Monthly Archives: December 2015

Is There a Professional Turf War in the Mental Health Field?

By Marvin Ross – First published in the Huffington Post on March 9, 2015

One of my pet peeves is the use of the term “mental health problems and issues” to reflect mental illness. Some have told me that if we imply that people are mentally ill then we are stigmatizing them because we are saying that there is something wrong with their brain. Well, there is, and so what? With cancer, we don’t say someone has cell problems and issues but rather they have cancer and we are usually pretty specific because there are so many different forms of cancer each with its own unique outcomes.

And the same goes for mental illness. But, someone recently pointed out to me that the reason we use the vague term “mental health problems and issues” is that what we are seeing is a turf war amongst professionals. And I think that person is right.

When we think of an illness, we think medical doctor. When you are ill, you see an MD who uses diagnostic skills, tests, imaging — a methodology developed over time, to determine what the problem is. Once determined, the MD decides on a course of action (with the patient) which may include referral to another more appropriate health professional (dietitian, counsellor, medical specialist, hospitalization) or medication. The MD is at the apex of the pyramid and the gatekeeper for others.

Now as my cynical friend stated, there is only one relatively finite pot of money for services for the mentally ill and, if we call it an illness, then the medical docs are going to get most of it. Other professionals will get the crumbs. However, if we don’t call it an illness but a problem, then it becomes more appropriate for other professionals like psychologists, social workers and others to be the first line of assessment and treatment.

Last year, one of my blogs upset the Canadian Psychological Association because I pointed out that in 2006, they were concerned that the newly formed Mental Health Commission of Canada would focus on mental illness to the exclusion of mental disorders and behavioural health. That generated a reply from Karen Cohen, the CEO of the CPA.

In November of last year, the British Psychological Society issued a report called Understanding Psychosis and Schizophrenia where they conclude that “psychosis can be understood and treated in the same way as other psychological problems such as anxiety or shyness.” And that “Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages.” And they conclude that “Psychological therapies — talking treatments such as Cognitive Behaviour Therapy (CBT) — are very helpful for many people.”

What they have done is to trivialize schizophrenia and suggest that its treatment be shifted to themselves and that they can uncover the underlying trauma that is the cause over the course of many talk sessions and help.

To be fair, before they had any effective treatments, psychiatrists tried this as well, and it did not work.

First out of the gate to criticize this report were three bloggers on theMental Elf. Keith Laws, a Professor of Cognitive Neuropsychology, analyzed their claim on the efficacy of CBT and found that the research does not support the statement that it is as effective a treatment as medication. Alex Langford, a psychiatry trainee who also studied psychology, challenged their conclusions on medication and pointed out that there is “solid evidence for elevated presynaptic dopamine levels being a key abnormality in psychosis, and there is copious evidence that inhibiting the action of this excess dopamine using antipsychotics leads to clinical improvement in psychosis.” Samei Huda, a Consultant Psychiatrist, points out that the “reduction of psychosis to just hallucinations and delusions is flawed.” He points out that “Cognitive impairment and negative symptoms (depression, lack of enjoyment, lethargy) are important as they often have a bigger effect on social functioning than hallucinations or delusions.”

James Coyne, a psychologist himself and one who is very critical of his colleagues, pointed out that:

Key stakeholders were simply excluded — primary care physicians, social workers, psychiatrists, police and corrections personnel who must make decisions about how to deal with disturbed behavior, and — most importantly — the family members of persons with severe disturbance. There was no check on the psychologists simply slanting the document to conform to their own narrow professional self-interests, which we are asked to accept as ‘expertise’.

He goes on to say that this paper is not evidence based and that “quotes are carefully selected to support the psychologists opinions expressed before the document was prepared — like 15 years ago in their Recent Advances in Understanding Mental Illness and Psychotic Experiences. ”

Dr Ronald Pies, a psychiatrist, writes that what is missing from the report “is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia.” The psychologists see psychosis and schizophrenia simply as hearing voices that others do not and/or having fears or beliefs that those around us do not share. Pies points out that this is a shallow and superficial description of the psychotic experience and does scant justice to the nightmarish reality of severe psychotic states.

