Monthly Archives: November 2014

On Solutions to Psychiatric Burnout

David Laing DawsonBy Dr David Laing Dawson

The anorexic girl is down to 84 pounds. It is time for her weigh-in. She stands on the scales, dressed as before, and, lo and behold, she now weighs 84.5 pounds. Excellent. You offer praise before you notice the suspicious bulges in the pockets of her sweats. And was that a whiff of ketones you smelled on her breath?

The call comes at 11 pm. Your patient is in emergency, suicidal. How can that be? You just saw her in the afternoon and not only did she say she was doing fine, but that you had been a big help.

He is agitated today, restless; his eyes scan suspiciously. You ask about his medication and he tells you he tossed his pills in the toilet. You ask why. He tells you he doesn’t need them anymore. In fact, he’s never felt better. And now he knows it is true. He does have a mission to spread the word of God. Or maybe he’s evil and should be killed. And then he’s standing, glaring at you, and you glance at the clock and see that your next patient has probably arrived, and you haven’t finished your notes from this morning, and the man in front of you was doing so well last month, and now — do you have time to talk him into going back on his meds? Is it safe to let him leave? What are the odds of the inpatient unit having a bed? What is that new process for admitting someone? And then the receptionist calls to tell you your next two patients are waiting.

He is depressed. There is no doubt he suffers from depression. Your pills, the combination he is on now, keep him functioning marginally. But he wants more Lorazepam to get through the day, and he’s already taking too many. He is overweight. You’ve talked about diet and exercise but the chances of him following a healthy diet and exercising daily are nil. He just wants to feel better. And you would love to be able to make him feel better but… And now he’s telling you he can’t make it through the day without more Lorazepam and you just finished reading how this drug shortens life expectancy….

He has chronic pain. It is real, and so are his traumas. But you know there is little you can do for him but listen to his complaints about all the doctors he’s seen, the insurance company, the Workers Comp, all their stupid decisions, and now because he has a tenant in his house paying rent they want to reduce his pension….So you listen, and you hope he doesn’t come back to see you, but you know he will because you listen, and he survives another month, and he is a hard man to like, but ….

Ah, the weight and burden of responsibility. People talk of Compassion burnout. Listening to all those difficult lives and tragic stories day after day, and trying not to take them home with you. But the faster route to burnout that I see among mental health workers is an assumption of responsibility for events over which they have no control, leading to a sense of failure, and then cynicism, anger and blame.

In other branches of medicine and nursing, responsibilities are usually clearer, not always, but usually.  Yours and your patient’s responsibilities.

Perhaps you advised against flying in the third trimester, after that little bleed. But your patient ignored this advice and flew to an American city and went into premature labour. You gave her the correct advice; she is responsible for her decision to fly.

You put a cast on and advise no weight bearing for two weeks. You are fully confident your advice will be followed.

You prescribe antibiotics for bronchitis. You know she will take them as directed on the bottle. She, your patient, may even know a little about the history of antibiotics, and how they work, and accept though the drug might have side effects, the benefits outweigh the risks, and she knows as you know that when it comes to bacterial infections, Amoxicillin will work better than megavitamins and positive thinking.

He has chest pain. You ask him to take his shirt off. He complies. He lets you take his blood pressure, listen to his heart. He will wait for the ambulance, let you take a blood sample. He will let you perform an ECG, send him down for an X-ray or CT scan. When you tell him what you think his diagnosis is, he won’t argue. You offer nitroglycerine and morphine. You admit him to hospital and discuss a bypass operation. He doesn’t tell you he disagrees with western medicine and would rather have an incantation, a healing ceremony, or take those little brown Chinese Medicine pills.

Burn out. The problem stems from the burden of responsibility without power or control. A mental health worker who repeatedly assumes (emotionally) responsibility for that which is either not within his or her control, or only marginally so, will become stressed, cranky, dispassionate, and begin to blame the patients.

In this work, dealing with, as examples, that first grouping of anecdotes, the mental health worker must constantly monitor his or her own assumptions of responsibility, know when to act, what he can change and what he can’t, when and how to assume responsibility, and when to sit back, offer compassion and understanding, but allow the universe to unfold, allow people to lead their own lives in their own way. It is a very difficult balance to maintain throughout every day of any mental health professional’s life.

That first girl. She’s cheating by putting rocks in her pockets, isn’t she? She’s making you look stupid. And you are doing your best. And it makes no sense. She is killing herself and you just can’t get through to her.

