Christopher Banks talks to Dr. George Forgan-Smith, a Melbourne GP, about helping men cope with depression, PTSD and mental distress.
First published on BipolarBear.co.nz as part 2 of a 5-part interview with Dr. George Forgan-Smith, a Melbourne GP, by Christopher Banks, also known as “Bipolar Bear.”
Men and doctors. Increasingly, it seems, men are uncomfortable with being in a doctor’s office, no matter which side of the desk they’re sitting on. A decreasing proportion of medical graduates in New Zealand are male, and the reluctance of men to see doctors when they’re having problems is legendary.
In addition, when it comes to mental distress, we might not be able to spot the problems, because we’re not looking for the right thing.
“In Australia and New Zealand, men are tough,” says Dr George Forgan-Smith. “They don’t cry, they never admit vulnerability, they never feel hurt or anything like that. So when it comes to mental illness, there’s a belief that when someone is depressed that they’ll be sad, sitting in the corner and teary. That’s the picture that’s commonly shown in the media. Men don’t present with depression like that.
“Men are more likely to be violent, agitated, irritable–and for that reason often they won’t come into contact with people like myself until they’re a crying mess and somebody drags them here, or they’ve come in contact with police because they’ve been intoxicated and beaten somebody up. Or they’re intoxicated and been pulled down from a bridge after trying to throw themselves off.”
So, how is a GP expected to deal with those kinds of intense issues in a 15-minute appointment?
“You can’t,” he says. “Naturally, if somebody’s acutely unwell, that’s it – however long it takes is however long it takes. You just have to suck it up and hope that the next person in line will understand that if they were in the same situation I’d give them just as much time.”
In Australia, the government pays GPs extra money for dealing with mental health issues, in recognition of their greater complexity. When first seeing a patient that presents with mental health issues, plans can be made for future appointments to be longer.
“It’s really about touching base on a regular basis, and allowing time for a relationship to slowly evolve.”
George remembers dealing with one man over a long period who first presented in a very distressed state.
“He was a police prosecutor with severe post-traumatic stress disorder,” he remembers. “He wanted to die. As part of his job he had to look at child pornography, very graphic scenes of accidents, and it got to him. It was too much, and he couldn’t sleep because he had those images in his brain 24/7.
“Over 18 months, we went through a very slow process and by the time he left he had a new career as a personal trainer, looking after women who’d just had breast cancer. So it was a very big change for him.
“A lot of people might think, ‘that must be such a drop in status’, but for him it was a really nice change and he was happy. And thankfully the police force in that instance were very helpful.”
Some people reading this might find it hard to imagine having such a long-term relationship with a GP. It doesn’t quite sound right – normally you go in, say you’ve got a crook stomach or a busted knee, and get some pills. Away you go. What on earth happens over 18 months?
“Listening,” George says. “Say we met every two weeks, part of the time would be allocated to dealing with very medical things, like medications and how they’re affecting you – that takes 2-3 minutes to have that discussion, and the rest of the time is really just devoted to them. What’s happening? What have you been doing?”
Sounds suspiciously like counseling. When I go to the doctor, I want to leave with a piece of paper – ideally a prescription – or at least something that gives me something to do. Apparently, I’m not alone.
“Men love plans,” George says. “As a GP, if you want a guy to leave a room happy, give him a plan. Because they can tick things off and its great.
“So I make a plan for the next two weeks, and then the next time we meet, I say, ‘how did you go with the plan?’ And sometimes they’ll come and say, ‘I’ve done nothing on the plan’, and I’ll say ‘well that plan must have sucked. What would have worked better for you?’
“We make some goals for the week, and I don’t make very ambitious goals at all – I’m a believer in chronic underachievement. To do very, very small things and achieve them. For somebody who’s very depressed, that might be getting up in the morning and brushing their teeth.
“And if that’s their only goal for the day and they achieve it, it actually sets up a programme in the mind that reassures them that they’re capable people, that they’re able to set projects and finish them. To me I think that’s wonderful. What that does is it sets up an expectation in their mind that they’ll be able to do other tasks.
“We’re often told to set up these big, strong lofty goals, and when we fail, we feel like shit and we feel like a failure – that’s a really bad expectation to set up. I often say, nobody starts running a marathon. They start by walking down the street, or walking to the shop instead of driving. It’s about slowly adding to previous successes, and celebrating successes when they happen.”
George has a very blunt, down-to-earth communication style in person, and it’s one that he says he carries across into his working life – where appropriate.
“I don’t talk like a physician. I swear, I get angry, I get grumpy, but it’s about meeting your market where they’re at. When I was in the hospital system, I understood you could be anything – I had stretched earlobes, all sorts of crap, visual tattoos, but I learnt if you’re going to be in the business of being a GP then you have to look like they expect you to look.
“From a visual perspective, when I’m at work I’m neat and tidy and shaved, I have a nice shirt on and stuff, but when it comes to dealing with guys, you’ve really got to be quite open and very frank with them.
“So if somebody comes to me and says ‘I’m having difficulty getting erections’ – if they’re game enough to say that, more often than not I have to ask. Say they’re on a medicine that’s likely to cause erectile dysfunction – I’ll say, ‘look, one of the more common side effects is that people have problems getting it up. Do you have that problem? And they’re shocked, because nobody’s ever asked them that question.
“And you have to get really detailed. ‘Do you get erections in the morning? Can you get hard enough to penetrate?’ I use very simple terms. You don’t get extra points for being sophisticated.
“The key is to get the information that we need. Why use a big word when you can use a small word? Half the time I can’t pronounce the big words, and don’t even ask me to frickin’ spell them.
“The thing I pride myself on is that I’m able to connect with people at their level. I’ll say, ‘I’m a very simple person and this is how I talk, I hope you don’t mind.’
“I will swear and it’ll be very unusual for me not to be laughing in an appointment, and that’s not laughing at the patient – it’s laughing with the patient. Laughter is an important tool, and it’s the key to any good relationship.”