When the Mental Health System Refuses to Listen

By  Maria Lorenzoni With Marvin Ross

Much of my writing on mental illness and the flawed system that we have to endure deals with privacy and the absurdity of keeping family and mostly parents in the dark about their loved ones diagnosis, treatment and progress. Maria Lorenzoni recently  gave this  edited presentation this past August to the Service Coordination Council on Mental Health and Addictions of the Central Ontario Local Health Integration Network (LHIN). The LHINs co-ordinate services in geographic areas.

She describes her families experiences with the secrecy of the treating officials and the impact that had on her family. Here is what she had to say:

Every serious sickness is stressful for family members, but caregivers of people with severe mental illness face challenges that are unique in some ways. Imagine for a moment that someone you love has been stricken with a devastating stroke and is in the hospital and can’t communicate, at least for the moment. Now imagine the doctors treating him or her and not giving you details of the diagnosis, prognosis, the exact information in their reports, or the treatment plan. Or just leaving you out of the picture completely. And then imagine the patient slowly recovering, but still not cognitively able to function properly, and perhaps unhappy that they are in hospital, and then being visited by a patient advocate to be informed that he or she doesn’t have to stay in hospital if they don’t want to.

You would argue that this is absurd.

According to a statement from the College of Physicians and Surgeons of Ontario, physicians can share information with others involved within the patient’s circle of care without asking for the patient’s consent if the doctor has no reason to assume that the patient would object.

Sadly, this does not apply to mental health!

In my case, it was only after three hospitalizations that I was able to press the family doctor to give me the diagnosis of my loved one. We finally got our son  into the Centre for Addiction and Mental Health and we were desperately trying to find the right meds and treatment plan. He doesn’t have insight into his illness, he doesn’t think he needs meds, so it took some hard work to get him to cooperate. And then, this vulnerable person that is in serious need of care is visited by advocates who tell him he doesn’t have to stay there.

Then what?

The onus is entirely on the family to persuade the person to stay in treatment. As a family member, you try to cooperate as best you can, BUT, you are not allowed to have any private discussions with the doctor unless the patient is in the room. Being spontaneous and giving some helpful comments is tricky when the person is right there. The doctors, therefore, make all their decisions based on communication with a patient who’s confused and will not share much because they don’t think they are sick.

He finally went to a Home for Special Care and was put under a team.  While we acknowledge the good work they did, there were a lot of misunderstandings and frustration due to a lack of communication.  No one is perfect, and families need to listen to constructive comments without being made to feel that they are just part of the problem.  In the time that he was there, we had three short meetings with the team , there were serious problems with reactions to meds, but we were not given input.  In fact, when I asked a question, I was told quite clearly…”look, you be the mother and we’ll be the treatment team.”  My family was shunned and made to feel that we were not cooperating, and in fact, we were discouraged from even visiting.

SO, POINT NUMBER ONE – family caregivers need to be able to give and receive information (unless there is a very clear reason not to), be given a diagnosis and prognosis, and consulted on a plan of action for the future.

SECONDLY, we definitely need a media campaign to focus on the obstacles faced by people with “hard core” mental illness. Sadly, the current campaign to destigmatize mentally ill is aimed at the people who have a more socially acceptable emotional problem like depression and who are in a position to ask for help. People are under the mistaken notion that everyone with a mental illness has easy access to good, consistent, hands on care. I’ve spoken to some in the health field who have asked me why my loved one isn’t in one of those residences that provide “professional rehabilitation”, and another health professional who recommended that I access a support group that helps caregivers with the tremendous grieving process that comes with caring for someone with serious mentally ill. They didn’t realize that there are no residences with professional staff, and while some support groups are good, none of them have a counsellor to help caregivers, and actually some of them are nothing more than lectures with information that you’ve read from a book a dozen times.

SO, POINT NUMBER TWO – we need to promote public awareness that people with illnesses like schizophrenia exist – that they are from every walk of life, they are people just like everybody else, they are not the dangerous individuals you imagine them to be and CONTRARY to popular opinion, they do not have easy access to services. Caregivers also need counseling as well to be able to deal with living with their loved ones on a day to day basis

NOW, THE THIRD POINT, and the most difficult, is the problem of housing. There are far too few residences and the ones that are available are overcrowded. A few are decent, others have low standards, and the people who live there are not in a position to stand up for themselves.