In fact, he finds that the psychologists responsible for this report do nothing but trivialize the profound suffering that is psychosis and schizophrenia.

It is well to remember that the prime directive for any physician, including psychiatrists, is not to “be clever”; not to “define abnormal,” not even “to diagnose,” but to reduce suffering.

And while the psychologists lobby for a greater piece of the treatment pie or, as Coyne says slanting to there own “narrow professional self-interests,” and debate with other professionals, the suffering of those with the most serious of mental health problems and issues — real illnesses — continues.

A Christmas Blog For the Families of the Mentally Ill

I Was A Person

By Marvin Ross, Katherine Flannery Dering and Ilene Flannery Wells

I was originally simply going to reblog Katherine’s wonderful blog called Christmas Past and Present but then, yesterday, I read Ilene’s poem about her brother on the eighth day of Christmas from the 12 Days of Christmas blog and found it so moving that I wanted to share it as well. But first a little digression.

Every couple of Saturdays, I drive to Toronto to have lunch with friends. My route takes me through the heart of downtown Toronto up Yonge St from the Gardiner Expressway. This past Saturday was the first cold day of the year and, of course, I pass numerous bodies in sleeping bags on the sidewalk. Some of our homeless and likely mentally ill citizens.

I also know from past experiences going into Toronto for meetings that had I gone to the next main street west of Yonge, Bay St and the financial capital of Canada, I would have seen the very same. On weekdays, I’ve seen bankers, stock brokers and others stepping over and around these people. Our treatment of the homeless and mentally ill is shameful in both Canada and the US.

I’m writing from Canada and Katherine and Ilene from the US but our advocacy is the same. Here they are:

Christmas Past and Present by Katherine Flannery Dering:

About five months after my family moved to Switzerland in 1959, Mother went into labor early, with what we thought would be her eighth child. After three weeks of complete bed rest, the surprise twin babies – eighth and ninth – were born Christmas Day.

How auspicious!  Paul was so beautiful, with his blond curls and long, lanky body!  Even his fingers were long and elegant.  Ilene, two pounds smaller than Paul, was tiny and had straight dark hair and intense dark eyes set into a little round face.  She looked like the Japanese dolls, friends had sent us from Occupied Japan a few years before.

The twins were baptized a few weeks later in a tiny, Medieval stone church in the nearby town of Versoix, each of them dressed in a piece of the Christening gown my father and the older seven children had been baptized in.  My older sister Sheila and I (first and second of the eventual ten) held them for the service, filling in for the official godparents, who were back in the States.

On Christmas mornings, for all the years that the twins were growing up, the ten of us kids (our tenth – and last – child, Julia, was born two years after the twins) woke before dawn. We waited at the top of the stairs in our pajamas, our dog Charlie whining and whimpering in the excitement, until Mother and Dad went downstairs and turned on the tree lights.  Once they gave us the go ahead, we all rushed down to the living room, big kids looking out for little kids, and opened our presents in a frenzy of ripping paper and squeals and barking and the beeping and clanking of new toys.

Someone put Christmas music on the record player.

O little town of Bethlehem/how still we see thee lie./Above thy deep and dreamless sleep/the silent stars go by.

 … Our one perfect day of the year.

After presents had been opened, we older girls helped Mother fix a big breakfast of bacon and eggs that we ate in the dining room.  The candles on the Advent wreath, changed out from their pink and lavender to red in honor of the day, blazed all morning.  There were too many of us to go to church together, so those who hadn’t been to Midnight Mass drifted off to Mass in twos and threes.

From noon on, Christmas changed over to the twins’ birthday. Following family birthday tradition, Ilene didn’t have to help with dishes or set the table, the usual girl chores.  Both she and Paul got to laze around in the living room and ask other people to bring them a soda or a glass of juice while they played with their new toys or watched some old movie on TV, which they got to choose.  At dinner, while Dad read the gospel from the Christmas Mass, Paul and Ilene got to relight the red candles on the Advent Wreath.  Mother carried in the roast beef with great ceremony and placed it in front of Dad, and the twins got their pick of the roast – they usually chose the ends, valuable mostly because there were only two of them – and they were served first. Our ten sequined, red felt Christmas stockings hung from the dining room fireplace mantle.  Above them, the little brass angels of the Swedish chimes, pushed by the rising heat of little candles, clanged against bells as they swung by.

