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A children’s book on depression is a tough sell, but it’s an important topic. On authoring and self-publishing The Semicolon.
When I think of the countless rejections I received for The Semicolon, two stand out. The first was from an incredulous literary agent who wondered why I would even choose depression as a topic for a children’s book. The second agent, even more blunt, told me flatly: “I’m not interested in the mental-health-for-children part.”
Rejection comes with the territory as a writer, and I am the first to admit that my story is offbeat. I was inspired to write it after reading an article about Amy Bluel of Project Semicolon and other mental health advocates adopting the semicolon as a symbol of hope and resilience in anti-suicide initiatives. Many of these individuals have gotten semicolon tattoos in solidarity or as a way to validate their own experiences of survival. The choice is informed by the reason a semicolon is used; it signals the continuation of a sentence rather than its end. That symbolism resonated with me — not only as an author but because, having gone through severe depression in my 20s, I knew that depression could be just as misunderstood as grammar.
I wondered if I could take this beautiful concept of the semicolon and, in a non-didactic and age-appropriate way, introduce it to younger readers who are themselves susceptible to mental health struggles.
Yet I chose an uphill climb. The children’s book market is difficult enough to crack for writers who don’t illustrate their own work, and here I was pitching a story about a difficult topic told in an abstract way. Still, I didn’t want to underestimate the depth and capacity children have to imagine and reflect, even those unfamiliar with semicolons. My concept may have repelled literary agents, but I saw it fitting into a category of picture books on difficult themes that are intended to be read — and discussed — with children (alongside titles such as The Scar by Charlotte Moundlic and Virginia Wolf by Canadian author Kyo Maclear).
Britt Sayler
What’s more: this was (and still is) a topic that desperately needs talking about.
Even before the pandemic, the CDC assessed the prevalence of depression in children between six and eleven years old at two per cent (and more than triple that for adolescents). By all accounts, children’s mental health has only worsened since then. Manitoba-based Kidthink now estimates that 10 to 20 per cent of very young children in Canada are experiencing mental health problems. And in October, the Canadian Paediatric Society warned that young people are experiencing growing wait times for mental health support.
In this light, why did writing about mental health for a young audience feel so taboo? Was it the act of putting it into words? Was it because, as a society, we still cling to the idea of childhood as a happy and carefree time? Or was it depression specifically, rather than mental health in general, that was uncomfortable?
More than once, I was advised to pitch the book as a story about grief, since the main character’s depression follows the loss of a parent (drastic life changes are a common trigger). To me, this guidance missed the point. So finally, I decided to self-publish. I just couldn’t mute the very point I was trying to get people talking about.
Reaching kids who aren’t all right
Even for children, depression can be all-consuming. I wanted to capture that (literally — a slurping pit figures prominently in the book) and engage readers without being moralistic. That is, story first, message second. I also wanted to trust children’s ability to learn new concepts, in hopes of offering something that resonated beyond the last page.
Of course, without the near-automatic access to schools and libraries that established publishing houses enjoy, reaching kids becomes the challenge. I worry generally about the commodification of mental health, but to get my book to those who need it, I would have to market it.
There is an obvious audience in mental health practitioners who work with children. Equally important, though, are the parents, educators, and caregivers with first-hand experience of mental illness — especially recovery from depression or familiarity with semicolon tattoos. The fact is, most picture books are marketed to adults who buy and read them to kids, and those with lived and living experience can make for the most passionate advocates.
The biggest hurdle would be getting the book to children who need it now, not just those at risk of depression in the future. It can be unpalatable to think of a young child in your life as depressed. Furthermore, depression rarely looks the same in children as it does in adults — a clear theme from the experts I spoke to in writing this book. We all struggle at times to process our feelings, but children are still developing their self-awareness and vocabulary to communicate these. It’s up to adults to look for the signs.
Because 2SLGBTQ+ youth are at a higher risk of depression and suicide than their peers, I also made the conscious decision not to specify the gender of the child narrating the story. The language is gender-neutral, and the illustrations are ambiguous to leave space for each reader to perceive the main character according to what they need.
Now that The Semicolon is in print, I hope it finds a place among the growing number of picture books devoted to mental health. Many of these focus on aspects of wellness like emotional awareness, self-regulation, and self-esteem; I want mine to shed light on the prevalence of childhood depression, and deepen society’s understanding without diluting it. There’s a difference between ordinary sadness and depression, just as there is between normal worry and clinical anxiety.
As a resource for children, I hope it can spark conversations and help readers gain lasting perspectives on dark feelings, but all of these books should be viewed in context. They are not substitutes for diagnosis or treatment. They are tools in a bigger toolbox intended to help children be the healthiest possible version of themselves — a box our kids are needing more and more.
Further Reading
Illustrator: Dorota Rewerenda
Author photo: Andrea Gray, Trio Photography
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It’s time to talk about mental health in football
The world of professional sports brings to mind scenes of packed stadiums, screaming fans, and lavish contracts for the most celebrated athletes, who display dazzling feats of skill and endurance. But this image of players fulfilling a life’s dream doesn’t always square with reality: the challenges many of them face in maintaining their mental well-being. The truth is, many elite athletes are struggling. Ahead of the 109th Grey Cup, The Catalyst looks at the way organizations like the Saskatchewan Roughriders are joining with others to tackle the issue.
According to a recent study in Psychology of Sport and Exercise, more than 40 per cent of 186 elite national team athletes in Canada “met the cut-off criteria for one or more mental disorders,” with stress and training load being “significant predictors of depression and anxiety.” To understand why, it’s important to acknowledge the realities athletes run into, both on and off the field.
Before reaching professional or top amateur levels, competitors must prove their skills in junior, university, and semi-professional leagues. This often means having to balance their sports aspirations with school, work, and family obligations, not to mention the growing public profile that comes with each success.