People with very serious mentally ill are most in need of supportive housing, yet they are the least likely to obtain it. They DO NOT GET MEDIA ATTENTION, AND DO NOT HAVE A VOICE. There is no easy solution, but with SOME BRAINSTORMING AND SOME PROPER REDIRECTING OF FUNDS, some pilot projects can begin to appear. Families would be delighted to help in any way they could, and IN FACT, THEY NEED TO BE PART OF THE PROCESS, so that a proper support system could be implemented.

I know so well that parents of adult children with serious mental illness are very concerned about the future of their kids and want to see them living in a place where there is hope, dignity and support.

If the public becomes more aware, and less afraid of mental illness, if there is more communication with families on the part of health professionals, more guidance and support for families and the hope for proper supportive housing, the future can be much more promising.

 

Trump’s Great Service to Americans – But Time To Go

By Dr David Laing Dawson

The unraveling of Donald Trump is nigh. And if it happens soon, and if the reaction he has provoked has staying power, then, surprisingly, Donald Trump will have performed a great service for America. Perhaps the reaction to Donald will bring about a better America.

Donald has brought to light the simmering racism, the unholy divide, and the hypocrisy that is America. It has always been there of course, addressed politely from time to time, but recently not so overtly, so publicly that it could not be ignored by others.

To be fair though, the credit probably goes equally to Barack Obama, for it may be this unusual sequence of a first black president, and a very good one, followed by a Donald Trump that so ignited the fires of white supremacists and then lifted the fog of denial from the eyes of liberals.

All of them, the KKK, the Nazis and neo-nazis, the white supremacists, they all quietly nursed their wounds and hatred during Obama’s eight years. Now Donald has set them free.

On Tuesday, August 15, off the teleprompter, peppered with questions, Donald Trump revealed Donald. He was of course full of himself, referring back to his successes, even to his riches, boasting of his holdings, taking credit for an improved economy, defending his first statement after the events in Charlottesville, even taking it from his pocket and reading it again, even shamelessly claiming he received praise from the mother of the woman killed.

He became combative with the press, calling them fake news, stating he is more attentive and truthful than they are.

But most of all this exchange revealed his brittle narcissism and the extent to which he cannot tolerate any criticism, any possibility that he may not be the smartest, the best, the most successful person in the room, that he may have been imperfect this one time. And it revealed how his ego overshadows any concept of country, democracy, history. Asked if he would visit Charlottesville he told us he owns a house and a golf course there, the biggest, thus demonstrating his confusion between being president of a democracy and the emperor of all he surveys.

And it gave us a hint of how mad (this word meant to be read both ways) he will become when he is finally cornered and dethroned.

Do it soon. Do it carefully. Do it with a safety net in place.

On Democracy

By Dr David Laing Dawson

In my childhood I took my birth certificate with me to sign up for a summer soccer league. Of course I lost it. There is a good chance I did not tell this to my parents. But three nights later we all responded to a knock on the door. Standing on the porch was a stocky man who proved to have a thick middle European accent and my birth certificate, a little grass stained.

I remember all this because he gave me a stern lecture about my birthright as a citizen in this democracy while I blushed under my father’s gaze. Although, in my defense it was either my father or my mother who allowed me to take this precious piece of paper on my bike ride to the soccer field in the first place.

Among many others I have been writing about the threat to democracy Donald Trump and his colleagues pose as they systematically undermine the Fourth Estate, the judiciary, instill unease in the citizens, point their fingers at immigrants, and undermine the people’s confidence in the electoral process.

But I did not think it would be so easy. Surely the very idea of free, regular, unfettered elections is sacrosanct in this American Democracy of which they are so proud.

Apparently not. A new poll finds that over 50 percent of Republicans would be quite happy to have the 2020 elections postponed if either Trump or the Republican Party suggested or requested this.

Wow. Should not their instinctive response be, “No way!”

So the groundwork has been laid. And apparently few Americans received the awakening I received in my childhood, a stern lecture from a man who escaped a tyranny, and who knew shortsightedness, indifference, and stupidity can lose a democracy but only bloodshed can regain it.

Fire and Fury

By Dr David Laing Dawson

Some years ago the person who oversaw both the men’s and women’s shelters in this city expressed his surprise that far more actual physical fights broke out in the women’s shelter than in the men’s.

