Treating Social Ills to Improve Mental Illness a Mad Idea Pushed by Mad in America

By Dr. David Laing Dawson

Of course there are social determinants of mental health, just as there are social determinants for all health, happiness, longevity, and the outcome of all illnesses. This is not news. And those social determinants can be as individual and commonplace as loss of a parent or sib, some bullying, a bad marriage, divorce, assault, job loss, car accident with injury, failure at a task or ambition, and as broad and culturally and politically and economically determined as poverty, poor or absent housing, poor or absent medical care, poor or absent education, poor or absent employment, and, of course, war and discrimination.

The biopsychosocial model has been touted in Psychiatry for a century now, though I have often thought it should be the biosociopsycho model. For when it comes to the determinants of human behaviour, biology is primary, our social world and experiences come second, and actual cognitive processes such as thinking come in a distant third.

Through the sixties, seventies, eighties into the nineties much of psychiatric treatment was delivered within multidisciplinary teams. And as much as possible these teams would have connections with housing and other services. And I have often caricatured the team meeting about a given patient as:

Psychiatrist: He needs his depression treated with antidepressants.

Social Worker: He needs a job and better housing.

Nurse: He needs a relationship, someone who cares about him.

Psychologist: He needs to think differently about himself and the world.

Each could be right, but usually we would find that until the depression was adequately treated the possibility of successful job hunting or retraining, of engaging in the process of finding better housing, of establishing a relationship, and of viewing the world differently, was zero.

A few years ago at a conference someone was touting the benefits of exercise. I had to point out that I had been recommending exercise to all my depressed and anxious patients for precisely 47 years. My success rate at this was approximately 0.3 percent. At least 0.3 percent before their depression, schizophrenia or anxiety was adequately treated. Then it might improve somewhat.

As a psychiatrist and physician my prime directive is to relieve the suffering of my patient. That may mean treating an illness. It may mean calling in the social worker to ask if there is any chance of finding better housing. It may mean calling in the dietician to see if she can influence my patient’s eating habits, or referring to an exercise program, or talking with his teachers, or filling out forms to increase his disability pension, or encouraging him to see his family physician for better general medical care, or talking with the welfare officer, lawyer, probation officer……

And definitely, if one develops schizophrenia the outcome of this illness is likely to be better if that person lives within a good functioning family, has adequate housing, experiences no more “adverse events” than the average child, has opportunities for education and suitable employment, some kind of social support, at least one meaningful activity, good general medical care, and adequate finances.

But the suggestion that “we should diagnose and treat social adversity within our societies.” is paradoxical nonsense in that it actually suggests we take a biomedical approach to social ills (diagnose and treat), while at the same time being hollow virtue signalling.

We are citizens and voters in this democratic society and we can do what is possible to do to prevent war, reduce poverty, increase equity, eliminate racism, improve housing, banish guns from the streets, and improve the health care system. But as physicians it is still our primary duty to treat (reduce the suffering) of the ill and/or wounded.

Things a rural doctor has in his iPhone during Alberta’s COVID-19 pandemic – Reblog

Last week, Dr Dawson wrote about the incomprehensible anti-vax sentiment and then I came across this blog from an old acquaintance with a medical practice in rural Alberta. Dr. Greg Smith outlines what doctors are contending with because some people do not trust proven vaccinations and are willing to chance ending up in ICU’s, on ventilators and possible death to avoid a simple injection. Here is Greg’s account.

Doctors were early adopters of Palm Pilots. My in-laws gave me one as a graduation president from medical school more than twenty years ago.

The ability to carry large texts around in your pocket was revolutionary–it saved many medical students from carrying the telegraphic handbooks with which my lab coats were always too stuffed. (Hard on the shoulders! Plus they tend to spill everything out of your stupid little short medical student coat, which makes you look even dumber than you actually feel, which is saying something.)

We’ve come a long way since then. Like most people, I now carry a supercomputer everywhere in my pocket. Sometimes I use it to watch funny videos.

But, I also use it as an “auxiliary brain” for medicine. It’s particularly useful for stuff that I will rarely use, but if I need it, I need it right now.

One of those things wasn’t in my iPhone until the COVID-19 pandemic. But it is now.

It’s an article that appeared in the Canadian Medical Association Journal. It begins like this: “All physicians should be prepared to manage dyspnea, especially during the coronavirus pandemic.”

What’s dyspnea?

It’s feeling short of breath–of being starved for oxygen, like you’re smothering or drowning. It is a terrible way to die. Even with all the oxygen we can blow at you, it isn’t enough. Each breath is torture.

Usually, my patients with dyspnea get quickly transferred to Lethbridge for an ICU. I might intubate them (sedate them and put a tube into their breathing passage) to help.

Right now, that’s what my patients with COVID get. (All of them that I have had to transfer to Lethbridge thus far have been unvaccinated.)

If the health care system becomes overwhelmed, and if we have to triage care (as described here), then that won’t happen. I even wonder if I might be sent patients from Lethbridge for whom there is no space in the ICU. The Lethbridge docs might decide that I can at least “palliate,” and so unclog their hospital slightly.

They help me so often with my patients, it would be nice in a way to return the favour.

What’s palliate?

To “palliate” means to treat symptoms for comfort until the patient dies. It is “keeping you comfortable.”

We can treat dyspnea.