“It can be a grind at times,” said Ty Logan, a former university athlete and current professional defenceman with the Albany FireWolves of the National Lacrosse League. “When you’re in school, your weekends are spent travelling on a packed bus between cities, while trying to finish assignments and catching up on the lectures you missed during the week. It’s late nights in the library followed by early mornings at the gym. If you’re not careful with your time, it’s easy to fall behind in one way or another.”
Only as good as your last game
The expectation to perform in the midst of multiple obstacles and responsibilities can be a huge source of stress for young athletes. “You definitely feel the pressure from both sides,” Logan said. “Even when you turn professional, there are no days off, and you never know when it might be your last contract or last game in the league. You have to try to block out the outside world and focus on playing your best.”
This pressure intensifies for emerging athletes with the increasingly slim chances of becoming a professional in any given sport. According to the National Collegiate Athletic Association, around four per cent of all college athletes will reach a professional league or the Olympic level. Even fewer will stay there for more than a handful of games.
When you have a large group of highly motivated, competitive athletes battling for a finite number of spots, with the promise of fortune and fame on the line, it’s easy to see how the pressure can mount for aspiring professional athletes. Add in the need to maintain grades and a part-time job to help pay the bills, and the risk to one’s mental well-being becomes just as clear.
Knowing this, the Mental Health Commission of Canada (MHCC) adapted The Working Mind (TWM) training program to address these issues. TWM Sports modules focus on scenario-based, practical applications for both athletes and coaches which are grounded in the voices of people with lived and living experience of mental illness
Research shows that coaches fulfil multiple roles as motivators, counsellors, advisers, and parental substitutes — all of which require considerable emotional labour. And athletes must fully understand their own mental health — and that of those around them — to maximize their capabilities. To address these requirements, each of these TWM Sports courses provides tools and skills for adverse situations and the ability to support teammates — skills that apply just as much to people in beer and recreational leagues as they do to top athletes.
A nation of athletes
According to a 2016 Statistics Canada poll, 27 per cent of those age 15 and older regularly participate in sports. That’s more than eight million people across the country in some form of sporting activity, with fun, fitness, and physical health cited as the main benefits. But beyond the average individual, the trend shifts. For elite athletes, who dedicate their lives to professional competition, sports can change from a positive influence on physical health to something that puts mental wellness at risk. For instance, when it means sacrificing friendships and one’s personal life to the pursuit of sporting greatness.
This was one of many insights that emerged out of the development process for TWM Sports. The MHCC partnered with the Saskatchewan Roughrider Foundation to pilot the program with players and coaches, along with other elite athletes from Saskatchewan communities.
After Cindy Fuchs, the foundation’s executive director, saw the potential of having a TWM program designed specifically for athletes and coaches, she immediately contacted the MHCC to ask how she and her team could get involved.
“The Roughrider Foundation is dedicated to supporting health, education, and amateur football in our local communities, and the TWM Sports program weaves perfectly into those pillars,” she said. For Fuchs, TWM also aligns with the foundation’s other initiatives, including Win with Wellness and Game Changers Playbook, a collaborative project with the Saskatchewan Ministry of Education to address youth mental wellness in the province.
Throughout the pilot phase, a common thread in the feedback she received from participants was about how impactful the sessions were. “It forced them to reflect on their own mental well-being,” she said. “I think a lot of the players didn’t realize the stress they were going through until they reflected on it.”
By implementing a box-breathing technique from the program into his game-day routines, one kicker was also able to help his on-field performance. And the program also had a positive impact on team morale.
“You can see that the players who have taken the training have a special bond,” Fuchs added. “They know they can be open with each other about how they feel without any judgment.”
It’s this sense of openness — and the de-stigmatization of mental health in sports — that motivated the foundation to spread the word about the program and cover the entire cost of TWM Sports training for all university athletes in Saskatchewan.
Starting with the University of Saskatchewan, all student athletes — regardless of their sport — will have the opportunity to take the program. In addition, all Roughrider players who give presentations for the foundation’s in-school programs will undergo training, allowing them to share the lessons they learned through the course with young people in the community.
“We want as many athletes as possible to have the opportunity to experience this program — it’s that impactful,” Fuchs said. “How cool would it be for a player to be able to tell their coach they aren’t having a good day and not have to worry about being benched or blacklisted? It’s about mutual respect and openness to have this dialogue between the two sides.”
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A broader term captures the rich diversity within communities. Why we use ‘ACB’ over ‘Black’
This article is part of the Catalyst series called Language Matters.
In early 2021, the Mental Health Commission of Canada adjusted its language guidelines and started using the term African, Caribbean, and Black (ACB) when referring to the diaspora who were often grouped under the heading, “Black.” Prior to the change, Black was broadly applied to anyone with dark skin, regardless of their cultural identity or heritage. Imagine the differences of experience and perceptions between a multigenerational Black Nova Scotian and a newcomer from Gambia.
While my family hails from Barbados, I was born in London (England) and grew up in Montreal. I self-identify as a Black woman, a Canadian, and a Caribbean, and I’m not conflicted by those intersecting titles. On countless occasions, people have attempted to “other” me through comments or questions, now identified as microaggressions. “You speak so well,” one of them said, surprised as if, despite my going to the same schools and receiving the same education since age three, my Blackness would subvert those teachings. My personal favourite is, “Where are you really from?” — because Montreal and London didn’t fit the expected answer.
My Caribbean background has often felt like a cozy place of retreat in the face of this insistence that I am not Canadian. I imagine that for folks born and raised in Canada with parents and grandparents who had the same experience, these questions would be more than frustrating. If you can spend your whole life in a place, be taught at the same schools, eat the same food, and still be considered an outsider, it is like remaining stranded on the ancestral slave ship, belonging neither to the new world nor the old.
Our identities are wrapped up in myriad little and big things that give us definition and grounding. What we are called matters. Those names do more than identify our skin colour. They reflect our experiences and knowledge. I have no idea what it would be like to arrive as an adult in a new country and have to fit into a different, often unwelcoming culture. Nor do I want to maneuver through the expectations of those who assume that this is my reality. Whether here by choice or by birth, we are Canadian. Like my fellow citizens of Italian, German, or other descent, I also proudly enjoy the rich offerings of my Caribbean history.