But it did make perfect sense after we discussed it.

Some irritation would occur, expected when living on top of one another, and a man would verbally insult another man. Then a pattern of behaviour would unfold that was learned on the playgrounds of every public school, playing field and back alley, one that probably has genetic roots we can observe with our cousins, the apes and chimpanzees.

“Yeah, and who’s gonna make me?”

“You and who’s army?”

Chin thrust forward, the baring of teeth, the snarl, the threatened encroachment on the other’s space, insulting the other’s sexuality, his courage, his birth, his mother, name calling, dire threats for the future, the unfurling of plumage.

Other men (boys) would intervene pulling the two apart as they hurled their last insults at one another. Their assuaging words were always of the order of, “He ain’t worth it.”

This last part is important, for it is face saving for both antagonists. And an actual fight is averted. Life goes on.

In the women’s shelter, one would insult the other, and the recipient of the insult would hurl herself at the antagonist. They had not experienced the same playground socialization.

I am thinking about this because of Kim Jong Un and Donald Trump and the way war begins, and even those words of Tillerson and others, “It’s the only language Kim Jong Un understands.”

No. No. No.

Tillerson, your job is to put your arm around Donald Trump, pull him aside and say, “He ain’t worth it.”

Maybe no one can do that with Kim.

It doesn’t matter. All that matters is that one of the protagonists, these blustering would-be alpha males, especially the stronger of the two, gets pulled back.

“Donald, he ain’t worth it.”

Now if American leadership really was smart and confident, it could offer Kim some face saving device. “But we will look weak,” American leadership will scream. This despite the fact they have the capacity to destroy the world and we all know it.

Tillerson, you appear mostly sane to me, and a man who understands a few things. It is your job to pull Trump aside and tell him, “He ain’t worth it. You could take him easy, but it ain’t worth it.”

And would it kill you to promise Kim that you will stop flying B 52’s over North Korea and stop practicing war in South Korea if he stops testing A bombs?

“I Think Anthony Will Do Amazing.”

By Dr David Laing Dawson

In his brief sojourn in public life Anthony Scaramucci managed to provide hours of material for the late night shows and many columns of commentary by serious pundits.

It is all so troubling and disturbing. A man so obviously unqualified to be a Communications Director quickly drops the tenor of the office to the level of teen boy locker room talk in an under founded school system.

He has come and gone.

But within all the inaccuracies, lies, egoism, and stupidity of Donald Trump’s statements in an interview with the Wall Street Journal on July 25, this particular use of language stood out for me:

“I think Anthony will do amazing.”

There is a time in one’s development of intellectual and linguistic abilities when nouns and adverbs and adjectives get all mixed up, when the brain cannot yet formulate explanatory secondary clauses, and when the brain does not yet notice the misuse of words, catch this, and then explain further.

That age is about 13, 14, 15. (and younger than this of course)

13, 14, 15 is the age at which I hear kids use the phrase, “will do amazing.”

By 17, if they say “will do amazing” they catch themselves and explain further in a second clause, such as, “I mean, like, I think he will get really high marks.”

By university level they realize that the quality of being amazed belongs to the observer, not the doer, and the whole thing is phrased differently.

And all through the transcripts of recent interviews and off-the-teleprompter speeches it is clear Donald Trump does not catch his own absurdities, his own unfinished thoughts, his own deviations from logic, and his own outrageous boasting.

I hear the same from 14-year-olds in my clinical practice. By 17 or so, most have the ability to hear what they have just said, to notice when it veers from truth or logic.

My American friends, your president is a very narcissistic entitled 14 year old.

Though, I must admit, as damaging as he is to the reputation of America in the rest of the world, he may be less dangerous than many Republican alternatives.

Might I suggest a strategy to keep us all safe: Every other leader in this fragile world of ours should send Donald Trump an effusive Valentine card four times a year, at least.

Ignorance and Depravity Goes to Washington

By Marvin Ross

Every week I think it can’t get any worse and it does. I’m talking about our southern neighbours of course. Just how low can it go? Well, it seems that there is no bottom to the ignorance and depravity of the Trump administration.

First, we have the attacks against the transgender community. If people are law abiding and civil, what they are or what they do is their business. And do normal, sensible people really care where others pee? I remember being in a hotel in the 1960’s in some small community in Guatemala. Down the hall were two doors – one marked damas and the other caballeros. They both lead into the same large room with cubicles and basins lining either side of the room. That would likely cause a stroke in South (or is it North) Carolina in 2017.