If that chest pain patient in the last medical anecdote dies of cardiac arrest you will know that you did everything you could to prevent that outcome. But the suicidal patient in the emergency room? What should you do? How much can you do? Is it even feasible to try to assume some responsibility for her actions, her behaviour? Did you miss something she didn’t tell you during that last visit? This is the third time she’s been taken to the Emergency in as many months. You know your colleagues in that department are now blaming you. They are also wondering how come you let your psychotic patients go off their medication?

To prevent burn-out, to prevent the development of cynical attitudes, mental health workers need a supervisory support structure that understands this perennial problem, this complex burden of responsibilities, and which provides mechanisms that help deal with it, help with it. Counseling, workshops, direct help, sharing, consultation, debriefings.

And all too often that administrative and supervisory structure does the opposite. It directly or tacitly blames the mental health worker for events he or she never did have the power to control.

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Psychiatric Staff Burnout?

Marvin Ross

By Marvin Ross

Recently, I reviewed a book manuscript from a woman who had developed bipolar disorder in her 40s and had been hospitalized a number of times. What I found particularly interesting was that the woman had originally been trained as a nurse although she was not working in that capacity. She said that as a student nurse, she and her fellow students hated their rotation on the psychiatric ward. She admitted that she and the other students had disdain for the patients and that they felt that their illness was their own fault.

I don’t know how many of those student nurses ended up working with the mentally ill nor do I know if those attitudes are held by the majority who work in this area. And,  while I recognize that there are many kind and compassionate people working with the mentally ill, I’ve found from personal experience and from what others have told me that there are still far too many who display the same attitudes as those student nurses. Is it the attitudes they came into the field with or is it burnout? I don’t know. These are but some examples reflecting attitudes between those who do work with the mentally ill and those professionals who only come in contact with them periodically.

A young man with schizophrenia had been going to a very nice community dentist who left his practice and so he asked his psychiatric case worker to recommend one. He was sent to a dentist who looked after many of the clients of this particular agency and the dentist was rude, impolite and suggested that this individual needed to have a number of teeth extracted. He complained to his caseworker and was told that many clients complained about this dentist but they had no one else they could recommend.

I referred the individual to another community dentist who saw no need to extract any teeth, was aware that his new patient had schizophrenia and bent over backwards to provide caring and compassionate service.

Now because this person is on clozapine, it requires regular blood monitoring to ensure that the white blood cells are not being depleted – a serious side effect of this particular anti-psychotic. The agency has all its clients go to one blood lab which is not convenient for many of them who do not live near the lab. The agency refused to allow any client to have their blood taken at other labs and argued that only this particular lab could do the job as they specialized in clozapine blood work.

That was absurd as the blood work is for a white blood cell count which is a common and standard test. In fact, the blood labs that take the samples do not do the analysis as the samples are sent to a central laboratory. The real issue was that the staff of the psychiatric agency could not be bothered to write up a separate requisition for each client who wanted to go to a more convenient lab. I suspect that they had one requisition and just sent in a long list of names of clients who required the test.

When this individual went to another case management agency, the staff expressed surprise that he was only allowed to go to one inconvenient blood lab and gave him a requisition that he took to a lab withing a short walk of his home.

And, outside of the psychiatric hospital pharmacy, only one drug store dispensed clozapine so clients from that agency had to have all their prescriptions dispensed by that one pharmacy. And the staff at that pharmacy were completely rude to their customers which I observed on a number of occasions myself. Again, the new agency arranged to have the clozapine dispensed by the hospital pharmacy so the individual could take his other prescriptions to a more convenient community pharmacy. He was quite tense about the move and tremendously relieved to find that the new pharmacy was efficient and treated him with respect.

A number of years ago, I did a short piece called a Tale of Two Systems where I compared the care given to a man with schizophrenia between a specialized psychiatric group home and a residence for seniors. The relatives could not believe how much better care and respect the man received from a seniors home than he got from the psychiatric facility. In fact, the mental health staff ignored what were obvious signs of developing Parkinson’s until the poor man broke his hip, developed pneumonia and ended up in a seniors home. And the relatives got much more information from the staff. They did not hide behind privacy as an excuse to ignore the family as often happens in psychiatric facilities.

Katherine Flannery Dering describes a similar situation in her book Shot in the Head A Sister’s Memoir, A Brother’s Struggle about her late brother Paul. Hospital staff in the psychiatric stream noted and ignored a tumour on Paul’s lung. It was only when the family moved him into a seniors residence that the doctor also noted the existence of the tumour on his lung, had it biopsied and discovered lung cancer.