We’ll give you things like morphine or fentanyl, and maybe drugs like Valium or Ativan if needed. Don’t worry, I don’t even need to look up the doses in my iPhone.

If things get bad enough, we’d put you into a medical coma. Not to save you–it won’t–but to spare you suffering. You’ll be unconscious as you drown to death.

Medical coma doses–those I would have to look up. But I’ve got my supercomputer to help. Won’t take long.

We won’t let you suffer. Your family might suffer–it’s hard to watch someone die of dyspnea. But, if you’re dying of COVID and the health care system is in the kind of crisis where a rural family doc is your top care provider, your family probably won’t be allowed at the bedside anyway. So they won’t have to hear you suffer, except as you say good-bye via Facetime before we sedate you.

I’m not trying to be dramatic. I hope it doesn’t come to this.

But this is the outcome we in health care have feared all along, and what we’ve tried so hard to prevent. And right now it is hard to see how this won’t happen to someone in Alberta in the next few weeks, maybe many someones.

Last thoughts

If it does come to this, the last thing you see will probably be the nurses’ and my gowned and masked faces (plus goggles or face shield and sweaty gloves). We drilled how to get in and out of all the gear safely at the beginning of the pandemic, since we knew we’d have to look after people while being vulnerable ourselves.

A nurse’s gloved hand will probably hold yours as we administer the meds. You won’t have to ask, and I won’t have to order it–it’s just what they do.

When I’ve done my part and moved on to the next patient, the nurses will watch you closely to make sure you don’t come out of sedation and suffer some more. I won’t have to order that either.

But, after you’re asleep and comfortable, we’ll probably think of all the people who told us COVID was a hoax, that vaccines don’t work, and masking was too inconvenient.

I might even think about all the people who’ve screamed at my clinic staff or the nurses I work with when asked screening questions. I hope not. Such people don’t bear thinking about.

We’ll be wearing masks. And yeah, they aren’t as comfortable as we’d like.

But we’ll be far more uncomfortable about everything else that’s going on. So we probably won’t notice the masks much.

You, at least, will be comfortable. We promise.

Anti-Vax Protests

By Dr. David laing Dawson

I should not be astonished by the anti-vax mandate protests. It is after all just an expression of the same instinct that lies behind much human progress and evolution. It’s that “Nobody’s gonna tell me what to do” thought that jumps into our minds occasionally for most of us and frequently for some. And it arrives long before any rational thought, research and analysis can take place.

I remember well that the only time I became suddenly interested in lighting up a cigarette was the moment it was announced that smoking was forbidden in public buildings. “Nobody’s gonna tell me what I can’t do.”

But I am still somewhat astonished. After all, the evidence for second hand smoke causing much harm to others was a bit iffy at the time. Though it was clear that choosing to smoke meant choosing to cut 10 to 20 years off one’s life and die in great discomfort.

We seem to have found a reasonable compromise for smoking. Our citizens can opt for emphysema, lung cancer and coronary artery disease, they just can’t give these things to others. And as an old medical statistician once pointed out to me, the idea that smokers cost the health system a great deal was erroneous; smokers didn’t live long enough to burden the health care system with all the chronic diseases that befall us between 70 and 95.

The same could be said for the unvaccinated. But they should know that getting vaccinated and having to prove this before sitting in a theater or teaching a class of 10 year olds, or selling me groceries, or giving me nursing care, is not for your benefit. It is for your family, my family and our community.

That instinct, that automatic mistrust of received wisdom, having doubts about the prime motivation of Big Pharma, that resistance to being told what to do – that is all good. In fact it is essential for progress and democracy. But it needs to be followed quickly by thought, by research and consideration, and by some empathy for others.

So, protesters, if you don’t want to get the vaccination or wear masks, you are welcome to do this in the comfort of your own home. You can smoke there too. Just don’t come anywhere near me, my children, my grandchildren, my friends or my community.

Guest Blog – Mental Illness and The Law

Last week, we featured a blog by Dr. David Laing Dawson on the need for immediate treatment which often gets derailed when lawyers become involved in the medical process. In response, Patricia Forsdyke recounted this event from her years of advocating for those with serious mental illness and their families.

I was called to a Review Board as a witness by a father who bravely took standing at his son’s first Board hearing. Ten years before, an attempt to hospitalize his son had failed in the Emergency Department, when he was not seen by a psychiatrist.

The patient who’d been trapped in a psychosis for well over a decade had landed in hospital this time, so might get much needed treatment! My testimony was to describe how he had behaved very dangerously at a traffic intersection when he was clearly hallucinating. At the end of the hearing he said, pointing at me, that I had not seen the traffic screech and hit him.

The patient took over the hearing when I was called. He first demanded to know who I was. I told him my name: “Patricia Forsdyke.” He promptly told me that I was not HER, and he demanded that I get out my ID. As I proceeded to do so, the Chair stepped in while I fumbled through my untidy handbag. I was the President of the local Chapter of Friends of Schizophrenics and was on the Provincial Board, and pretty well-known in town. The patient told me that I was not Patricia Forsdyke, because “she” had black hair and black eyebrows ( obviously the female Lucifer). After I finished as a witness, I stayed for the rest of the proceeding. It was bizarre. His father did a wonderful job. It was excruciating for his mother.