Setting the tone
I don’t blame people for feeling confused or even frustrated with the evolving use of terms. They are legion and often come with an array of confusing and (at times) contradictory explanations. I spent many years explaining to friends and neighbours that I was not “coloured” but “Black.” Then, some well-meaning collective determined that “people of colour” was acceptable. Years later, after moving through the terms “visible minority” and “racialized communities,” Black Lives Matter blew into the media spotlight with “Black, Indigenous, and People of Colour” (BIPOC). At that time, it had become more important to acknowledge that a disproportionate number of ACB and Indigenous people were being incarcerated and attacked by police or denied access to health care (the list goes on), that their realities were different from others. The debate over the merits of capitalizing the “b” in “Black” is forged in the same social furnace. The use of uppercase is an attempt to recognize the shared history of violence, oppression, creativity, and triumph. Though it may seem like a simple grammatical issue, it covers a host of previously ignored or denied experiences.
These conversations reflect a complex and ever-changing social dynamic. It isn’t as simple as saying, opinions vary, or minds have changed. At their heart they reflect emerging knowledge, a growing awareness. More voices are being heard, and that results in more measures being taken, more information being gathered. Consider how hard it is to talk about the disproportionate police-on-ACB violence when authorities refuse to capture skin colour in their reports. It took a collective of intrepid reporters working nationally to collect, collate, and track how many ACB people had been shot by police before those numbers forced authorities to acknowledge that reality. Armed with the facts — the evidence of racism’s impact — people could suddenly be heard when they said, Don’t call me that. Don’t lump me into a broad group. My experiences are different.
Names matter. Using ACB rather than Black (if preferred) is not a new politically correct affectation. It’s a respectful reflection of the very real and very different experiences of people who may share nothing more than similar skin tones.
Debra Yearwood, CHE, made a conscious rap playlist after researching this story. Her work appears regularly in The Catalyst.
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Are you having a lightbulb moment?
The SPARK Knowledge Translation Program charts a path for those with an idea to improve research and practice around mental health, substance use, or addiction. A look at the Grand Council Treaty #3 project, which serves as a mental health life-raft for 28 communities.
In the early days of COVID-19, Darlene Curci was taking note of the challenges in Kenora, Fort Frances, and Dryden. She is the Indigenous systems coordinator for Grand Council Treaty #3, which comprises 28 First Nation communities across 142,000+ square kilometres in northwest Ontario and southeast Manitoba.
“A lot of things were happening on the ground while we were going through lockdown,” she recalled. “Our health team was being deployed to help our communities through COVID by providing resources.”
As she worked, Curci was able to observe the evolving needs and challenges of coping with the pandemic. “Some of the communities are isolated and have few resources, which must then be shared across a large geographical area,” she said. “We don’t have specialized resources to address mental health or addiction issues. Psychiatrists have to fly in from Toronto, or else people must go to Winnipeg for specialized services.”
While those services may be rooted in a clinical practice, Treaty #3 communities have land-based, traditional, or combined approaches that include Western models of health and wellness. As Curci was looking for a way to bridge these approaches for Treaty #3 communities, she saw a social media posting about the Mental Health Commission of Canada’s SPARK program. After seeing how SPARK works to ensure success, she applied to the program — which includes 16 hours of workshop time and a one-year followup mentorship — to turn that idea into action.
Connecting the dots
SPARK’s Knowledge Translation Program seeks to provide the tools and resources needed to close the gap between what we know and what we do in the mental health and substance use fields. It gives people who have the germ of an idea — the spark — the means to foster positive change in their communities. As studies show, that process normally takes several years. But the SPARK Innovation to Implementation (I2I) framework can dramatically reduce that time.
Recent graduates (or SPARKies) include the Writers Collective of Canada, a charity that creates workshops for those under-represented in society. They partnered with Veterans’ organizations to offer expressive writing workshops as a non-clinical health intervention. Another charitable organization called Body Brave also worked with SPARK to help address service gaps for people seeking support for disordered eating.
The SPARK program asks applicants to focus on a problem they’d like to address and provides coaching and mentorship to participants across the seven I2I steps:
- State the purpose
- Select an innovation
- Specify actors and actions
- Identify agents of change
- Design the knowledge translation plan
- Implement
- Evaluate
For Curci, “the exercise provides a rigour that focuses the mind while also balancing the need to be agile and adaptable in working with different communities, specialties, levels of expertise, and ways of communicating. When I was going through the application process, I had to write out my intention, and that helped me focus on where I wanted to go with my idea.”
Over the course of the program, she developed the key output — The Grand Council Treaty #3 Mental Health Survival Guide Toolkit — which now serves as a “mental health life-raft” for all of its First Nation communities.
“It was a challenge to bring great value to the community by analyzing a large volume of information and conveying it in such a way that it would be useful to them,” she said. “But in the end, that process helped me reconnect with people in a less intrusive and more engaging way.”
A SPARK planning session from February 2020.
The 50-page booklet includes practical advice on how to respond while in crisis, guidelines for engaging with Elders, practical hang-on-the-fridge lists with key phone numbers, colouring pages, worksheets to assist with stressful times, and tips for interacting with people based on where they’re at. For example, a section for teens and youth discusses boundaries, pointers on creative expression as a form of wellness, and red-light/green-light examples of healthy relationships.
The booklet is based on Ga-nan-da-wis (good health), a therapeutic concept rooted in traditional and cultural healing approaches to achieve emotional and mental balance, culturally and spiritually. Also included are mental health tips for parents, activity suggestions for Elders — like taking a walk or having a sweat with people in your bubble — and those contending with the cumulative and collective effects of historical (or intergenerational) trauma. Substance use, addiction, family violence, and suicide prevention are all addressed, along with isolation, loneliness, and finding balance when using technology.
Curci’s project is rooted in the Minobimaadziwin strategy (cited below) developed by Treaty #3 organizations, Elders, and community members, and was launched as a guiding framework in December 2019. Its 13 values are a throughline connecting Indigenous knowledge, wellness, and current realities related to COVID-19.