People with schizophrenia have a life expectancy that is about 20% less than others. Part of this stems from the condition itself but studies have also shown that assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards.

Now, I realize that It is not easy dealing with people who can be difficult and frustrating to work with because of the very nature of their illnesses. I get that but management should be better attuned to burnout if these attitudes stem from that and should develop strategies to deal with it.

I’d love to hear from others if what I’ve observed is as common as I’ve noticed and some ideas that might help burned out staff to deal with their problems.

Rat Brains, Youth, and Jihadists.

David Laing Dawson

By Dr David Laing Dawson

There is something wonderfully insightful about our parliamentary form of government. We have a queen. We could have a king. She lives in luxury surrounded by symbols of history and power. She, or her representative, is visible at all major ceremonies. Her representative delivers the throne speech. She can be honorary leader of our soldiers, open libraries, commission battleships. And she has absolutely no power. It is even considered bad form should she express an opinion on anything save motherhood and endangered species.

Because of this we can give some power to our prime minister. We limit his term in office. We can challenge him publicly. Because we have a Queen, we can think of our prime minister as just another self-serving politician. He is not us. He has no divine right. He may fall from grace without damaging either the institution of Parliament or our self-esteem. His office is far more important than the current occupier. And he occupies this office entirely at our whim. And because we have a Queen, we need not project unto our prime minister all those two million year-old impulses, fantasies, wishes and hungers that we might otherwise project unto our leader.

I was thinking of this, oddly, because of ISIS and the recent videos and pictures of all those young mislead men. They have bought the insanity and delusions of ancient documents and a charismatic psychopath.

Slick videos and a bearded all-powerful leader with a simple formula have tapped into a hunger deep within the rat brains of these young men. Brotherhood, purpose, an unleashing of all that masculine aggression – clearly the best first person shooter video game on the planet. The only other ingredient these young men need is a sense of immortality, invulnerability, which they might have until age 22 or so, and after that, well, a promise of life everlasting as a revered martyr.

I am sure it is too late to save them. That level of primitive tyranny will provoke competing tyrannies, unleash other hatreds, and ultimately, self-destruct.

But, back to our parliamentary democracy. How wonderful it is that for all but a few of us, we have managed to develop a form of governance that does not allow, would never allow, a single man with an ancient text under his arm to command our loyalty, our fealty, our love and our sacrifice. How creative and insightful we humans have been to create a system of governance that does not, will not, allow the blossoming of those primitive needs and impulses.

Editor’s Note – Dr Dawson is the author of The Adolescent Owner’s Manual where he discusses how a parent’s goal should be to get your adolescent child into adulthood, alive, healthy, preferably educated and skilled, without a major drug problem or criminal record or pregnancy. Anything more is icing and a pleasure to behold.

Families of the Seriously Mentally Ill Need Support Too

schizcover

By Marvin Ross

It is  said that it takes a village to raise a child. But, if that child grows up and develops a serious mental illness, the village often disappears and the parents are left on their own. One of the most poignant descriptions of community response to a parent with a mentally ill child versus a child with another type of illness was provided by Laura Pogliano, a mother and advocate in Maryland. It is a very long list but the bottom line is:

“Your child is not homeless. Your child is not incarcerated for years. Your child is not maligned in general by society. Your child’s illness is not romanticized or mythologized with ideas like “Madness is Genius.” Your child is not part of the Gun Control debate. Your child is not automatically part of the legal system. Your child does not have a Preventable Tragedies national database. Your child is not a throwaway. Mine is all of these things.”

And the stress of both having a child with a serious mental illness and the lack of empathy from many can be overwhelming. The European Federation of Families of People with Mental Illness (EUFAMI), a European non-profit organization that primarily advocates on behalf of families and family carers, has just released the results of a survey they conducted on the impact of serious mental illness on families.

The results are not pretty!

The survey of 400 people so far was conducted in Australia, Canada, France, Germany, Italy, Spain and the UK and was designed to understand the needs and challenges of those caring for relatives with severe mental illness, in particular schizophrenia. It will continue collecting data till the end of this year.

Almost half the participants (46%) were not happy with the support they’ve received from medical/healthcare staff and 38% do not believe they are taken seriously. 44% are not satisfied with their ability to influence decisions about the care of their relatives.

Four out of 10 of the family caregivers feel they cannot cope while 1 in 3 suffer depression, 1 in 3 worry about their own physical health as a result of their burden and 1 in 3 are close to the breaking point. Almost all (90%) want and need help with their burden.