Everyone there could see how ill and trapped in a psychosis the patient was. Yet the Lawyer won. His doctor was defeated. He was not to be treated. The young female lawyer looked very concerned and almost tearfully confided in me that she knew that he was ill, but that she was JUST doing her job!

The patient remained in hospital for at least a year untreated. But after the NINTH Review Board he was given treatment. And believe it or not, despite his paranoia, he responded pretty well to treatment, and was able to live thereafter, with support and good follow up, in the community. Later he was a great help to his elderly mother, who, in a few days time will be 100! He loves her dearly as she does him. From time-to-time I come across him walking downtown and he is always very polite to me. He gives me updates on his mother.

THE LAW IS AN ASS! And it has no mercy

Schizophrenia Resources

Since 2014, we’ve been providing weekly information for our readers on important issues in schizophrenia and serious mental illness. We’re pleased to say that we rate in the top 100 blogs and websites worldwide dealing with these topics according to Feedspot. From 2011 to 2018, one of us also posted regular blogs on serious mental illness on Huffington Post.

For those who are interested, we’ve produced a number of book titles since 2008 exploring various aspects of serious mental illness written either by those who suffer or their families. These books have been well received and favourably reviewed internationally and can be found in numerous libraries in North America, Asia, Europe and Australia.

See

This year, we’ve produced three new volumes exploring other areas of what we hope are of interest.

All of the books (save for the book on recovery) are available in print from major booksellers worldwide. They are also available in all of the e-book formats.

The Reality of Involuntary Treatment

By Dr. David Laing Dawson

Some years ago a very smart young lawyer helped the physician employees (Medical Directors of Psychiatric Hospitals) of the Ministry of Health of Ontario navigate the arcane legalese and complexity of involuntary admission for assessment, capacity to consent to treatment, involuntary treatment, and informed consent. Then one day, informally, she admitted to some of us she had just that weekend learned the true nature of “informed consent” for medical procedures. Her toddler son had fallen out of his high chair and cracked his head on the tile floor.

He was rushed to the hospital, moving quickly from emergency services, through imaging services, to the pediatric surgery department. And then the Chief of Surgery came to talk to the lawyer/mother of the boy, and told her that they would have to operate to relieve pressure on his brain.

The lawyer asked, “What will happen if you don’t operate?”

The doctor replied, “Your son will die.”

She gave consent.

And for the first time, I think, she understood that within the realities of disease, injury, urgent care, and medical treatment there really is no time for the protracted rhythms, ponderings, delays, appeals, postponements, and deliberations of the legal profession.

The social contract between doctor and patient is different that that between lawyer and client. The timing, rhythms and imperatives are different. The goal is different.

We must of course have in place transparent checks against the potential abuse of power by any person in a position of power, be it a doctor, priest, lawyer, police officer, or teacher. But our mental health acts tend to be written by lawyers who don’t understand the rhythms and imperatives of illness, disease and its treatment.

And the people who must abide by these “mental health acts” are doctors who have no spare time nor inclination to engage in the protracted theatre and language parsing of the legal profession.

The mental health act of Ontario would probably work well if every psychiatrist had but one or two patients at a time and enjoyed the theatre of review boards, hearings, courts, and writing briefs, and if every review board could be assembled within 24 hours.

Ultimately the mental health act of Ontario forces psychiatrists not to consider first and foremost the welfare of his or her patient, but rather the balance of probabilities of outcome and the cost (time, money, grief, rapport) of “trying the case” before a Review Board. These are adversarial systems and they are theatre.

Hence the present situation of untreated psychotic illness, homelessness, very short and repeated admissions to hospital, excessive police responses to mental health crises, and the dramatic expansion of Forensic Psychiatry. And now the same psychotic patient who should be receiving timely and thorough psychiatric treatment must wait until he or she commits a crime of sufficient seriousness to allow the lawyers and courts to decide on the issues of hospitalization, incarceration, competence, and treatment options.

An Open Letter From Ontario to the BC Government in Defence of Their Mental Health Act

By Marvin Ross

The British Columbia Mental Health Act is being challenged by disability rights groups who object to some psychiatric patients not having the right to decide if they get treated or not. Consequently, they have begun a court challenge based on the Canadian Charter of Rights and Freedoms to have that part of the act rescinded.

The ability to treat people when they need it is a key feature of the BC Act and one of the reasons the BC Act is the best in Canada. Ontario allows involuntary patients to decide if they want treatment which has resulted in patients remaining locked up and their health deteriorating for, at times, years, when they could have been treated and released.

What follows is my support for the present act. If you have any experiences with delayed treatment, please let me know. Here is my letter.

Dear Premier and Ministers of Health, Mental Health and Addictions and the Attorney General

I am writing to you as an Ontario advocate for the mentally ill who holds the BC Mental Health Act as one that Ontario should emulate. It concerns me greatly that you are facing a charter challenge to allow involuntary patients to refuse treatment (Maclaren v. AG). This would turn your sensible Act into something similar to the very deficient Ontario act. Allow me to explain.

I am a medical writer/publisher and the author of three books on schizophrenia. I also wrote a regular blog on mental illness for Huffington Post from 2011 to 2018, and I also write a blog with a psychiatrist on mental illness and have since 2014. My Huffington Post blog had numerous followers and my current blog is rated in the top 100 blogs, websites on mental illness worldwide.