Grand Council Treaty #3 Minobimaadziwin Strategy
- Unified approach
- Engage Elders
- Promote cultural way of life
- Support Anishinaabemowin as healing mechanism
- Partnership and network development
- Address root causes of mental health
- Build community capacity
- Education and prevention centered
- Treaty #3-specific tools and training — Promote education and awareness on COVID-19 prevention practices
- Culturally safe services
- Healing rooted in traditional knowledge and practice-land based approach
- Respect treaty rights and relationships
- Every door is the right door
These guiding principles are informed by Treaty #3 traditions. “We are very strong and focused in our traditional ways,” Curci said. “We have developed our own child-care law, health law, and natural resource law — Manito Aki Inakonigaawin — it is the framework for how we do business.”
Her survival guide toolkit was launched during Mental Health Week in May 2021. After all 28 communities received an initial box of booklets, an increasing demand led to a subsequent reprint of 2,000 more copies. People see great value in what it offers, often using different resources for their specific needs. They tear out pages to post near their desks or take photos of the contents that help them most in challenging times.
“In a moment of distress, when things seem impossible, it’s a way to check in on yourself,” Curci said. In addition to being the creator of the booklet — she uses the tools herself. “I find it relaxing,” she said, referring to the colouring pages, along with activities like 10 Minutes to Reflect on Your Day (to build self-esteem) and the My Moods exercise.
Social workers also appreciate the quick tips to help guide people through thoughts of suicide by discussing risk and protective factors and providing counselling helplines, in addition to traditional guidance on grief and loss. The booklet’s foreword from the Grand Chief notes that “everyone’s mental health needs are different.” Rather than put forward well-intentioned platitudes or oversimplifications, his message focuses on the importance of asking for help when it is needed, “because there is always hope for new and better day.”
Learn more about Grand Council Treaty #3.
Fateema Sayani is constantly re-examining her relationship with technology. She is the Manager, Content, at the Mental Health Commission of Canada.
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With stigmatizing language, things can get pretty cloudy
This article is part of the Catalyst series called Language Matters.
“I hate this weather, it’s so bipolar. One minute it’s sunny and the next it’s raining. I never know how to dress in the morning.” I roll my eyes at my friend, and she apologizes. “I’m sorry. I forgot.” She’s not the first to use my diagnosis to describe something negative, and she won’t be the last, but it stings every time.
Adopting clinical terminology to emphasize our experiences happens all the time. How often have you heard someone say they’re OCD when they really mean they’re organized or respond to a new story with “That’s so crazy! That’s insane!”? We’ve all heard such things (or even said them ourselves). But just because something is familiar doesn’t make it OK. Using that kind of hyperbole reduces mental illness while doing a disservice to the people who live with those concerns. It also affects how we think about mental health conditions.
It’s called associative activation, and it happens when we unconsciously attach an emotion to an idea. Usually, the process is so quick that we’re not even aware we’re making a link. Yet our brains are hard at work producing a response to the words we use and hear. When my friend is talking about the weather, she’s also associating a negative emotion with bipolar disorder. It sounds innocent enough, but it has a lasting effect. And it’s one of the ways stigmatizing language is able to flourish.
So what’s the big deal? No need to be such a stickler. They’re just words.
Actually, those words do have a big impact on people. Think of a time when someone said something hurtful to you. How did it made you feel? For those living with mental health concerns, it can be disappointing to learn that someone you thought of as an ally has unconsciously held negative feelings about your condition. It can also be frustrating to hear your diagnosis being reduced for the sake of a quip or to exaggerate a point. Of course, anyone within earshot of that conversation about the weather is likewise forming their own negative views about bipolar disorder. What might their reaction be if they or someone they love is diagnosed a mental health condition?
Language is constantly evolving as we understand more about mental health and strive to do better. While it can be difficult to keep track of shifting ideas around acceptable language, it’s certainly possible. A good place to start is to learn about stigmatizing language and some of the available alternatives.
Another thing to remember is to try not to get defensive if someone asks you to adjust your language. It probably just means they care enough to want to keep you from making the same mistake again. Many of us instinctively resist the idea of removing language from our vocabulary, but it does get easier with practice. And since choosing other words is one of the simplest ways that we can all help reduce mental health stigma, it’s worth the effort.
My friend and I put our umbrellas away. The sun was now peeking out from behind the clouds and warming our faces. “What I meant to say is that the weather is unpredictable these days. I should have worded it differently. I spoke without thinking. I’ll do better next time.” And for a long time now, that’s a promise she has kept.
Find other articles in the series: Person-first language.
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Belgian singer Stromae — whose European hits meld weighty themes with clubby beats — touches on the complexities of mental health on his recent album, Multitude. Ahead of his North American tour, Florence K — CBC Music host, singer, author of three books on mental health, and PhD candidate in neuropsychology — looks at its lyrics and layers.
We read it everywhere. We see it everywhere. We say it everywhere. There’s no place for shame or guilt when mental suffering knocks on our door and no valid reason to maintain stigma around mental health. It took a lot of speeches, awareness campaigns, expert testimonials, and hashtags to spread that message until it became loud and clear and to make inroads into social norms still enclosed by taboos.
This work has taken decades.
Yet in one song — in just a few sentences — Stromae challenges an entire generation, and he needn’t say more. A loose translation of the lyrics from “L’Enfer” (Hell) is at once hard-hitting and spare:
I’m not alone…To say that many others have already thought about it, but still, I feel alone…As a result, I sometimes have suicidal thoughts and I’m not very proud of it…These thoughts that make my life hell. —
While words are his craft, Stromae is a man of very few. His raps are slow, and he never crams syllables into the same verse. The effect is like an underline — his words stand out and paint precise images that linger and stick in your mind — you can’t unsee them.
Pretty pictures aside, there’s also plenty of straight talk throughout the album. On the same track, Stromae steps out from behind the metaphors to discuss his mental health challenges and the sense of shame that would wash over him, despite his best efforts to be vocal and challenge stigmas.