Caring for a family member, the survey concluded, was similar to having a part time job involving an additional 23 hours a week and a job that often lasts for the rest of their lives. As Kevin Jones, the Secretary General of EUFAMI said, “this hidden workforce of family carers is a lifeline for society and we must take steps to ensure they are fully recognised for their contributions, their voices are heard and they are supported in order to allow them to continue caring effectively and safely for their loved ones, without putting their own physical and emotional well-being at risk”

Kathy Mochnacki, a mother in Richmond Hill, ON in a letter to the Toronto Star, pointed out that

“since the deinstitutionalization of hospital mental health services, family caregivers of people with serious mental illness have shouldered most of the responsibility of care and have become the default mental health system. Furthermore, we often do our work in isolation, coping with discrimination and unrealistic privacy legislation that could potentially put us and our ill relative in harm’s way.”

And it is that absurd privacy legislation that is a large source of the stress felt be caregivers. Imagine having an adult child with life threatening cancer and being told by the medical profession that they cannot talk to you because of privacy. A sick child of any age needs all the help and support that they can get and it is the family who are often most in tune with their state of health. To continue to deny families information, involvement, and to refuse to listen to their suggestions is unproductive and absurd. And yet, despite recommendations to end this situation in both Canada and the US, it continues.

Men Versus Women on War – Reflections of Remembrance Day Follow Up

David Laing Dawson

By Dr David Laing Dawson

Men, war, women. Kathleen Mochnacki challenged me to consider why women’s attitudes about war are very different than men’s after my  Reflections of Remembrance Day post.

We are different, men and women. Our biologies, our hormones, our muscles and bone structures, our brains. Our brains are different, differently constructed in a few important ways. And these differences allow (on average) different skill sets to flourish. A small group of boys walks to the shore of a lake. You can be sure that within minutes something will be thrown into that lake. A small group of girls walks  to the shore of a lake and they stand around, and sit, and talk. And what they talk about is not the question of who would win in a no-holds fight between Superman and Batman, assuming Batman had no Kryptonite on hand, but rather, relationships, and other girls, and boys. Okay, some boys will engage in that talk as well, and some girls will throw a rock in the lake, but on average….

About two million years ago the first of our ancestors left Africa and crossed what would become the Sahara Desert to Northern Africa and the Middle East. With DNA we can now trace these pathways to India, Asia, Europe, Australia, and the Americas. These early hominids had evolved to become the most successful species on the planet. That evolution included the development of opposable thumbs, tool making, abstract thinking, and language. It also included the development of sets of instincts and behavioural traits that would ensure survival of both the individual and his or her family, and, gradually, bigger and bigger tribes. They were hunter/gatherers. The men were hunters, the women gatherers. Women looked after the babies and children and maintained the kinships. Men monitored the boundaries, fought off invaders, lead the raiding parties. They made the tools, constructed the weapons, built the rafts.

In a sweet little rethinking of Margaret Mead’s famous work about life in Samoa, called “Are Men Really Really Necessary?”, the authors point out that the nuts and berries the women gathered in the woods contained sufficient protein for their babies and children (they didn’t really need meat to survive), and that the men, the successful hunters, rather than bringing the product of their hunt back to feed their families, used this prized meat to barter sexual favours from the most bodacious women of the village. And this makes perfect sense from an evolutionary perspective; it ensures the fittest genes combine to form the next generation.

With rare exceptions, social organizations (families, kinship groups, tribes) were structured around an Alpha Male. As with other primates, this alpha male, this Grey Back, would have to be visible and defend his position on occasion. Eventually abstract thinking, the ability to think and converse in language symbols, allowed the formation of larger and larger tribes organized within a social structure dictated (at least according to the apostles, prophets, and acolytes) by an Invisible Alpha Male.

And there we have it. We have not much changed biologically in the past million years. In fact we shrunk a little when we shifted to agriculture, and only recently regained our height.

We are really the same biological beings of a thousand years ago, even though, in our part of the world at least, we evolved socially. We passed through a period of enlightenment, the development of science, industry, medicine, birth control. We socially evolved to such an extent that we can now cohabit the same ecology with people who speak differently, dress differently, have different coloured skin, and who perform different rituals. We socially evolved to the point that we can govern ourselves within a form of democracy without recourse to an invisible Alpha Male and his scriptures. We socially evolved (with a little help from medicine) to the point where we no longer need that old biological male/female division of traits, labour, and skills.

But our biologies have not much changed. The old instincts, traits, skill potentials, impulses – our genomes, our rat brains, our primitive brains – remain the same.