Through my publishing company I am reasonably familiar with the BC Mental Health Act and systems. Five of my authors are from BC. Susan Inman in Vancouver is the author of After Her Brain Broke; Sandra Yuen Mackay of Vancouver wrote My Schizophrenic Life was given the Courage to Come Back Award from Vancouver Coastal Health and was one of the five faces of mental illness in Canada; Erin Hawkes-Emiru wrote When Quietness Came (see below) and her newest When Neurons Tell Stories. She is also a Courage to Come Back Winner; Marion Gibson of Victoria wrote Unfaithful Mind and Lembi Buchanan of Victoria did the e-book called The Emergence of the Recovery Movement.

As a parent, I became involved with schizophrenia advocacy because I have a son with schizophrenia. My advocacy on his behalf has been extensive because of the many deficiencies of mental illness care in Ontario. Like many family members, helping a relative in the system can become almost a full time job. And like many family members, the personal advocacy led to public advocacy. I became chair of the Hamilton Chapter of the Schizophrenia Society of Ontario and then a member of the provincial board. I was also on the executive of the Hamilton Program for Schizophrenia.

As part of my advocacy, I was one of 238 individuals who made a presentation to the Ontario legislature’s all party members Select Committee on Mental Health whose report was released in 2010. As you know, Ontario can commit someone to a psychiatric facility involuntarily, but that person then has the right to refuse treatment. But the Select Committee wants to change that (more below).

As I’m sure you will agree, that makes no sense. If someone is committed to a secure residential facility in order to treat a severe mental illness that, untreated, will cause serious harm to the person or others then surely the person deserves treatment. But treatment can be refused in Ontario now. I understand that so called “rights” groups want treatment refusal to also happen in BC.

In Ontario, and in BC if the Charter challenge to your Act is successful, necessary treatment can be refused if the person is capable of consenting to treatment (e.g. Prof Starson refused and was detained for 7 years); or an incapable person’s substitute decision maker must refuse if the person had a made a wish not to be treated when they were capable (e.g. Mr Sevels – 404 days in seclusion); or the substitute decision maker refuses. This simply prolongs suffering and creates serious problems for the person, staff and family.

May I refer you to Treatment Delayed Liberty Denied which appeared in the Canadian Bar Review Volume 87 by Robert Solomon, Richard O’Reilly, John Gray and Martina Nikolic. That paper has an excellent description of the issues with examples of people who have spent up to 25 years incarcerated when they could have been treated and discharged in a short period.

The horrors for patients, staff and families detailed in this paper are illustrated by Mr Sevels. This man when capable expressed a wish not to be treated. His substitute decision maker, the Public Guardian and Trustee, had to refuse treatment under Ontario law. The consequences were that Mr Sevel’s dangerous behaviour forced staff to seclude him for 404 days. He had a total of 5 years detention because he could not be treated. He only was treated when he severely injured a staff person. He responded well to the treatment he had refused for 5 years. The cost in suffering, staff injuries, extra staffing and lost liberty and dignity rights for Mr Sevels is not worthy of a civilized province. Please do not let that happen in BC by adopting Ontario’s laws.

The other excellent description of this issue can be found in chapter seven Psychiatric Treatment Authorization and Refusal in the book Canadian Mental Health Law and Policy by Gray, Shone and Liddle. The chapter shows that untreated involuntary patients have much longer periods of detention, continue to suffer symptoms, assault nurses and fellow patients, have worse long term prognoses and turn health care workers into jailers.

An example is a patient of Dr O’Reilly’s who could not be treated for two years waiting for a Supreme Court of Canada hearing. During the nearly two years that the patient was detained and not treated, he remained extremely paranoid and uncooperative. He threatened his wife and assaulted her once, causing her to fear for her life and to change residence. The Supreme Court of Canada dismissed the leave for appeal. When permission to treat was finally received from the court, it took over three months to get him well enough to leave the hospital. Dr, O’Reilly reported: …” the patient signed a living will, in which he requested that, if he ever became ill again, he be given prompt treatment with medication so as to “avoid wasting my time with a lengthy hospitalization due to my inability to decide on being treated”.

The Right Honourable Beverley McLachlin, former Chief Justice of the Supreme Court of Canada, in a speech she gave in February 2005 outlined the moral dilemma facing those who believe that involuntary patients who have not consented to admission like all other medical patients should be allowed to refuse the treatment necessary to restore their liberty, health, autonomy and other human rights.

Once again, the competing values of autonomy, treatment and protection are at play and the law in different provinces has adopted distinct approaches to deal with these issues. Forced treatment of a capable patient raises serious concerns with respect to liberty, physical integrity and equality. As the majority noted in Starson, “The right to refuse unwanted medical treatment is fundamental to a person’s dignity and autonomy”. Similarly, in Fleming v. Reid, Justice Robins of the Ontario Court of Appeal wrote that “Few medical procedures can be more intrusive than the forcible injection of powerful mind-altering drugs”. In the case of a mentally ill person who understands all relevant treatment information, as well as the benefits and risks of treatment, yet nevertheless refuses to consent, the interference with autonomy is great indeed.