The echo of this refrain has resonated in millions of hearts, validating the suffering many of us feel. In this chorus, listeners have a chance to step away from solitude and feel, for a moment, less alone. How many have asked themselves, “If Stromae suffers from depression, maybe I’m not the only one? Maybe I shouldn’t feel so bad?”
Florence Khoriaty
It’s an important message because, even after decades of work, depression is still too often seen as a sign of laziness or weakness. Yet nothing could be further from the truth (Stromae’s prolific career is shorthand for that). Research shows that depression is a mental health disorder whose causes involve biopsychosocial interactions with complex mechanisms — neurophysiological, genetic, psychological, and environmental — that factor into each individual’s unique situation.
In opening up about his experiences, Stromae is declaring that a mental health disorder is not a choice and not something that discriminates by socio-economic class, by education level, by the contents of one’s wallet, or by one’s success. There’s a side effect to these words, set to endlessly catchy music; namely, that it reaches people differently than a public service campaign. That’s the magic of the album. And he advances the cause in leaps and bounds without a commercial tinge. The songs and lyrics have nuances and textures as real as the vicissitudes of life in all its rich complexities.
The full range
As with “L’Enfer,” the album’s other tracks are forthright accounts of the state of our society. It brings to mind the words of the rap group N.W.A., who said, “Our raps are documentary. We don’t take sides.” In that sense, Stromae’s album also avoids simple polarities with an honest portrait that isn’t couched in toxic positivity or end-of-the-world pessimism. Nor does he seek to be a standard-bearer for a particular disease or social cause or claim to be The Defender of All Those Who Suffer. Still, his lyrics have teeth.
In “Déclaration,” he denounces the hypocrisy of those who pride themselves on being fashionable feminists, while true progress continues to elude society. Stromae’s sarcasm belies a benevolence that serves as a through-line on the album. You hear the compassion clearly on the track “Santé” (Health), a celebratory toast to the disregarded: pilots, nurses, long-haul truck drivers, flight attendants, fishers, and bakers — along with professional insomniacs and “those who do not have the heart for celebrations.”
Let’s celebrate those who don’t celebrate themselves. A toast to the heroes of the worst times. —
In “La Solassitude” (which combines loneliness and lassitude), he explores the ups and downs of romantic relationships and the with-or-without-you challenge of maintaining a quality couplehood. He also looks at real solitude — that inner emptiness that follows you like a shadow and is seemingly inescapable no matter the surroundings.
In expressing the maudlin dark sides next to life’s more luminous moments, Stromae avoids easy divisions of “good” and “bad.” Yet he offers a winking reference to black-and-white thinking in two songs artfully sequenced toward the album’s end: “Mauvaise journée” (Bad Day) and “Bonne journée” (Good Day). Back to back, they express wry and poignant lyrics where listeners will likely recognize themselves in one way or another. They do so because we all have our ups and downs, just like we all experience a multitude of states of mind and see our lives from different angles as our perspectives evolve and shift. As Stromae reminds us of this, his album has a uniting effect. It reaches out to those who may need to hear that they’re not the only ones suffering in this giant universe, where we’re all just trying to get by.
The North American leg of Stromae’s tour starts October 21 in Vancouver.
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Is there a right way to grieve—and for how long? Bereavement in the age of COVID is getting a re-think.
Ms. B, age 65, has been feeling intense grief after her husband died of a heart attack. Not only is she tearful when remembering how wonderful he was, she avoids specific reminders of him (pictures, places they visited) to prevent even deeper bouts of misery. She is also angry that he died and has recurring thoughts about mistakes she believes his doctor made. In addition, she feels that the church she belongs to can no longer help, since no one can bring her husband back, and often forgets to take her hypertension medication, even though she knows that doing so is dangerous.
Would you consider what Ms. B is going through normal or something to be treated by psychotherapy or medication? Would your answer depend on how long it’s been since she lost her husband?
Since March 2022, as the pandemic’s third wave was setting in, those questions started to hit home with clinicians for the first time. Why? Because it was then that the American Psychiatric Association (APA) officially placed death-related grief into the realm of pathology with its latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).
Let’s think about what that means. The DSM is the authority for diagnoses and research on mental disorders in Canada, the U.S., and Australia. Ever since it published the DSM-III in 1980, it has adopted a biomedical-brain disease model, directing psychiatrists and clinical psychologists to see mental disorders in terms of symptoms and illnesses, much like a physician diagnoses physical ailments. Despite the fact that scientists have yet to find “a biological cause of . . . any mental disorder,” it would be difficult to overstate the sway of the DSM’s classifications and diagnostic categories on the way clinicians treat people who come to them for help.
12 million people
Before looking at the APA’s reasons for including death-related grief in the DSM-5-TR — under the name prolonged grief disorder (PGD) — let’s first consider its possible effects in light of COVID-19. The international toll of COVID-19 deaths in September 2022, according to data from Johns Hopkins University, was nearly 6.5 million. With each loss affecting about nine others, (the reverberating effect is known as “bereavement multipliers”), we can expect almost 60 million people to have experienced death-related grief as a result of the virus.
That 6.5 million number is staggering enough in normal times. But restrictions in care facilities, hospitals, and indoor gatherings have made both the usual physical closeness during a loved one’s imminent demise as well as bereavement rituals difficult or impossible. Such isolation has surely added an even greater burden for those left behind in terms of dealing with their loss. The APA itself has said as much, estimating that the usual rate (5-10%) of the more intense and longer grief found in PGD may double in the pandemic context at 20 per cent.
With some fast math, we could estimate PGD afflictions at 12 million people worldwide.
No matter what the final number turns out to be, the pandemic has become doubly relevant to the normalcy or pathology of grief. Given that short-term psychotherapy is currently “the treatment of choice,” the decision to enshrine PGD into the DSM-5 as a psychiatric disorder has and will put unprecedented demands on already overburdened mental health professionals.
