Why we need to be Less Afraid of Uncomfortable Conversations: Perspectives from a Medical Student and a Crisis Line Responder

Written By Sarah MacLean

By: Chloe Ahluwalia

The following post contains references to abuse, trauma, and suicide that might be upsetting to some readers. Support resources are included at the end of this post for anyone who might need them.

While I was doing my undergrad in Psychology at McGill, I kept noticing a need. An ever-growing need for mental health services, especially for youth, which was going unmet. While it wasn’t always explicitly said, it was always there, lingering behind every lecture, every statistic, and every treatment caveat. By the end of my degree, I felt personally obligated to help. I had been let in on the not so well kept secret, and had learned too much about the underserved needs of this population to sit back and do nothing. All those years spent learning about such profound struggles in a classroom, I felt absolutely useless. I wanted to do something proactive, I wanted to help in a concrete way. So I decided to volunteer with Kids Help Phone as a Crisis Responder.

For those of you who don’t know, Kids Help Phone is Canada’s only 24/7 e-mental health service offering free, confidential support to young people. Started in 1989 as a unique telephone counselling service, they have evolved their services to include more accessible options for today’s youth, including their Crisis Text Line. This line allows youth to talk to a trained Crisis Responder for support at any time, about anything, just by sending out a quick text message to Kids Help Phone’s registered number.

As a Crisis Responder, my job was to respond to those who were texting into our line in a time of crisis. I would talk to them until I felt that the texters had gone from a state of crisis to a stable, cooler calm. I was shocked at how many people were texting in every day. I could see how much these kids craved someone to talk to. I could feel the weight being lifted off their shoulders when I did not judge them, when I told them their feelings were valid, when I empathized with their struggles. I was a total stranger, and the only person they had to talk to. 

I would get messages from texters every day thanking me just for listening. At the end of conversations, they would tell me how much better they felt just talking through things than they had before texting in. I learned so much from the experience that it became a core part of what inspired me to apply to medical school. These kids felt totally alone, they didn't feel comfortable talking to their friends, their family, or their doctors, because they felt that they wouldn't understand. I knew then that I wanted to be the doctor who did understand, and I wanted to teach other doctors how to understand as well.

And yet, when I tell my fellow medical students about how fulfilling this role has been to me, how it inspired my career trajectory, and how these children have no one to talk to, the number one response I get from them is “Oh, I could never talk about those things with someone, it sounds so uncomfortable!” Once again, I was shocked. No wonder these youth didn’t feel comfortable talking to their doctors, if this is the attitude future physicians have right off the bat! Medical students, who are supposed to be able to give people some of the worst news imaginable, are afraid to talk about mental health. Sounds like I have my work cut out for me on teaching the next generation of doctors how to understand, huh?

So step one of my lesson plan for today is to explicitly say that there is nothing wrong with uncomfortable conversations. Although difficult and even hostile at times, uncomfortable conversations are not harmful, and they are extremely necessary. I've had my fair share of uncomfortable conversations, such as discussing abuse, trauma, and self-harm, to name a few. But I think the subject matter that best illustrates both the hesitancy and necessity of uncomfortable conversations is suicide.

About 22% of our conversations with texters involve suicide [1]. It is a complete myth that by talking about suicide, you're putting the idea into someone's head. These texters have already thought about it many times, some even have a plan in mind, so being direct about the subject will not be what tips the scale. In fact, by talking about suicide, we open up a judgment-free line of communication about a highly stigmatized subject, and this can actually lower anxiety and risk of harm. In fact, when suicidal texters were asked how they felt after talking with a Crisis Responder, the number one response given was that they felt less alone [2]. Moreover, only 1-2% of those who text in with suicidal ideations require emergency services by the end of the conversation [3]. So, in my experience, the difficult and uncomfortable conversations I've had to partake in have actually been safe and protective ones.

Step two is to emphasize why doctors especially need to be able to have these uncomfortable conversations. There is clearly a gap in the healthcare system when it comes to mental health. Psychiatry is understaffed, with residency spots going unfilled year after year. If a patient wants to talk about their mental health, they often have to pay for therapy or wait for a specialist, instead of chatting to their family doctor. Considering human beings are both physical and mental beings, this is an extremely flawed system. Why do we put such an emphasis on physical health in our healthcare system when it is only one half of the picture? Why is there such a hesitancy in medicine to recognize the relationship between mental and physical health as bidirectional? In my opinion, it is partly because doctors are too uncomfortable to talk to their patients about delicate mental health concerns.

Step three is to try to offer some solutions. First off, we as medical students need more training on how to have uncomfortable conversations. We are given acronyms, and told to choose the right setting, but that’s where the concrete education stops. What do we do next? How do we react when our patients start crying, or screaming, or expressing the want to die? When these conversations arose at Kids Help Phone, I handled them by validating feelings, being empathetic and open-minded, exploring the source of the pain, and collaboratively problem solving to create safety plans that will get texters through the night. We can teach medical students these skills. We MUST teach medical students these skills. The attention paid to these “soft skills” in our curriculum is minimal at best, but I’m sure all our patients, in any area of medicine, would benefit from them.

We also need to start including mental health as an essential component of medicine. When we are doing a “full physical” on our patients, this should include a mental health check. In school, we are taught to check the heart, the lungs, the abdomen, the liver, the feet, the eyes, and everything in between, but not the mind. We learn how to ask for signs of heart failure, liver disease, lung obstructions, and systemic infections, but not depression, abuse, or trauma. No wonder my peers are so hesitant to talk about mental health considering they have no idea how to even broach the subject. I’ve seen first-hand how students can rattle off questions to a patient with back pain lightning fast, but as soon as it comes to a patient with suicidal thoughts, they freeze up.

This is a huge problem. Every day, an average of more than 10 Canadians die by suicide, and for every death by suicide, at least 7 to 10 survivors are significantly affected by the loss [4]. Moreover, suicide is the fourth leading cause of death among youth aged 15-29 worldwide [5]. Despite being completely preventable, it is a serious public health problem, and it needs to be treated as such. We need to be integrating mental health into all fields of medicine. We need all physicians to be a mental health resource. We need less youth texting into Kids Help Phone in a time of crisis because they feel like they can’t talk their doctor. In order to achieve this, we need to be less afraid of uncomfortable conversations.

Ottawa Mental Health Resources:


If you live outside the Ottawa area, your region may offer similar services. Please reach out if you need someone to lean on.

[1] Kids Help Phone (2022, May 25th). Mental health insights: Get data about suicide. Retrieved on June 15th, 2022 from https://kidshelpphone.ca/issue/mental-health-insights-get-data-about-suicide/

[2] Kids Help Phone (2022, February 15th). Suicide: Important things to know. Retrieved on June 15th, 2022 from https://kidshelpphone.ca/get-info/suicide-important-things-to-know/

[3] Kids Help Phone (n.d). Insights across Canada. Retrieved on June 15th, 2022 from https://kidshelpphone.ca/get-insights/home/

[4] Public Health Agency of Canada (2021, September 17th). Suicide in Canada. Retrieved June 23rd, 2022 from www.canada.ca/en/public-health/services/suicide-prevention/suicide-canada.html.

[5] World Health Organization (2021, June 17th). Suicide. Retrieved June 23rd, 2022 from https://www.who.int/news-room/fact-sheets/detail/suicide

 

Sarah MacLean
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