It was disheartening recently to see Vladimir Putin pound his chest, pump his pectorals, snort and huff, only to have thousands of middle aged men, pundits and politicians, on this side of the divide, do the same. The two million-plus-year-old male instinct at work.

We are unlikely to biologically evolve, at least in Darwinian terms, over the next few hundred years. In order to survive, one of our tasks through this period will be to recognize some of these instincts as no longer viable, no longer of value. In fact, we need to recognize that they could now lead to our destruction. We will have to wait to see if social evolution can trump our biology. Our male biology.

Not that women are exempt from this challenge. Although, let’s face it, the more women we have in leadership positions, the more likely we will be able to follow Winston Churchill’s admonishment: “Talk, talk, talk is better than war, war, war.”

Who’s to Blame for Parents Chosing Quackery Over Science?

David Laing DawsonMarvin RossBy Dr David Laing Dawson and Marvin Ross

The family of an 11-year-old aboriginal girl with cancer has a constitutional right to opt for traditional medicine over chemotherapy, an Ontario judge ruled Friday in what some observers called a landmark decision.”

We can understand the difficulty, the sensitivities weighing on the judge’s mind when he  made that decision. Memories of recent land disputes in Caledonia, the Oka stand off, mercury poisoning in Northern Ontario, a history of insensitive forced resettlement, and residential schools. We need to be sensitive and cautious and respectful.

And had this been the case of a family choosing a long established culturally relevant healing practice over an only partially effective Western Surgery, the decision would have made some sense. Even if it had been refusal of a transfusion that would have only improved chances by, say, 10 percent, the judge’s decision would be understandable.

But it wasn’t. It was the family choosing to pursue not a traditional native treatment as they claimed but a very modern European/North American flim flam to treat an illness that is fatal, rather than a scientifically proven treatment that is known to be 90 to 95% effective. And not just partially effective, but curative.

But rather than rant about the decision, and the “alternative treatments”, we should point out “our” failure. By “our” we mean the institutions of scientific, evidence-based modern western medicine. The competing systems here are, in one corner:

McMaster University Health Sciences Center. McMaster University Department of Pediatrics. McMaster University department of pediatric oncology. And all in association with researchers, clinicians, libraries, scholars, journals filled with scientific evidence around the world.

vs.

In the other corner, The Hippocrates Health Institute of West Palm Beach, a licensed massage institute and its director, a man who calls himself doctor who is not an MD, one Brian Clement. According to scienceblog.com, its programs are a cornucopia of nearly every quackery on the planet.

We looked at their website. The website is very slick, replete with testimonials and promises, and physically the place could pass for a resort in Tahiti. A smiling personnel awaits you. A store will sell you its products. The founder is one Ann Wigmore, a self-educated nutritionist with a fondness for raw foods. I have no doubt a week or two spent there would be, for those of us with a penchant for alcohol, barbecue, stress, and worry, a healthy experience.

But surely, with a little more tact, a little more patience, a better way of explaining, a more thoughtful and empathic approach, some honesty coated with hope, understanding of human fear and trepidation, an understanding of a parent’s pain while watching a child in pain…. Well, maybe they tried their best. But really, surely the McMaster University Health Sciences Center should be able to win the hearts and minds of its patients over the Hippocrates Health Massage parlour of West Palm Beach.

Addendum on Nutrition By Dr David Laing Dawson

My mother (and I’m sure your mother) used to regularly tell us kids to “Eat your carrots.” This included raw carrots of course, though mostly boiled. She might vaguely mention they were good for eyesight, for night vision. And fish every Friday was good for the brain. Some greens on the plate were important, a little fruit every day. Brown bread was better than white. Not too much fat. Not too much meat. Plenty of “ruffage” for the bowels.  And chew carefully, eating slowly, while sitting at a table. Don’t skip breakfast.

If you need a snack between meals, eat an apple. Drink lots of water. And the only two supplements we received every morning were Vitamin D, and cod liver oil.

She was just my mother. I had no idea at the time that she was really a pioneer nutritionist. A pioneer in the field of alternative medicine circa 1950. Of course she didn’t know this either.

It is quite fascinating to learn that after another 64 years of scientific study, after countless reports and vastly increased knowledge of human physiology, there is little more to good nutrition than what my mother already knew. There have been many fads since. They come and go. But my mother’s ideas of good nutrition are the only ones that have withstood scientific study. So science supports my mother. And my mother knew, as does science, that though her nutritional advice was a good foundation for a healthy body and brain, it is not a cure for cancer.