But then, to top off that bit of idiocy, we have the new communications director for the White House who has no idea how to communicate suggesting that another official is a fu@@@ paranoid schizophrenic. Words fail me at this total display of ignorance, indecency and lack of civility.

I’ve just finished reading White Trash The 400 Year Untold History of Class in America and I have to say that the author got it wrong. White trash extends into the White House.

Like most Canadians, I have friends and relatives in the US and they are intelligent decent people with whom, mostly, I share similar values. But those sensible, decent, civil people need to stand up and do whatever they can to get their country back and to help it move into the 21st Century. And lest we forget, that includes health care for your citizens. No one in civilized society anywhere can fathom how you can argue about the need to provide citizens with health.

Before you suggest that no one should throw stones, let me explain that other countries have grown. Racism and incivility exists everywhere and probably always will but most countries have gone beyond that being the norm and deal with it when it occurs. Canada’s record with Indigenous people is not very impressive but efforts are being made. The overt racism towards others and homophobia is no longer the norm. Just look at the minorities in the current Canadian cabinet or the Sikh with a full beard and turban running for the leadership of a national political party.

In Hamilton,  posters promoting Fringe Festival plays  about feminist and LGBQT topics were defaced with biblical anti-feminist and anti-gay graffiti. That was denounced in social media and by civic officials and festival officials have put rainbow coloured stickers over the graffiti saying “All for love. And love for all”.

I lived in England for a year during the Enoch Powell era when racism and anti-immigrant sentiment was very strong. Today, I marvel at the English cultural mosaic that is reflected in British TV mysteries and the BBC News. The vote for Brexit may have been a bit of a setback but gone are the days when BBC newsreaders and journalists had to be white and all talked with that upper class Oxbridge accent. Not anymore.

Countries evolve and also regress as liberal Germany did in the rise of Hitler. It is time for the decent Americans I know to actively work to take back their country and to evolve. I’m waiting for US organizations like NAMI, Mental Health America and others to speak up and and denounce the obscene insult to people with mental illness and  hopefully, they will by the time this gets released on Monday. I am writing it on Friday.

The Ministry of Silly Walks

By Dr David Laing Dawson

We are living within a Monty Python skit. I must try returning my dead parrot to a Pet store and see what happens.

The American Congress has just granted Charlie Gard and his parents resident status in the U.S. so that Charlie can “receive the first rate American Medical care that he needs”.

This is the same Congress trying to repeal and replace Obamacare with a plan that would eventually deny health care for 30 million Americans, many of them children.

Polio is making a comeback. Measles is making a comeback, thanks to the antivaxers. Cholera is sweeping through Yemen.

Today, a child with cystic fibrosis in Canada will live, on average, ten more years than the same child in the United States.

A doctor from the U.S. flew to England to examine Charlie. The money spent to fly him there and back could feed 10 starving children in the Sudan for a year if he flew economy, perhaps 5 years if he flew first class. Or bottles of clean salty water and a dose or two of tetracycline for thousands of cholera victims.

This doctor, who has been experimenting on rats, would like to try his therapy on a human. He guesses at a 10% chance of “some improvement”.

With the goal being “some improvement” and the odds only 10%, most placebos do better. And I am not sure what “some improvement” looks like with an infant who cannot breathe or eat on his own, has brain damage at the structural and cellular level, and is dying from an incurable progressive genetic disease involving the mitochondria, one of those essential bits in every cell.

As with much of American culture and politics, I guess this isn’t about health care, saving and improving lives, treating illness, preventing disability. It is about money, self-aggrandizement, career, and celebrity.

In another real life skit NASA has had to officially deny that it is running a child slave camp on Mars. Or was that a child sex slave camp?

And in an open hearing a Republican Congressman asks “if Mars was different thousands of years ago, could there have been a civilization on Mars?” The scientist on the panel tells him Mars was different billions of years ago, but there is no evidence of any civilization ever existing on Mars.

The chairman thanks the congressman and says, “Looking forward to finding what’s up there, for sure.”

This last statement is interesting. Besides the notion that Mars is “up there”, this chairman doesn’t seem to know that with probes, orbiting satellites, and rovers, we have been receiving information about Mars for over 40 years.