Cultural complications
The APA considers PGD a type of trauma- and stressor-related disorder characterized by “intense yearning or longing for the deceased (often with intense sorrow and emotional pain), and preoccupation with thoughts or memories of the deceased.” Because in “normal” grief these experiences generally lose their force over time (6 to 12 months), it says that PGD can be deemed to occur when “the duration of the person’s bereavement “exceeds expected social, cultural or religious norms.” In other words, clinicians should only consider grief symptoms as pathological (that is, subject to diagnosis and treatment) after this period of “expected norms” has run its course.
But will they? Putting such weight on a clinician’s judgment about social, cultural, and religious norms has certainly raised questions. One concern relates to applying a universal secular standard to norms which themselves contain values about healthy and unhealthy grief. Kaori Wada, a registered psychologist and the director of training at the University of Calgary’s counselling psychology program, points to a study involving Canadian undergraduates, which found that religious women participants with experience of bereavement were more likely to see the same grief responses the DSM now deems pathological as healthy.
A second issue is the APA’s adoption of a “normal grief period” in relation to social, cultural, and religious norms. This is something Harvard psychiatrist and medical anthropologist Arthur Kleinman questioned in the Lancet as the DSM-5 was being prepared. As he pointed out, “there is no conclusive scientific evidence to show what a normal length of bereavement is. Across the world, societies differ in what they regard as normal grief.”
Wada likewise stresses the newness of the DSM-5-TR’s “too much for too long” criterion, which is at odds with many cultures and expectations; for instance, those that see honour and moral depth in deliberate, enduring grief and emotional pain. She therefore thinks we should recognize the important shift that happens when we begin to fit what was once “understood outside medical language into a treatable disorder, [using a] ‘diagnose and treat’ logic.” By doing so, she argues, the DSM-5-TR “officializes [the idea] that if you’re grieving too long or too intensely, then you have a mental disorder.”
Wada’s concerns extend to the social, cultural, and religious norms designed to restrain the assessment and treatment of PGD. For her, not only are these norms diverse and complex, they are often far-removed from a psychiatrist’s or therapist’s expertise. In her view, the APA’s instruction to apply them puts a “tremendous amount of weight on the clinician’s shoulders.” And since most people in Canada rely on (short visits to) primary care physicians to address their mental health needs, she doubts whether such assessments are likely to be used very much in practice.
What can we expect when clinicians fail in this task of assessment or else ignore it because they feel ill-prepared? The most likely result would be the erasure of any grace period before recommending therapeutic interventions or dispensing medications.
Take this pill and . . .
While no pharmaceutical treatments for grief have been approved, the research traffic light is blinking bright green. That’s because, when the DSM-5-TR established PGD, the APA also changed complicated grief — a previous diagnostic category left out of the DSM-IV due to insufficient evidence and concerns about overdiagnosis — into persistent complex bereavement disorder (PCBD). While doing so, it also defined PCBD as a condition for further study (rather than a disorder in its own right). Thanks to that change, opportunities for new research were endorsed, including studies to establish medications for PGD.
So far, the leading candidate is naltrexone, currently being used to treat opioid and alcohol use disorders. A number of experts have found this opioid antagonist choice surprising. Indeed, the basis for considering it is the theory that PGD is an addictive condition — in this case, addiction to grief itself. So, as with opioids and alcohol, the purpose of naltrexone is to reduce the grieving person’s connection to the deceased. But since this medication does not discriminate which social connections are affected, psychologists have argued that it’s a mistake to reduce those ties at a time when relations to others are so important. They also emphasize that the pharmacological approach itself neglects the context involved in grief; for instance, the grieving person’s relationship to the deceased, the qualities of that relationship, and the kind of death involved (e.g., natural or unexpected).
Donna Schuurman, who is an expert with years of experience dealing with grief in children, youth, and families in connection with unnatural deaths, offers a less reserved critique, seeing efforts to develop a “grief pill” as entirely removed from the human context: “If you yearn or pine too long for your dead child, partner, spouse, or friend, you may be addicted to grief, according to the new revision of the DSM.” As it turns out, the road that has led to the possibility of a grief pill — while paved with good intentions — includes a rather dramatic shift. But to see it requires a bit of context.
A key element to support the DSM-5-TR’s new position on grief is the role played by major depressive disorder (MDD). MDD was initially distinguished from grief in the 1990s through the work of Holly Prigerson, then a professor at the Harvard department of psychiatry. After noticing the difficulty certain people had in resolving their death-related grief, she and others began arguing that this situation called for a new disorder. The point is that the initial justification for what was to become PGD was the discovery of grief symptoms thought to be distinct from those of MDD.
Remember Ms. B from our opening description? Her case was included in a 2010 paper by Prigerson’s colleagues as a way to offer insight into this distinction, since Ms. B’s mood symptoms failed to meet the criteria for MDD (as did her behaviours for post-traumatic stress disorder [PTSD]).
Yet Wada believes that an argument against overmedication — which Prigerson and her colleagues originally put forward to justify the separation of grief from MDD — has now fallen away. One of their key rationales for this distinction was to “spare [people] from being wrongfully medicated.” But today, with PCBD becoming a condition for further study, some of those same MDD medications that were ineffective for grief are being considered as potential solutions for PGD. While Prigerson herself agrees that antidepressants have not been effective for grief, she thinks it’s important to continue learning more about grief in psychiatric terms to help people in such pain.
The way ahead
Supporters of using medications (perhaps alongside therapy) for those diagnosed with PGD insist that “no one wants to medicalize a normal, adaptive process.” Still, a clinician’s assessment of social, cultural, and religious norms as the sole constraint does not inspire confidence that such an aspiration can be achieved. Nor does the DSM-5’s contentious removal of the “bereavement exclusion” from the DSM-IV — which at least provided a two-month grace period before clinicians were supposed to consider symptoms during death-related grief as major depression. Although these shifts occurred in the name of relieving suffering and concerns over the risk of overlooking such depression, Wada points out that the act of “establishing a disorder category enables, even stimulates, further research into pharmacological interventions.”