Perhaps the even more fascinating thing is, that though science has so far proved my mother both correct and thorough in her advice, millions of people today follow wildly crazy nutritional patterns, usually propounded by other people set to make a profit on such behaviour, and more than a few are seduced into believing that my mother’s nutritional advice, coupled with my father’s advice to always look on the bright side and get a little exercise, cures cancer and numerous other diseases.

How Did We Get Here? Further Reflections on Recovery in Mental Illness

David Laing DawsonBy Dr David Laing Dawson

When trying to understand society’s, or a country’s, concepts, thoughts, approaches to, treatment of, mental illness, we can look at medical and scientific progress: This is the “march of progress” approach to understanding history – our advances in diagnosing and treating mental illness over the past hundred years. But history also tells us that attitudes toward mental illness have always been influenced by the economics of the time (only when we can feed our own children do we have the capacity to worry about our strangely behaved neighbour), our preoccupations of the time (being at war leaves few resources for the mentally ill), and, finally, the folk wisdom of the era.

Folk wisdom – the thoughts, rationales, explanations, assignments of responsibility and blame that linger in our consciousness long after being modified or disproved by science. Our brains are programmed to look for causation, a way of understanding an event, and, wherever possible, to ascribe blame. We also quite naturally and quickly look for a cause, a thing to blame, that we ourselves can avoid.

It is reported that a man younger than myself dies suddenly. I can’t help it. I search the report for cause, and relax when I find that he was a heavy smoker, which I am not. A woman is assaulted after midnight in a sketchy part of town. We know it’s wrong, but our brains immediately ask, “What was she doing there?” The child is behaving badly. We immediately think, “He could use some better parenting.”

It is always surprising to hear nurses blame the full moon for a perceived increase in the number of patients flooding the emergency room, though this “lunacy” has been thoroughly debunked by science. And otherwise intelligent people continue to ascribe perceived behavior to an astrological sign, or numerous other semi-mystical notions of alignment, karma, vapors, chakras, auras, and miasma.

Most of all it is comforting to think that if we behave well, and morally, and kindly, pray before bedtime, and avoid certain pleasurable but dangerous substances, we can also avoid dis-ease, illness, and a fall from grace.

We know that alcoholism and addiction include an action taken, engaged in, by the sufferer, engaged in willfully, of free will, and that recovery from addiction will entail a mind set, a decision, a commitment, a major effort on the part of the sufferer. So with alcohol and addiction programs this process is supported, encouraged, often through peer support, non-judgmental encouragement, soul searching, an acknowledgement of weakness, a trust in a “higher power”, and even, in some programs, forms of confession and penance. When we talk of treatment for alcoholism and addictions we are really using the word “treatment” to mean a complex sophisticated form of persuasion. We don’t really have a treatment for those two problems beyond persuasion and support.

In the post WW II era, our mental hospitals became “psychiatric hospitals”, and, a few years later, at least one ward in most general hospitals became a psychiatric ward, or colloquially, a “psyche ward”. This naming was important. It acknowledged a medical specialty, and a group of diseases treated by that specialty, much like an orthopedic department, a gynecology wing, a surgery ward. In fact the federal funding in Canada to support general hospital psychiatry wards (via federal provincial transfer payments) was a considered effort to acknowledge mental illness as illness, deserving of the same attitudes, funding, and professional support as “physical” illnesses.

Through the 1970’s and 80’s it appeared to be working. Programs were developed, new more effective medications were developed, attitudes were changing, physical facilities were improved, and maybe, we thought, this de-institutionalization will work.

Mind you, addictions got short shrift from the mental health system in those years (though the hospitals were psychiatric hospitals, the overall system of care was still called “the mental health system”). Generally addicts and alcoholics were told that they would have to get those problems attended to before we could help them with their mental illnesses. They had to first attend detoxification programs and then alcohol and addiction programs, which often had little patience for either mental illness or psychiatric treatment.

So detox centers, alcohol and addiction treatment programs developed apart from and separate from psychiatric wards and hospitals. And from these centers the “recovery model” developed. The word alone is nothing but positive, but it contains all the implications and expectations and attitudes outlined four paragraphs above. It implies that full recovery is possible, if you put in the effort. Peer support, will power, the power of positive thinking, goal setting, avoiding negative thinking, take life a day at a time, take responsibility for yourself……..

And, absolutely, for addictions and alcoholism, recovery can be defined as a life free of alcohol and drugs, and it is certainly achievable.