Dessert was always the same – two layer-cakes in the shape of a Christmas tree, one white, one chocolate, both of them made from Betty Crocker mixes and decorated with green frosting and little globs of red, blue and yellow frosting made to look like Christmas tree ornaments.  After the dinner plates were cleared away, Sheila, Mary Grace or I would go out to the kitchen to light the candles on the cakes.  The twins would squirm and grin kitty-corner from each other at the long table.  When we gave the signal, Johnny or Patrick would turn off the lights and start the singing and we’d deliver the cakes and birthday presents by the light of all the candles.

Fast forward to today

The above is an excerpt from Shot in the Head, A Sister’s Memoir, a Brother’s Struggle, my memoir about my family, and more specifically about taking care of our brother, Paul.

all I want for christmas is hr2646-2

Little did we know back in 1966 when the five little kids posed for this picture – Charlotte, Monica, Paul, Ilene and Julia – how it would all turn out.  Our beautiful baby Paul grew into a handsome teenager, full of promise…

…until he succumbed to a psychotic episode at age 16. Christmas was never the same again for our family.  Despite frantic efforts to get him psychiatric care, Schizophrenia killed the brother we knew and left in his place a confused, delusional man, who had no more than a few scattered minutes of sanity ever again. And his situation worsened over the years, as most of our psychiatric facilities were closed and fewer and fewer facilities were available for the care of those most seriously ill.

Our system of care for people with serious mental illnesses in our country is simply not working.  4% of our population suffers from a serious mental illness, and many of them, like my brother Paul, never really recover, even if they stay on medication. Only about one third of people diagnosed with schizophrenia recover, a third cycle in and out, and a third never achieve any appreciable recovery. Many of these are homeless or in jail, due to the lack of appropriate care facilities and supportive housing.

The Twelve Days of Christmas – On The 8th Day of Christmas, My True Love Gave to Me – Eight Maids A-Milking…

Dedicated to the Flannery family and to all caregivers everywhere who have been subjected to this injustice and neglect of their loved ones who were left abandoned and had to learn to care for their beloved ones on their own.

By: Ilene Flannery Wells, Paul’s Twin Sister

Tall Paul, Pure of Heart
Was born on Christmas Day
The 8th child born to John and Mary Kay
The 9th child came just
15 minutes later!
Oh, what a Blessed day!

His bright Blue eyes
And winning smile
Made it easy for all
To love Tall Paul
Including his two
younger sisters

For his first 16 years
He graced our presence
With laughter and fun
And gregarious charm
Paul skated through life
Always pushing the edge
Until his Brain took a hit
From his gene pool and drugs

Schizophrenia they said
One doctor after another
He’ll never recover
You must think of the others
So off Paul went
To Rockland State Hospital
And then Wingdale where
Tall Paul, Pure of Heart
Was…

James Bond
Clint Eastwood
Dick Butkus
A King Fu Movie Star…
From Korea
Who made millions of dollars
Paul wrote to his mother
In a Mother’s Day card
A camera was Imbedded
In his head
Which had been shot off
By Dickie and Homer
And maybe there were others
I couldn’t keep track
The Last of the Mohegans also
Invaded his thoughts but
Perhaps that was due to the fact
Paul was scalped at 16

When Wingdale closed
Paul watched a different train
Go by each day and
Dreamed of hopping on
He took a few rides in his time
But that was on the Harlem line
These were chugging by
The sides of the Hudson River

For 20 years
Paul walked and paced the halls
Of crumbling Psychiatric wards
Not for lack of trying Paul was
No better and no worse
Than the day he became
A different Paul than the
Twin I Knew from birth

His life was so rough
But that was just the beginning
Upon his release
They said he was competent enough
To make his own decisions
Mary Kay and John
Were now years gone
So we siblings
Stepped In