While, at the policy level, the crux of the debate may rest on values related to the overuse of medication, the path the DSM-5-TR has cleared for the development of a grief pill is hard to deny. No matter where the APA’s new conception of grief takes us, in light of the millions of vulnerable people experiencing longer and more intense grief due to COVID (or the next mass trauma), this new diagnostic landscape will no doubt itself receive longer and more intense scrutiny.
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Activating an entire school community (parents, peers, education workers) can reduce the nefarious long-term impacts of bullying — a look at promising models to create kinder environments for kids
Bullying, including cyberbullying, is a growing and worrisome epidemic. Not only have one in three children been bullied at some point in their lives, the long-term impact on young people and adults can be life changing. An increasing body of evidence points to its detrimental effects on people’s mental and physical health. Studies also show that there can be lasting impacts in terms of future social and financial outcomes.
“It’s part of life”
Contrary to lingering social attitudes, we now know that bullying is not just an inevitable part of growing up or a harmless rite of passage. Bullied children and adolescents have a much higher risk of developing psychosomatic symptoms than those who escape it. Commonly reported problems linked to bullying include poor health, loss of appetite, sleep disturbances, headaches, abdominal pain, breathing difficulties, and fatigue.
For Eric, it started in elementary school, where the bullies targeting him kept up a relentless campaign of abuse. Its effects, he recalled, included anxiety, headaches, nausea, weight loss, and the absolute erosion of his self-worth. But those weren’t Eric’s only worries. After two years, with no hope in sight, he had reached his breaking point: “I didn’t care whether I lived or died,” he said. His family, desperate to find help, turned to a psychiatrist, who took Eric out of school and put him into intensive treatment. Thankfully, after some time, things turned around for him. In fact, he ended up becoming a kind of champion of the underdog among his peers. Today, Eric describes himself as “lucky.”
A young person being bullied can feel isolated, have trouble trusting people, and lack quality friendships. Should they end up believing that they can’t do anything to change their situation, they may stop trying. This feeling of defeat can also lead to hopelessness and a conviction that there’s no way out, often because they think telling someone won’t change anything. They might also prefer to suffer silently rather than risk escalation or imagine that the bullying will eventually end if they just keep quiet.
As bullied young people become adults, they may continue to struggle with relationships and avoid social interactions. Difficulties with self-esteem and trusting others can undermine significant personal relationships as well as their social and work lives. Victims of bullying also have a greater risk of emotional disorders in adulthood, including depressive and anxiety disorders, panic disorder, generalized anxiety, and suicide.
“There is clear evidence that a wide range of childhood adversity has long-term negative effects on both mental and physical health,” said Dr. Keith Dobson, a professor of clinical psychology at the University of Calgary. “Further, the emerging literature demonstrates a strong linkage between bullying and later depression and other health problems.”
Role modelling
Why does bullying still happen? Many experts point to the lack of a systematic approach to tackling the problem in schools. For a long time, it was left to teachers to address bullying behaviours — and for that to happen they would have had to witness it. Beyond that, the responsibility for reporting the problem was often left to the student, which meant that much of it was never reported.
Enter proactive bullying prevention.
The research on anti-bullying interventions is extensive, with numerous school-based programs having been evaluated scientifically. Some, like the KiVa program in Finland, focus on mobilizing the bystanders who witness bullying. These work through the power of peer responses to inhibit or fuel such behaviour.
Other programs seek instead to actively create a kinder school environment. The most prominent of these, the Olweus Bullying Prevention Program, is also one of the most widely tested. Developed by the late Swedish-Norwegian psychologist, Dan Olweus, it’s rooted in the idea that bullying is often the product of a wider culture’s tolerance toward victimization. On that basis, it tackles bullying from the perspective of a school’s entire ecosystem.
Olweus therefore works by changing the social climate around bullying: raising awareness among students, adopting anti-bullying norms, and having teachers clearly communicate their anti-bullying attitudes. But it also goes beyond the student-teacher dynamic. Every adult in the school gets basic training about bullying — not just educators and administrators — but cafeteria staff members, bus drivers, custodians, and others.
The program is effective when all these adults function as positive role models, reinforce good behaviours, and refuse to allow victimization. As part of this process, clear expectations are set for acceptable behaviour, as are the consequences of failing to abide by them. In ending their support for the culture of secrecy around bullying, each person helps to create an environment where reporting it is appropriate and expected. When saying no to bullying becomes everyone’s responsibility, it is soon ingrained in a school’s culture.
The research strongly supports the success of whole-school programs to decrease bullying behaviours. In fact, a recent study of 69 randomized clinical trials concluded that such interventions not only reduce the incidence of bullying and victimization but also improve the mental health of students.
A kinder community
When parents commit to the prevention of bullying, especially if they actively participate, a school program will be more successful. Parents can set a good example by getting involved, raising awareness, and supporting anti-bullying measures.
But since bullying is not confined to school corridors and the playground, and not all children who are bullied ask for help, parents and caregivers should also be on the lookout for warning signs. These include unexplainable injuries; lost or destroyed clothing, books, electronics, or jewelry; frequent headaches or stomach aches; feeling sick or faking illness; or changes in eating habits (like suddenly skipping meals or binge eating). In this last scenario, kids may be coming home from school hungry because they didn’t eat lunch. They may also have difficulty sleeping or frequent nightmares, declining grades, loss of interest in schoolwork (or not wanting to go to school), sudden loss of friends or avoidance of social situations, feelings of helplessness or decreased self-esteem, or self-destructive behaviours such as running away from home or harming themselves.
As well, parents can empower their children to stand up to bullies. Start by talking about what bullying is and what healthy friendships are and are not. Children themselves can also learn how to report bullying when they see it. Here, it’s important that parents help them understand why they don’t want to be a bystander and offer them practical knowledge on how to handle the situation. Taking such steps can make a big difference in the outcome.