Donald Trump thinks the “biggest crowd that ever gathered around the Eiffel Tower” came to see him dine, shortly after he made the “best speech any president has ever made on foreign soil.”

Ground Control to Major Tom.

More on Families, Privacy And Suicide

By Dr David Laing Dawson

Much of psychiatry is about convincing people to do things that will improve their mood, their health, and their lives. Exercise, better diet, overcoming fears, taking necessary medication, stop taking harmful substances, go to bed earlier, turn off electronics, find balance in your life, join something to overcome loneliness, stop procrastinating, call a relative, tell your husband, plan your day, stop worrying about things you cannot control, take baby steps, take medication regularly as prescribed, go for blood tests, enjoy small pleasures, scream at someone rather than cut yourself….

It is not in the DSM V (I think) but we know “no man is an island”. We are social beings. Maybe not to the extent of bees and ants, but no less than chimpanzees. We are never fully independent life forms. Even a hermit has a relationship (albeit a distorted and contrary one) with the community and family he or she is rejecting.

We also know that the quick impulse to say to the doctor, “Don’t tell my family.” or “I don’t want my family involved.” is often derived from shame, guilt, a sense of failure, and sometimes the opposite, a genuine wish to not burden the other. This is further complicated in the teen and youth years by an ongoing negotiation with respect to power, control, individuation, responsibility. We also know in these years the adolescent often says, in the same breath, “I hate you. Give me a hug.” “Get out of my life. Drive me to the mall.” “Don’t tell my dad. Please tell my dad so he can protect me.”

And we also know that persons suffering from severe anxiety and depression develop a sort of tunnel vision that excludes broad levels of social awareness and understanding. “Leave me alone.” And people suffering from a psychotic illness often harbour delusions about family members. “She’s controlling me.”

So, absolutely, when the young person says, “Don’t involve my family.” professionals should explore this, and then convince the patient otherwise unless there is good evidence that keeping the family (parents, sibs) away will be ultimately better for this patient.

Families, Privacy and Hospital Suicides

By Marvin Ross

One of the constant themes in my writing of mental illness is the need to involve the family. And so, when I read a lengthy account of the suicide of a young 20 year old girl that appeared in my local paper, what jumped out at me was that she had requested that her family not be involved with her illness or treatment. She wanted to spare the family grief and, it seems that the doctors went along with her.

The young girl had a number of suicide attempts while in hospital and the family was told none of it. Dr Peter Cook, one of the psychiatrists, told the newspaper that “We were obligated to protect the privacy of Nicole. She was an adult.” The other shrink said that confidentiality between patient and doctor is “sacrosanct.” Nicole did not want to share her medical information with her family.

Sadly, this young lady is not the only suicide in the past little while at this hospital. There have been 9 – 3 in hospital, 2 of patients on leave and 4 outpatients. To its credit, the hospital did commission an external review to see if things could be improved. One of the recommendations was for “closer collaboration with families.”

Now, maybe the outcome would not have been different if the family was involved but we don’t know that. And, the privacy legislation is pretty confining but there are ways to get around them if the medical staff really care. The hospital recently established a family resource centre as the result of a donation from a philanthropist friend of mine. It was difficult to get them to accept the gift but they did and it is being used and it is being well publicized to families.

At the time we were negotiating for a family resource centre at the hospital, I wrote an op ed for the local paper on the need that families have for inclusion with staff when their loved ones are being treated. Aside from pointing out the anger that families have towards being ignored, I mentioned the very sensible guidelines that were produced by the Mental Health Commission of Canada for family caregiver inclusion. And I mentioned this:

“Very few, if any, mental health facilities have adopted these recommendations despite the fact that about 70 per cent of those with serious mental illness live with their families according to the Mood Disorders study. And family caregivers spend 27 hours a week caring for their ill relative according to the EUFAMI survey. That is five hours longer than the average in other countries surveyed by EUFAMI.”

I don’t know if St Joes ever did adopt these recommendations and I do know that the Privacy Act is very restrictive. But, with a little effort, it can be sidestepped as I pointed out in a Huffington Post Blog.

I was basing what I had to say on an excellent paper on the topic that had recently been published by Dr. Richard O’Reilly, a professor of psychiatry, Dr. John Gray, an adjunct professor of psychiatry along with J. Jung, a student in the Faculty of Health Science at Western University.