On the other hand stands the argument that not treating severely mentally ill persons on account of their refusal to consent represents a particularly impoverished understanding of their rights and civil liberties. It assumes that the “formal” autonomy rights of persons whose will and understanding are seriously impaired by illness should be preferred to their substantive freedom and to other fundamental rights and freedoms that continued mental illness denies them. Failure to treat may well result in permanent impairment of their right to be free from physical detention and their right to have a mind free from debilitating delusions, terrifying hallucinations and irrational thoughts. Although respecting a mentally ill person’s decision to refuse treatment formally accords them equal treatment with non-mentally ill patients, abandoning such people to the torments of their illness, mental and physical deterioration, substance abuse and perhaps suicide surely does not respect their inherent dignity as human beings the argument concludes.”

One of the best defences of immediate treatment was written by Herschel Hardin, a BC Civil Libertarian and father of someone with schizophrenia in the Vancouver Sun, July 22, 1993. He wrote:

Civil Liberties, after all, are a fundamental part of our democratic society. The rhetoric and lobbying results in legislative obstacles to timely and adequate treatment, and the psychiatric community is cowed by the anti-treatment climate produced. Here is the Kafkaesque irony: Far from respecting civil liberties, legal obstacles to treatment limit or destroy the liberty of the person. The best example concerns schizophrenia.”

Mr Hardin also wrote that:

Clinical evidence has now indicated that allowing schizophrenia to progress to a psychotic break lowers the possible level of future recovery, and subsequent psychotic breaks lower that level further – in other words, the cost of withholding treatment is permanent damage. Meanwhile, bureaucratic road-blocks, such as time consuming judicial hearings, are passed off under the cloak of “due process” – as if the illness were a crime with which one is being charged and hospitalization for treatment is punishment. Such cumbersome restraints ignore the existing adequate safeguards – the requirement for two independent assessments and a review panel to check against over-long stays. How can such degradation and death — so much inhumanity — be justified in the name of civil liberties? It cannot. The opposition to involuntary committal and treatment betrays profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness — free them from the Bastille of their psychosis — and restore their dignity, their free will and the meaningful exercise of their liberties.”

I mentioned my author, Erin Hawkes (now Hawkes-Emiru as she is married and the mother of a daughter). Erin is a neuroscientist, an author of two books, a peer counsellor in Vancouver, and she lectures to medical staff on mental illness. Erin was hospitalized about 14 times mostly against her will and often dragged to hospital by police or paramedics. Finally, an anti-psychotic was found that quelled her delusions and, in 2012, she wrote an op ed in the National Post called Forced Medication Saved My Life. This is what Erin has to say:

Being involuntarily hospitalized and medicated against my will saved me from my suicidal self. The voices and deep meaning were silenced with mere little pills. Once stable, I could continue in recovery with psychotherapy and metacognitive training, having learned — the hard way — the positive power of anti-psychotic medication.

I now hear people lobbying for the end of involuntary treatment for people such as myself who suffer from a severe mental illness. It is a personal journey, they say, and everyone should be free to reject hospitalization and medication. It is a right, they say, to be ill; even, that there is no such thing as being “ill.”

So should I have had the right to refuse life-saving treatment? Would I have had a better life if I had not been admitted into a safe place and medicated toward death-defying insight? I am certain beyond a doubt that had I not been treated, I would have succeeded in suicide, joining the 10% of people with schizophrenia who kill themselves.

The right to live supersedes the “right” to not be involuntarily treated for mental illness. Those who are suicidal when ill but want to live when not, should have the safety of having another person decide to give us the chance to return to our lives and be well.”

Involuntary patients found Not Criminally Responsible on Account of Mental Disorder have a much higher rate of treatment refusal than civil patients. This should be a concern to BC. Treatment refusal for these dangerous patients means that more staff and other patients are assaulted, suffering continues and more are secluded and restrained. Untreated patients are detained longer in Ontario. In Ontario “Professor Starson” refused for 7 years and was only treated after he nearly died from delusionally caused starvation. Mr Conway has spent 25 years detained because he is untreated. That will probably happen if BC allows treatment refusal.

A recent example of treatment refusal in Ontario forensic system where Mr Ducharme with a serious but treatable illness is delaying treatment and prolonging incarceration by making multiple appeals. This could not happen under the current BC Act since you do not allow treatment refusal. This article from the National Post earlier this year details a number of other Ontario cases that might be helpful for your staff to examine.

The very important Ontario all-party Select Committee on Mental Health and Addictions spent 18 months and heard 238 witnesses concerned about the system and mental health legislation. The Vice Chair of the Committee is the current Minister of Health, Christine Elliot. In the report, the BC’s act is held out as a standard that should be emulated.

On Page 15 of the report, they state:

The Select Committee was particularly impressed by British Columbia’s mental health legislation. Similarly, we understand that countries such as Norway and the Netherlands, generally regarded as societies with an advanced understanding of individual rights and high standards for mental health care, have a lower threshold than the risk of serious physical harm for involuntary admission and treatment.”

The Select Committee understood that changes to how Ontario managed involuntary committal and treatments needed to change and to look more like that of BC’s. After my own testimony, I received a call from one of the committee researchers asking me for sources. She mentioned that the members liked what I had to say but that they were hesitant about recommending changes in involuntary status for fear of the outcry from the civil libertarians. I will say more of this below.

