tool. Not only is the visual easier for people to remember, it does not require a linear or fully verbal explanation.

As you can see in the visual above, I decided to take Figure 1 two steps further. Figure 1 is helpful but limited in that it conveys a more individualized understanding of mental health. Consequently, it visually misses the social and cultural conditions that are also at play in shaping mental health experiences. Alas, Figure 2 offers a third continuum labeled as “environments” (z-axis) that aims to represent external determinants within the greater community/organizational ecosystem that affect mental health. Finally, I added Figure 3 as a way of illustrating where can set our goals when it comes to building a mentally healthy organization. Thus with or without the presence of a mental illness, we should be striving to support people and designing environments where optimal mental health can be achieved.

As always, your thoughts and feedback are appreciated in the comments below. To me, the third dimension of “environments” is a helpful construct — I’d be curious to know if you think this helps portray a fuller picture of mental health. While it may not always make sense to use a visual explanation for mental health, I think it certainly has a lot of utility and carries with it a depth of meaning that could not otherwise be conveyed through words or text alone.

Affordable Mental Health Services in Toronto

Screen shot 2013-04-07 at 10.10.54 PM

 

It’s not always easy to find low-cost mental health services in Toronto. Even as someone who has worked in the health sector for some time now, it can be challenging to find a reliable, affordable and up-to-date list of available mental health services in the city, unless I get it from a service provider directly. After all, providers tend to stay most on top of these things (service changes, fees, availability, etc.) as this is a central part of their job.

I’ve had a few people ask me about affordable, Toronto-based counseling services over the last few weeks, so I wanted to share a list of resources that I feel not enough people know about. I got this list of organizations from a trusted provider I know. I have not personally vetted nor do I necessarily endorse these resources, but I share them here as they may be great starting points for people who are exploring their options. It would be devastating to think that someone would not pursue mental health help for reasons of cost, and I hope that this helps bring some level of awareness to services that are making help more accessible.

Please feel free to download and print the list of resources as a Word file here: Mental Health Resources

I find that not enough of these resources/lists are available digitally (especially from providers) so they can be shared easily and enable people to make notes, changes, and additions. I restructured and digitized the above file from a paper copy of resources I received and hope it’s usable and helpful in this format.

There are many, many great resources out there and some hidden gems among them. A trusted physician is one of the best starting points for seeking support as she/he can help a person create a personal health plan and refer an individual out to community programs (e.g., CAMH), other organizations, or specialists (e.g., psychiatrist) based on their own assessment of a patient. Either way, seeking support is a big and important first step.