For 9 more years
Paul struggled as did we
Our love wasn’t enough
We were one step behind
One bad decision after another
Made not by Paul or
His brothers and sisters
These decisions which inflicted Trauma
Were made by what is called
The Community Mental Health System

The numbers in prison, let alone homeless
Are so astoundingly large
That the prisons are now
Our new Asylums
A million sad souls getting
Kicked while they’re down
No treatment for you
Since you don’t know
You’re even around

Tall Paul, Pure of Heart
Didn’t know he was sick
But he was a lucky one
He never was homeless
Never even arrested
That’s now the norm but
Don’t get me wrong
There were no bed of roses

Group Homes
Adult Homes
Assisted Living Apartments
What Assistance? Are you kidding?
Foot fungus, lack of food
While the case workers looked on
Paul needed to learn
To live on his own
Paul “menaced” the public
And was picked up by police
Well, they were trying
To steal his kidneys after all
His lack of insight continued
It never abated
Even when cancer came
And took him away

That last year in the nursing home
So caring so warm
Was like a dream come true
Even though we knew
It wouldn’t last long
He was a person, the Governor,
A nickname he earned
A friend, and a brother again
Why did it take cancer to receive
The care he so richly deserved?

It’s been 7 years now and
The “system” is worse, not better
It is just so absurd
That the sickest among us
Get no treatment at all!

So on the 8th day of Christmas
Think of Tall Paul, Pure of Heart
The 8th child of Mary Kay and John
And remembered by his
Sisters and Brothers of
Perpetual Determination

Sheila
Katherine
John
Grace
Patrick
Charlotte
Monica
Ilene and
Julia

The Adolescent Brain, The Bible and The Koran

By Dr David Laing Dawson

In our teenage years and often well beyond them, the adolescent brain struggles to form a map, a system of cause and effect, a number of certainties, a group of expectations, some rules and criteria that might guide it through this life, and sometimes beyond. A very healthy brain settles on a few absolutes, and leaves the rest quite flexible, able to adapt, change, and grow with new awareness and understanding.

But a very significant aspect to this journey involves the acceptance and/or rejection of the received wisdom of our parents and teachers. And in this process, in this process of the adolescent brain picking and choosing what to believe, invariably it (the adolescent brain) perceives the inconsistencies, oftentimes the hypocrisies to be found in our parents’ and our teachers’ instructions.

This leads to one of two reactions, sometimes both at the same time: one is to reject it all, the other to swallow it all, to become more of whatever it is, than our parents. And this may be a phase that ends in a healthy compromise and adaptation.

In its benign form the teen may shout at her parents, “How can you call yourself Christians when you only go to church at Easter and Christmas?” or “Is there any archaeological evidence this actually happened?”

Or it may lead to the teen and post-teen joining a commune, “going back to the church”, declaring himself atheist, finding solace in the Hare Krishna cult.

And today, as we know, it might lead a young man or young woman, raised in a “moderate” Muslim family, into the arms of ISIS. Perhaps these young people are especially vulnerable, unable to otherwise find their way, to fit in, to belong, to succeed.

But in the process of adopting a strict, conservative, oppressive, violent, rigid, immutable code they are also overcoming, reacting to, the perceived hypocrisies of their parents and teachers.

These teachers and parents are preaching from ancient texts, the Bible or the Koran. And they are choosing only the nice parts, all the while claiming that the whole book is the word of God. I’m not really sure how they do it. “We think of those as parables today.” “But the message is evil.” “Well we don’t really believe that part anymore.” “But you said the whole book is a holy book.” “Well yes but…..”

Let’s face it. Both the Bible and the Koran contain truly evil, ignorant passages, advice, instruction, and rules to live by. If we really believed all of what is in these ancient texts we would stop reading this now and gather some rocks to stone adulterers and apostates, to kill a few homosexuals, get our kitchen knives sharpened to cut off a hand or two, choose a small flexible branch to beat our wives; we might all make it our life’s work to spread the gospel and to fight the infidels, the unbelievers, and worse yet, the fallen believers.