In my own testimony to the committee on Sept 8, 2009 , I said:

Most opponents of compulsory treatment cite John Stuart Mill’s On Liberty. Mill said, “That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.” When Mill wrote that, there were very few medical treatments for anything, let alone psychiatric disorders.

But Dr. Richard O’Reilly, a psychiatrist in London, Ontario, and the former president of the Ontario Psychiatric Association, points out that Mill also said in the very next paragraph: “Those who are still in a state to require being taken care of by others, must be protected against their own actions as well as against” personal “injury.”

We do that for the elderly with severe dementia and Alzheimer’s. We do not allow granny to refuse treatment for her dementia and to live in a refrigerator box outside, so why do we do that for young people with schizophrenia? It is cruel and inhumane for any caring society such as ours to allow people who are sick to remain sick.”

What the final report of the Select Committee stated is this:

After long and careful consideration, the Select Committee does not believe that it has the legal expertise to propose specific amendments to Ontario’s mental health legislation. However, the Select Committee is certain of the outcomes that are necessary to address the excessive and unnecessary suffering permitted under our current legislation:

Involuntary admission criteria must be interpreted or altered to include serious harms that are not merely physical.

Involuntary admission must also entail treatment.

The Select Committee has been advised that various legislative or policy changes could produce these desired results.

The Select Committee therefore recommends 21.

The Ministry of Health and Long-Term Care should create a task force, incorporating adequate representation from, among others, mental health clients and their caregivers as well as mental health law experts, to investigate and propose changes to Ontario’s mental health legislation and policy pertaining to involuntary admission and treatment. The changes should ensure that involuntary admission criteria include serious harms that are not merely physical, and that involuntary admission entails treatment. This task force should report back to the Ministry within one year of the adoption of this report by the Legislative Assembly.”

This has not yet been done. And while Ontario is not capable of providing adequate mental illness treatment for its citizens, it is hoped that BC will continue to show the way. To do that, you will need to remain strong and stick to science based evidence. Above, I promised to say more about the outcry from the civil libertarians. In fact, they may not be civil libertarians but rather people who oppose psychiatry and the science of brain disease for whatever purpose. I am reminded of a libertarian psychiatrist I know who once said that no one is more libertarian than I am. But, he added, how can someone whose brain is significantly impaired by mental illnesses like schizophrenia be able to make a rational decision. They cannot!

All of us who write in support of the mentally ill and advocate for proper medical treatment and medications approved by regulatory agencies face continual hostility from this group. I’ve personally been called all manner of names for what I’ve written in Huffington Post and other places. It goes with the territory and we have to remain resolute and in tune with the science. Personally, I classify these critics as the same as those opposing masks, lockdowns and social distancing for covid along with their refusal to vaccinate.

BC has an opportunity to resist this anti-scientific onslaught and protect the rights of the seriously mentally ill. I hope you will do so.

In summary my knowledge and experience from many families, patients and psychiatrists shows that refusing treatment in Ontario will likely have the same consequences if the courts or the legislature allow refusal in BC. Patients involuntarily admitted because they need treatment to address danger to self or others but refuse psychiatric treatment will: continue to be likely to harm themselves or others, continue to suffer, have longer (and more expensive) detentions, more seclusion and restraints, more assaults on nurses and other patients, more costs to the system, poorer prognoses, and create moral dilemmas for psychiatrists and nurses whose ethic is to do no harm. The harm is that patients lose their rights to health, to liberty, to autonomy, and dignity. Please learn from Ontario.

Please feel free to use this letter as you see fit. It would be nice to know that it has been received and shared with those involved in the defence of your excellent BC Mental Health Act Charter challenge.

We are Running Out of Time!

Image by Jörg Vieli from Pixabay

By Dr. David Laing Dawson

As a teen and youth I devoured Science Fiction, especially those authors who took current science and extrapolated far into the future. But I always thought in their imagining of social structure and governments they got it wrong. Surely we would have developed our democracies in a progressive manner, achieving a humane, inclusive, thoughtful, worldly form of governance, at least for this planet. But no, most of these writers imagined a return to a brutal form of tribal order, something like, well, the Taliban; along with massively powerful corporations lead by amoral self absorbed ridiculously rich men, sort of like Elon Musk and Jeff Bezos, men who would fly their rocket ships through the cowering masses to spend a few weeks on their mega yachts as our planet died.

But now I fear those science fiction writers may have gotten that part right as well.

I am writing this on my smart phone as we pull our solar and USB equipped trailer across the Prairies with our computer on wheels called an SUV, and it has just let me know it craves a quart of motor oil. To my left a very long freight train idles beneath massive grain silos that look able to feed the world if not for the recent drought. Much of the way to this point we have driven through a smokey haze from the wild fires to the west.

Surprisingly small towns now have Tesla charging stations, campgrounds have free WiFi, and a satellite watches our progress on the highway.

Forty years ago I would check the oil level by sticking a metal rod in the crank case and hope for a pay phone in the small town my paper map says is coming up. And these past 40 years have shown that science and invention and human cooperation could, in theory, overcome our climate crisis.

But not by vanity trips into space, colonizing the moon and mining Mars. Certainly not by tribal and populist governments. And not by politicians setting carbon emissions targets in grand speeches.