And through all this, our folk wisdom, that wisdom that often governs legislation and attitude, maintained a conviction that, ultimately, alcoholism and addictions are the sufferer’s responsibility. If he does not get well, or clean and sober, he is culpable, or at least, ultimately, to some degree, the architect of his own fate. And folk wisdom was shifting to believe that this is not true for schizophrenia, manic-depressive illness, depression or anxiety disorder. These are illnesses requiring treatment. They are usually chronic illnesses. Full and complete recovery is rare, though medications can alleviate symptoms and prevent relapse. There is nothing the sufferer can do on his own to prevent or stop these illnesses. And for these illnesses we do have actual treatment.

And then…. actually I’m not sure how this happened…. but somehow the bureaucrats and perhaps a few idealists, managed to bring these two systems under one much more economical roof. Three words were lost in this recent transition: “psychiatric”, “illness”, and “hospital”.

And suddenly we now have a multitude of “Centers for Addiction and Mental Health”.

And while this undoubtedly saves money, and perhaps serves better those who suffer both addictions and mental illness, it has had, in my opinion, some very negative unintended consequences.

  1. The recovery model, well suited to addictions, has been foisted upon those suffering from mental illness.
  2. The stigma of mental illness has been entrenched by the use of the paradoxical euphemism “mental health”.
  3. We have inadvertently allowed the folk wisdom of acknowledging personal responsibility for addictions (blame) to rub off on those suffering from diseases of the brain, those suffering from schizophrenia and manic-depressive illness.
  4. And ultimately it has allowed us well-meaning citizens to feel comfortable that now, not in 1950 or 1960 or 1970, but now, in 2014, our jails and prisons are filled with the seriously mentally ill.

Towards a More Honest Interpretation of Schizophrenia Recovery

Marvin RossBy Marvin Ross

Listening to an interview that Katherine Flannery Dering did last week about her book Shot in the Head A Sister’s Memoir, A Brother’s Struggle reminded me about how our emphasis on “recovery” in schizophrenia can actually hurt its victims and their families. As she explained in her interview, Ms Dering’s brother, Paul, was one of the many for whom recovery was and is a dream. Perhaps it is time that we applied some reality to schizophrenia outcomes before we wave the recovery flag for everyone. By not doing so, we make those with a horrible disease and their families suffer even more.

The professional version of the Merck Manual which is a highly respected medical source for all illnesses states that “Overall, one third of patients achieve significant and lasting improvement; one third improve somewhat but have intermittent relapses and residual disability; and one third are severely and permanently incapacitated. Only about 15% of all patients fully return to their pre-illness level of functioning.”

These outcomes have not really changed much over the years although, as a UK source states, “Early intervention and more effective treatment mean that the outlook is not as bleak as it once was.” Still, why do we act as if everyone is going to get completely better?

The term recovery does tend to imply that the person is cured. Recovery in schizophrenia is defined by the Scottish Recovery Network as “being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms”.

The goal for each person should be tempered by the reality of their situation. For someone like Ms. Dering’s brother, over time, they realized that the best the family could hope for was stability and compliance with the rules of his group home. Yet too many in the mental health community tend to set up “recovery” meaning “completely better” as a universally achievable goal. And then when the majority do not, and cannot achieve that goal, they and/or their doctors are deemed to be deficient.

There was and probably still is a concept for breast cancer that suggested that group therapy helped women with breast cancer to cope and live longer. This concept became quite popular with the 1990 publication of a book called Love Medicine and Miracles by Dr Bernie Siegel. Those concepts were subjected to considerable scientific study and I had the privilege to interview a group of women with stage 4 metastatic breast cancer who had offered to be in a clinical trial to test this. It was the most difficult interview I’ve ever done.

The women all knew they were going to die soon and all of them said how much they hated Dr Seigel. They said that they knew they were dying and that no amount of group therapy, imagining that their cancer cells were being destroyed by their thoughts, relaxation exercises or meditation was going to change that. And, while they did not want to die, they felt that theories like those of Siegel suggested that if they did not get better it was because they did not work hard enough at the exercises.

Not only did they have terminal cancer but they were made to feel that not getting better was their fault.

The American Cancer Society states “the available scientific evidence does not support the idea that support groups or other forms of mental health therapy can by themselves help people with cancer live longer.” It is cruel to suggest otherwise.

Similarly, when we hold up as achievable what 15 or 20% of those diagnosed with schizophrenia can attain as a goal for everyone, we do a disservice. Our goal for recovery should be for each person to be able to get the full range of treatment available so that they can achieve as much as they themselves are able to achieve.