I said this in my post:

They point out that clinicians often don’t even bother to ask their patients if they have permission to involve family.

If they do and the patient refuses, then they should take the time to explore the reasons for this refusal. Many patients don’t understand why it is important and do agree to allow their families information once it is explained to them. In some cases, there is some information they do not want shared (like sexual activity and/or drug use) and the staff can ensure that this information is not shared. Staff can also inform families of pertinent facts in meetings with the patient present. This often allays patient fears and is similar to the approach recommended in the UK and by the Mental Health Commission of Canada.

In those cases where no consent is given, the staff can give general information to the families and receive vital information from the family. The family can tell the doctors about new emerging symptoms, worsening of symptoms and medication side effects, all of which should be crucial information.

Until such time as political jurisdictions reform the privacy legislation, mental health staff can do far more to open the channels of communication with families for the betterment of their patients. It is time they do so.

I was pleasantly surprised that at a meeting with St Joes staff just after this was published, one of them told me that this blog was being read by staff and was being circulated within the hospital.

It seems that not sufficient attention may have been paid to that. I hope that more attention is paid to involving families so that these tragic events can be minimized going forward.

Drip, Drip, Splash.

By Dr David Laing Dawson

First Stephen Bannon and now Rob Goldstone. Both men obviously eat badly and bathe less often than desirable. I’m sure neither man picks up after himself. Goldstone may have been the image in Donald Trump’s mind when he said that the hacker could have been a 400 pound man in his mother’s basement. (Though in his actual statement Trump managed to attach the “400 pound” description to the bed upon which the man sat.)

Again I’m glued to CNN listening to the panels dissect the latest revelations, this time of Donald Trump Jr. and his meeting with a Russian Operative. And I know, looking at Don Jr., that if he were to emerge from the sales office on a Used Car Lot, I would take my business elsewhere.

I also think of the Kardashians, another name I cannot avoid, but about whom I need not waste a second of my time. I don’t need to watch them, read about them, think about them, despite their mastery of the celebrity game.

And Kanye West. Despite his crew’s mastery of Google algorithms, I can avoid reading, watching, or listening to him.

If only that were true of the Trumps. It should be. It should be.

Many politicians have lapses. The business of government can become corrupt. But it should always be serious. There should be some line between serious matters of democracy, of governance, of justice,  and the frivolous, infantile, adolescent high jinks of pleasure and titillation of Reality TV.

That line has frayed.

The impresario with no boundaries, a man who can’t tell the difference between using others and being used, emails Don Junior to tell him he can set up a meeting with a representative of the Russian Government who has dirt on Hilary Clinton. Don Jr., just as one might remark on a Facebook cat video, writes, “I love it.”

I can hear Putin saying, “Wow, that was easier than I thought it’d be. Make sure you get some video.”

Democracy can be slow, clumsy, frustrating, inept, but it is so much better than any other form of government. We have been told we need to be vigilant. We have been told we need to participate. We have been told how important the institutions of democracy are despite periodic scandals perpetrated by flawed men and women.

But it looks like we need to be told the operations of a democracy are serious. This is not reality TV. This is not Miss Universe promotion. This is not the bullshit and bafflegab of the entertainment industry. This is serious business, and it will affect the lives of my grandchildren.

Whatever their ideologies, from the freedom caucus to libertarian to liberal to socialism, it is time for American politicians to at least take their responsibilities seriously.

Now let me tell you what I think really happened one morning in the Kremlin a year or so ago:

“Vladimir, we have hacked the DNC server. We have many, many emails embarrassing to the Clinton campaign. Should we give them to Donald?”

“Nyet. He is stupid. He would boast about having them. Besides, we just give them to him what does that get us? Nothing. No. This is what we do. Find an intermediary to set up a meeting. Tell them we have dirt on Clinton and we want to share. This must be written. Go through Emin and that producer, Goldstone.”

“Who should they contact, my president?”

“Someone dumb enough to come to such a meeting. Donald Junior maybe, Manafort, Kushner, yes?”

“And when they come to the meeting we give them the emails?”

“No. No. That’s the beauty part. We get them to the meeting and record it but we don’t give them the emails. So then they’re compromised but we still have the emails and we can decide when or if to release them.”

“Mr. Putin, you are a genius.”

“I know. I know. Would you like to feel my bicep?”