The Internet tells me there are half a dozen designs and technologies to harness wind power, another half dozen ways to harness the energy of tides and waves, major advances in turning solar energy into electrical energy, major advances in storing electrical energy, that pound for pound escaping methane is worse than carbon dioxide, and there are multiple technologies for capturing and reusing carbon from the air. And then we have planting trees, saving the ones we have, turning arid land into sustainable pasture, and controlling population. And of course safe nuclear power.

The past forty years have proven we humans have the ingenuity, the technologies, the money and the means to stop global warming, but we need a multinational Manhattan project to do it, to decide which of these technologies and programs are feasible and the role they can play.

Imagine the money and scientists of NASA, the Canadian Space Agency, European Space agency, China and Russia all focused on the problem. Forget the moon and Mars, no one wants to live there and watch the home planet die. Imagine using some of the money held by that top 0.1 percent. Imagine as many carbon capture gizmos as there are cell towers, imagine the armies of the world turned to planting trees.

And population control: seems to me if we don’t do it, nature will do it for us, and not in a painless way.

So Justin, time to meet with Joe Biden, forget politics and looking good. Time to think big. Time for the engineers and scientists to tell us which of all those technologies could manage what part of this existential threat. Then go to work as if we were at war.

Coroners Join with Families Fighting for Mental Illness Justice

By Marvin Ross

With the help of a couple of coroners, Ontario families gained some slight measure of justice this month. The first case pertained to a 30 year old man with schizophrenia who died in prison where he was awaiting a psychiatric assessment. Soleiman Faqiri had suffered with schizophrenia for 11 years. In 2016, he was arrested for assault and threatening likely as the result of his schizophrenia. This was his first criminal arrest but he had been apprehended under the mental health act 10 times over the previous ten years. He had been an engineering student at the University of Waterloo.

The jail put him in solitary while he awaited a mental health assessment and his symptoms began to increase. As he worsened, records show that up to 30 guards subdued him using pepper spray, a spit hood covering his face and shackles. According to the original coroner’s report in 2017:

“he had suffered more than 50 injuries including a bruised laceration on his forehead, and multiple bruises and abrasions on his face, torso and limbs, from a three-hour confrontation with prison officers.

The report said it was unknown what injuries were from his struggle with the officers, and it couldn’t ascertain the cause of death.”

Three staff were fired although one was rehired, the police refused to prosecute and the family is suing. As the result of intense lobbying by the family and their supporters, Ontario’s chief pathologist revisited the case and concluded that death “was caused by correctional officers beating him, pepper spraying him and restraining him face-down — a position well-known to make it harder to breathe.” The chief pathologist has turned the case back to the police for a third investigation.

The Toronto Star editorialized that this is not the first example of such treatment in prison but it must finally end and the perpetrators brought to justice. In 2013, Ontario acknowledged that solitary is not appropriate for those with mental illness but it has done little to end the practice. The courts have declared solitary to be an outrage to “standards of decency and amounts to cruel and unusual treatment” but it continues.

The other example deals with families fighting a psychiatric hospital where their family members committed suicide. Between 2016 and 2018, a number of patients at St Joseph’s Healthcare in Hamilton, Ontario died by suicide while in hospital, on passes from the hospital or recently discharged. The families reached out to the coroner’s office and requested the deaths be investigated.

The families met with the coroner and put forth a series of recommendations that the hospital should follow when dealing with patients and their families. These recommendations were given to the hospital who then reported on what action they intended to take. You should be able to find the full report here but these are the recommendations that I find important.

The first is for the hospital to stop contracting with patients to not commit suicide. The practice is to get a verbal agreement from the patient that they will not kill themselves which, frankly, is ludicrous. The families asked for a proper assessment of risk to be carried out. That assessment needs to be thoroughly documented and followed up with. Further, a single staff person should be in charge of the case for follow up and review.

All facts about the patient should be confirmed with the family to remove errors and that the family be involved and have a clear understanding of which staff are responsible.

This, to me, is the most crucial:

“Although a person may not want family/friends informed of their status, there needs to be an ability for the family/friends to communicate with the clinical staff and ensure the information is available and being appropriately processed/managed. Also, the request for privacy needs to be addressed in an ongoing manner (often day passes require consent by those that will be accepting the individual), as well as a patient may agree to changing their restrictions during a hospitalization.”

And

“Hospital notification of family/friends prior to discharge should be strongly considered as a mandatory requirement and a safety plan documented in the chart if the location of discharge involves any of these individuals.”

When it comes to passes “It is recommended that all passes should be earned as sign of improvement, documented in the chart, and not as opening a bed for the period of the absence.”

What I particularly appreciated was

This is my own local psych facility and this is one of my pet peeves with them. Patients who are seen by outpatient staff do not get to keep the same doctor when they have to be hospitalized. Each inpatient unit has its own staff psychiatrists so unless your regular doc is assigned to that unit, you get someone you may never have been seen or treated by. And, from experience, I know that the two do not always talk to each other even though the medical records are electronic. That is a huge failure. And the lack of communication between in-house and “out-house” can be a major problem.

“Consider the importance of communication between in-patient and out-patient treatment providers in the planning and implementation of care and goals in the circle of care.”

When my son was first discharged to the outpatient unit (and both units were on the same floor), our first visit with the psychiatrist began with “tell me why you are here”. I suggested she might want to look at his chart and/or talk to the inpatient doctor. The reply was “I like to hear it directly” and I was never sure how much information was shared.