Reflections on Remembrance Day

single_red_poppyBy Dr David Laing Dawson

Today millions of bright young men and millions of not-so-bright young men are playing violent video war games. Some are playing these games from dawn until dawn, headphones on, internet-connected with another million young men around the world. They revel in a good “head-shot”, they compare weapons, get excited about a clever kill, taking out the enemy, and know far more about guns, explosive devises, battlefield strategies than they will ever know about history, art, literature, primate studies, or women.

It is fun; it is addictive; it is glorious; and I guess it is far too late to put this genie back in the bottle.

Most of these young men can distinguish fantasy from reality and their violent and aggressive impulses are confined to the virtual world. The debate is ongoing about how much this gaming affects their attention span, real-life problem solving, and ability to engage in a human world. We do know years of video gaming increases dexterity when piloting a fighter jet.

Which brings me in a round-about way to Remembrance Day and language. My grandfather fought at Vimy Ridge. He survived, but I am sure it affected the rest of his life. I’m sure he came home with, what in those days would be called, shell shock. He must have seen horror. He was wounded three times. He never talked about his war experiences, with the exception of funny stories whilst on leave, tossing his months-old underwear from the hotel window into the streets of London, and for his grandchildren, tapping the small metal plate he said he had in his head.

Let us remember the sacrifices, the terror, the horror of it all. Let us also remember that that war, and many others, was never, ever necessary. Let us come together in remembrance. Let us celebrate our survival and honor the fallen.

But let us not glorify that war or any other war. Our soldiers may look splendid in uniform. They may display great courage, and sacrifice much. But it is not a glorious thing they had to do.

War is not glorious, neither real war nor virtual war, for all its noise and thunder and drama, for all its fear and pain and suffering. It is not glorious.

It is a tragic failure of evolution that in real life our older Alpha males pound their chests and send adolescents off to battle other tribes; and a failure of evolution that our young males take so much pleasure in the game of killing virtual others.

The Disease and Medical Models as they Pertain to Illness and Addictions

David Laing DawsonBy Dr David Laing Dawson

The “disease model”, the modern concept of disease, developed alongside enlightenment and the science revolution through the 19th century. One of its components is the absolution from moral responsibility. This means, for example, that one is not held morally responsible for developing the affliction of lung cancer, notwithstanding the fact that twenty years of smoking may be an etiological factor. Similarly we do not hold people morally responsible for developing the disease schizophrenia. It is an affliction unwished for, unwanted, and it has nothing to do with the moral character of the sufferer. And once the disease begins, it is not within the power of the sufferer to stop the disease.

The “medical model” is short-hand for a definable relationship between a doctor and a patient. The responsibilities and privileges of each participant in this relationship are both traditional and defined in codes of ethics. One aspect of this relationship is responsibility. The patient’s responsibility is to do his or her best to get well and follow the prescriptions and proscriptions of the doctor. The doctor’s responsibility is to do his or her utmost to treat the patient’s illness and alleviate suffering. This model, this way of understanding the relationship between healer and sufferer, is age old, and predates science.

Can we apply these two models to addictions, the same way we can and should apply them to cancer and schizophrenia?

There is little argument about the second, the medical model. In its assignment of primary responsibility to the physician (as described above), the medical model always fails when it comes to addictions. When the doctor assumes the same level of responsibility for his or her patient’s alcoholism or heroin addiction as he or she does with pneumonia, cancer, and schizophrenia, trouble ensues. Usually, in fact, we physicians find ourselves contributing to a poly substance addiction. In fact, one can safely say that a major component of any addiction is the sufferer’s failure to assume personal responsibility for his own behavior. An understanding of this is built into the tenets of AA, and most addiction treatment programs. It is, ultimately, unlike with schizophrenia and cancer, the sufferer’s responsibility to stop reaching for that bottle or pipe.

Addicts suffer and we need to help and develop programs for them. But a full frontal medical model does no good.

What about the disease model? A cancer or schizophrenia sufferer cannot stop his illness by simply doing something or simply not doing something. An addict or alcoholic can, though to do so he or she may need extraordinary courage and a willingness to tolerate a lengthy period of physical and mental pain. We should help him find this courage and we should ameliorate his suffering and we should always consider reduction of harm (e.g. safe injection sites). But we cannot and should not assume responsibility for the actual act of his drinking, smoking, swallowing, or injecting.

Inebriation, intoxication, alcoholism, and addiction, do not qualify, under our law, our science or our folk wisdom, for “not criminally responsible due to mental illness.”