Programs such as HEADSTRONG, offered by the Mental Health Commission of Canada, can also play an important role in supporting healthy school environments by providing students and youth the tools, confidence, and inspiration to become leaders for mental health and wellness in their schools and communities.
While bullying can have long-term negative effects, it doesn’t have to, according to Dobson. What is important is to act and intervene for the sake of others and yourself. If you know of a child who is being bullied, try to understand what’s going on and intervene if doing so is indicated. If you’ve been bullied and are living with the ongoing consequences, resources are available to help you improve your well-being.
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First Nations First Aiders support individuals and strengthen communities
Those who teach Mental Health First Aid in First Nations communities have lived experience with trauma. Roger Chum’s experience is a stark example.
“I have a personal story,” said Chum, a member of the Omushkego Moose Cree First Nation near James Bay, and a residential school survivor. “I tried to take my life, too, as a young man because of all the trauma I was walking with.”
He was saved with the support of others, and now, years later, he’s a counsellor in the First People’s Centre at Canadore College in North Bay. He also travels to communities across Canada to co-facilitate sessions in the Mental Health Commission of Canada’s (MHCC’s) Mental Health First Aid (MHFA) First Nations program, where he sees reflections of his own pain in others.
“The common themes in all the training I’ve done — in communities from B.C. to Nova Scotia to Prince Edward Island to Ontario — seem to be suicide, racism, and discrimination that people face when they’re trying to walk in two worlds, trying to live in general Canadian society but keeping their cultural and Indigenous identity at the same time, trying to balance that,” Chum said.
He estimates that he’s trained about 2,700 people to be Mental Health First Aiders since the mid-2010s, when he completed training to be a MHFA First Nations co-facilitator. In turn, those First Aiders have gone on to support thousands of people in their communities. When those who receive support to help survive their own psychological turmoil go on to help others, it creates a cycle of support that strengthens entire communities.
What sets MHFA First Nations apart
Today, about 70 First Nations co-facilitators provide MFHA training across Canada, primarily in First Nations communities but also elsewhere. Chum, for example, continues to conduct sessions for members of the Greater Sudbury Police Services, most of whom are non-Indigenous.
MHFA is a series of actions that people can take to support those who may be experiencing a crisis or decline in their mental health. While the commission offers various MHFA programs, none are quite like MHFA First Nations.
The MHCC conducts regular reviews of the course. A recent update adapted its broader objectives beyond regular MHFA training, which is very much about the skills participants might use and the actions they might take to support someone whose mental health is declining.
Some areas of the MHFA First Nations coursenow have a lot to do with building community through activities that engage the group as a whole and addressing systemic issues that have impacted First Nations people more directly — things like social determinants of health, systemic racism, and colonization.
Learning to train Mental Health First Aiders
The program’s ongoing success relies on two First Nations master trainers, Amanda Petit and Mary Wabano-McKay. These trainers teach the course First Nations people take to become MHFA co-facilitators, who in turn teach community members to be Mental Health First Aiders.
“I couldn’t imagine taking a course such as MHFA First Nations and having it delivered by a non-Indigenous person,” said Wabano-McKay, a Mushkegowuk (Cree from Attawapiskat First Nation), who lives in Sault Ste. Marie and works for Algoma University as vice-president of Nyaagaaniid — student success and Anishinaabe initiatives. “How could they relate to the lived experience and life experiences of First Nations people without having that lived experience?”
She added that Indigenous master trainers “serve as positive role models in communities among our peers and colleagues to show that not only did we inherit a lot of loss, grief, and trauma, we’ve also inherited resiliency, strength, and determination. Those things are imbued in the co-facilitators that deliver the MHFA First Nations course across the country.”
To become a co-facilitator, candidates go through 20 hours of group instruction, then spend two days working one-on-one with master trainers to go deeper into the material and demonstrate that they can deliver the MHFA First Nations course. To be accredited as a co-facilitator, they must complete further requirements within one year.
Impacts, obstacles, ways forward
The course content to become a co-facilitator can be disturbing, Wabano-McKay pointed out. In addition to going through the colonial legacy of TB hospitals, residential schools, the 60s Scoop, and other intergenerational traumas, it covers “how all of these are continuing to have serious impacts on First Nations people, on overall wellness, on mental health — from anxiety and depression to substance use and psychotic disorders.
“Such material can often be triggering for those who take the course,” she said, which is why co-facilitators are on site when an MHFA First Nations workshop is held. Community Elders are also invited to provide further support to participants, as needed.
Another potential obstacle for co-facilitator training is for candidates to get past their own stigmas about mental health and understand that everyone has it.
For co-facilitator Laurie Belcourt, a Treaty 8 Nations of Alberta employee from Bigstone Cree Nation, the course was a revelation.
“It changed who I was,” she said. “The way I think about people, the way I interact with people, it’s different. I’m a lot more understanding, I’m a lot more empathetic. It’s helped me understand that people have mental health problems. They’re not just looking for attention; they just don’t know how to deal with what’s going on.”
Through the MHFA First Nations course, Belcourt passes on that empathy and understanding to help First Aiders learn how to recognize mental health struggles in their communities, perhaps in their own families or circles of friends. “You’re that bridge between where they’re at, and where they need to go,” she said.
Co-facilitators are not there to provide professional care. Rather, their task is to listen and provide support in the moment, much like physical first aid. The next step, said Wabano-McKay, is to “connect the person to appropriate professional help and explore other supports people may have within their community. We let them know that their role as Mental Health First Aiders is to be that go-between, to give somebody that opening to be able to say, ‘I’m not okay, and I need some help.’”
Because every First Nations community has its own history, all of these interactions are carried out while respecting each tradition and culture. As Chum puts it, we’re always finding that “their food is different, their ways of knowing are different, their culture is different. We’re a very diverse people right across this place we call Turtle Island.”
Mental Health First Aid is provided to a person developing a mental health problem, experiencing a mental crisis, or a worsening of their mental health. More than 500,000 Canadians have been trained since 2007 and you can as well. Find a MHFA course online or in person.