The hospital has been given a chance to respond to the recommendations and to say how much has been implemented and how they plan to implement the rest of the recommendations. When it comes to sharing information with family, the hospital is at a disadvantage because of Ontario’s bad privacy legislation. Despite that, the hospital guarantees that they can still accept information from the family and that in cases where the patient refuses to allow disclosure, the hospital states they will revisit that decision periodically. What they do not offer which they could is to probe if their is some information that can be shared while keeping other things private. That is a suggestion made in one paper at least.

While the families did make considerable progress thanks to the help of the local coroner, they are pessimistic. Their reaction to the response they got from the hospital was:

“Although we greatly appreciate the work he (the coroner) has done, our families lack trust in the hospital’s commitment to implement these recommendations. Their responses look good on paper, but in our experience, the hospital lacks the accountability to follow through on best practices. Many policies were in place during the time our loved ones were in their care, and if they had followed the guidelines, our family members would still be alive today. We must also state our disappointment in the lack of interest and respect the hospital showed in engaging with us during this review. It’s this lack of engagement and respect for families/caregivers that has caused many of the problems and lack of care for our family members. If the family concerns were truly respected and listened to, there likely would have been better outcomes in many of these tragic suicides.”

As I’ve personally had many disputes with this hospital to the point of threatening legal action, I fully understand their sentiment. Until those who run they system start to show some respect for the families and more compassion for their patients, not much will change. There are many who do both but the institutional culture is one of inertia in my humble opinion.

The Evidence for AOT and CTO – Why the UN and WHO are Misguided

By Marvin Ross

The United Nations Convention on the Rights of Persons with Disabilities, the World Health Organization and the many ordinary citizens who embrace anti-psychiatry would have governments allow the mentally ill to continue suffering by declaring Assertive Outpatient Treatment (AOT) and Community Treatment Orders (CTOs) illegal.

Their wishes which they push aggressively run in opposition to the research that finds these strategies to be beneficial. Ending these strategies would plunge many back into psychosis, homelessness, crime and prison. Unfortunately, their blinkers fail to allow them to see the benefits demonstrated by research that these programs create.

The Treatment Advocacy Center in the US has put together a summary of the research in the US for AOTs while Ontario does an evaluation of CTO’s every five years. The results are impressive.

Arrest, incarceration and days incarcerated were way down in New York State, Florida and the US as a whole. For example, there was an 83% decline in arrest rates and an 87% decline in incarceration for AOT participants. Homelesness also declined from 13.6 to 7%. In New York State there was a 74% decline in the incidence of homelessness for current AOT recipients compared to the three-year period prior to them becoming involved with AOT.

Violence towards self and others also dropped considerably as did victimization. And, all of this was cheaper than the status quo. Cost studies carried out in Ohio, New York City and State, California, Washington and Florida all showed the same savings. In California “for every dollar spent on AOT, the county saves $1.81 in reduced hospitalization and incarceration costs.” In Washington AOT decreased hospital costs over two years by $1.3 million.

As an added bonus, illegal drug use declined from 33% who said they used to 25% 30 days after beginning the program. You can contrast this with a housing program I am familiar with that states their drug policy is harm reduction. They give residents naloxone kits and suggest they use safely while they watch the paramedics continually arrive to cart off the O/Ds.

And the participants overwhelmingly approve of the program and find it to be effective.

In Ontario, CTOs must be evaluated every 5 years and have been since the program was implemented around 2000. The third review was completed in December of 2019. That study found that 93% of clients entering the CTO had at least one hospitalization before becoming enrolled in the program. Only 13% were hospitalized after becoming involved. Some clients felt that they had greater stability on the program and improved mental and physical health.

The best support for this program came inadvertently from a witness during a court challenge to CTOs brought by an anti-psychiatry group in Toronto. The judge commented on the testimony of one person who had been hospitalized numerous times for her schizophrenia, had chased her mother around the house with a knife and assaulted a doctor in the ER. After being put on a CTO, she non longer had hospitalizations, assaulted no one and was volunteering in her spare time.

The judge asked what was wrong with CTOs and she said she did not like them. The case was tossed out of court. In that same article that I wrote back in 2014, I referred to the finding of the most current evaluation of Ontario CTOs available at that time. It concluded that “Mental health care providers and consumers should continue to have access to CTOs. CTOs are an effective way to provide treatment and support in the community for some consumers.”

I added:

It also says on page nine that “Most consumers who responded to the survey agreed they felt better since being on a CTO. More than one-half reported an improved quality of life, were more satisfied with the treatment received under their CTO than with other treatment options, and felt CTOs were the best option for their situation. The family, friends and SDMs (substitute decision makers) we were able to engage with were almost uniformly positive about CTOs. They commented on the improvements they observed in their loved-ones’ quality of life and improvements to their own well-being as they worried less about them.

While Canada has not gone along with the prohibition in the Convention to get rid of involuntary treatment and CTO’s, the government recently nominated a disability lawyer from the University of Windsor law School to represent Canada at the UN. Dr. Laverne Jacobs is the lawyer and she has rejected my request to discuss the Convention with her. She did not respond to an e-mail and attempts by the media staff at Windsor to convince her to talk to me have fallen on deaf ears. Clearly she wears blinkers and is unwilling to consider the research.