But the point of what I am saying is this: When that moment comes in the adolescent brain in which her angst, his quest for certainty, their struggle to find a community, a set of rules to live by – when this is floundering – and when that young man or young woman sees the abundant hypocrisy, or at the very least, the paradox of claiming to be a true believer in a particular ancient text, but not really, not all of it, though it is the word of God…..well…there is the solution right there, spelled out in the early pages of that ancient text sitting on the bedside table. “It would be righteous to kill abortionists. An eye for an eye. The damnation of homosexuality. The closed door of heaven…….”

So, here is one thing we could do. Our churches and mosques could do. Tear out those pages. Stop teaching the whole book. Select the parts that time and enlightenment and education have proved valuable. Discard the misogynistic, racist, intolerant, violent passages.

Do this now. Please.

It is telling, I think, that the young women who left the very conservative Muslim school in Mississauga to join ISIS  felt that the teachings of this school were not sufficiently “conservative.” Well, in the eyes of most of us, what that school is teaching belongs in the 13th century.

But, they are using as their instruction book, their text, their Holy Book, the unadulterated Koran. And even though they were teaching those girls to behave as if living in the 13th century, they must have been skipping the more outrageous passages of the Koran – which is, to that adolescent brain, a tad hypocritical.

For humanities sake, let us rip out the stupid pages of both the Koran and the Bible. And, if you would like to test your knowledge of religion, Nicholas Kristof of the New York Times has this test you can take.

Mental Health Privacy Policies Leave Families In The Dark

By Marvin Ross

Originally published in the Huffington Post November 26, 2015

One of the biggest complaints that families of the mentally ill have is the failure of the health system to provide them with information. Families provide ongoing care, support and housing, and yet the privacy legislation in most jurisdictions in both Canada and the U.S. prohibit staff from talking to them.

However, a newly published paper out of Western University in London, Ontario argues that despite that legislation, “clinicians have a duty to their patients’ relatives, and that clinicians regularly fail to take available practical and legal steps to ensure that families receive the information they need.”

The paper written by Dr. Richard O’Reilly, a professor of psychiatry, Dr. John Gray, an adjunct professor of psychiatry along with J. Jung, a student in the Faculty of Science appeared in the Journal of Ethics in Mental Health, November 20.

The problem, according to the authors, is that because of the lack of availability of suitable supportive housing and psychiatric hospital beds, most seriously mentally ill people live with their families. Those families wind up taking on both therapeutic and supportive functions for their seriously ill relatives. Given this role and the fact that research has shown that involving families helps to improve treatment outcomes, it would be expected that the mental health system would make efforts to support those families — but they rarely do.

Families constantly complain about this failure to keep them informed or to consult with them. In the U.S., there are calls to reform the privacy legislation and that is one of the key recommendations of the Murphy Bill before Congress. The Mental Health Commission of Canada made those recommendations in its Report on Caregivers but they have no authority (Recommendation 7). One of the key recommendations of theOntario 2008 Select Committee Report that Ontario continually ignores is to revise the privacy legisltation.

Unfortunately, clinicians do not always understand the privacy legislation which varies by jurisdiction and is complex. British Columbia requires hospitals to inform families when someone is involuntarily admitted or discharged from hospital. Other provinces, however, prohibit staff from telling family without the person’s consent and, in Ontario, a $50,000 fine for failure to comply with privacy legislation can be imposed on health care staff. As a result, staff err on the side of caution and become even more secretive.

Professionals may be even more reluctant because of the high value they place on individualism, the lingering views by some that families are a cause of illness, and that staff are more experienced offering individual based therapy as opposed to family therapy. And, the authors state, if all this is not bad enough, there are logistical barriers imposed by the system.

Length of stay in psychiatric units have become shorter while staff have become busier trying to manage all the patients passing though. This rapid turnover makes it very difficult for them to meet with families. Arranging family meetings is more difficult and less efficient than spending time on the ward with the individual patient. Payment is another concern since staff often do not make as much talking to families on the phone as they would interacting with the patient and hospitals do not provide staff with the flexibility to accommodate family involvement.

Even without changing the privacy legislation, the authors suggest a number of steps that health care providers can take to help families. They point out that clinicians often don’t even bother to ask their patients if they have permission to involve family.

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

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

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