Suicide Prevention: In The Real World

By Dr David Laing Dawson

Marvin and I have written blogs about the failure of current and proposed “suicide prevention programs”, the crisis line, the gatekeeper programs, the public awareness programs. He points out these programs make us feel like we are doing something, at least, but are a waste of money.

I would go further. I think they actually increase the number of people who use “suicide threats” as negotiating tools, and then through the intervention of family, counselors, and teachers find themselves in the Emergency Department of Hospitals being assessed by nurses, emergency doctors, social workers, and often the psychiatrist-on-call over a three hour to three-day period. This uses up our resources and poses the risk of inuring these front-line professionals to true suicide risk.

The number of people who actually kill themselves each year is remarkably stable. We know it goes down in wartime, increases in peacetime, and poor economic times. We know the demographics of suicide. We know the high-risk groups.

We know that a few of these suicides constitute rational, understandable, reasonable, sane and logical decisions to end one’s suffering in the face of incurable disease and disability. Hence the current move toward allowing some physician assisted suicides.

We also know that the suicide of someone in other circumstances (temporary distress, intoxication, treatable illness) can be devastating to family and friends. It may in fact be an event from which a sibling, a parent, a child never fully recovers.

We know that many social factors put people at higher risk:

• inadequate housing,
• inadequate support systems,
• social isolation,
• bereavement,
• joblessness,
• addictions.

These factors have no simple solutions but can be gradually improved through well-funded social programs, retraining programs, affordable housing.

We also know that many suicides occur in the population suffering from severe mental illness especially when:

1.  Discharged from hospital prematurely,
2.  Unable to be hospitalized in a timely fashion,
3.  Drop out of treatment or go off medication,
4.  Their illnesses are not identified nor adequately treated.

We also know a particularly tragic circumstance is the suicide of a teenager, often responding on impulse to something they see as catastrophic, life impairing, hopeless, even while we adults know the situation is transient and will get better.

So what should we do if we want to spend our money on programs that will ultimately make a difference to that completed suicide statistic?

I don’t think I can answer my own question in a blog, but I can start a grounded discussion.

1. Easy access to family friendly mental health resources including hospital beds.
2. Hospitals return to somewhat longer hospitalizations with discharge waiting until true stabilization and a good discharge plan. Stop the fast turnover and length of stay pressure.
3. Better comprehensive outpatient programs for the seriously mentally ill (including PTSD), ensuring the best possible treatment and compliance with that treatment.
4. Training, organization of services, physical environments that allow optimal detection and response to depression, anxiety and psychosis by family physicians and emergency doctors.
5. Continue improving our alcohol and addiction programs.
6. If there are to be government sponsored public education programs they need to counter the very loud voices denying the existence of mental illness, and denigrating medical treatment. They need to focus on parents monitoring their adolescents’ online activity. They need to focus on parents ensuring their adolescent does not have access to lethal weapons and substances.

As for the horribly high rate of suicides on our reserves and among our first nation peoples: I do not think they suffer from a higher rate of actual mental illness than the rest of our country. But all those social factors that increase risk are ubiquitous on many reserves:

• Alcohol and drug abuse
• Poor housing
• Poverty
• Severe unemployment and underemployment
• Poor rate of attendance and completion of school.
• Easy access to lethal weapons and lethal drugs.
• Social disintegration and corruption.
• The hopelessness and anger fueled by dependency.

We should study the reserves that are successful, and then work with the leadership of the first nations people to recreate these factors within less successful reserves. Throwing money at the problem does not help. Sending in more “mental health professionals” does not help. Responding to political whims and self-serving demands does not help. We need to help the leadership of these reserves find clear-eyed solutions or improvements to each of the social problems listed above.

 

Suicide Prevention – Thoughts For Practitioners

By Dr David Laing Dawson

I have written a blog before about suicide prevention, about many of the things we do that don’t really make a difference, and about where we could and should put our resources if we want to make a difference. But this is a blog about suicide prevention on the ground.

We can talk about suicide prevention in general terms but the one and only time a health care clinician can actually prevent a suicide is when an at-risk individual is sitting in front of him or her. Your patient, new or known to you, at your office, in your clinic, at the hospital.

Some emergency and rapid response services have mandatory checklists. Most clinicians are taught to always ask the question. Many family doctors are fond of using a self-test for depression with questions like “Do you think of suicide?” with check boxes ranging from “all the time” to “never.” And many clinicians contract with patients – that is they extract a verbal agreement from their patients to not harm themselves, at least not before calling.

My suspicion is that these activities provide a false sense of security for the clinician and do not necessarily make any difference to the outcome.

• While asking and focusing on the checklist questions and filling in the boxes, and taking notes, a clinician may well miss what I will discuss later.
• The direct question about suicide intent and suicide ideation yields far more false-positives than useful and truthful answers, to say nothing of a few false negatives.
• How we answer those self-test questions depends more on how we want to present ourselves to the doctor than a realistic appraisal of mental state, especially when it comes to the question of frequency and future behavior.
• And contracting with patients poses two problems: one is that it does not work. The other is a logical fallacy: If the clinician truly thinks that the only thing preventing his or her patient from killing himself is a private promise that he won’t, a promise that he won’t let the clinician down, then that patient should be in hospital. And clinicians who contract in this way should think hard about the boundaries, the limitations, the nature and impermanence of the professional therapeutic relationship.

But day to day,  mental health clinicians are faced with the difficult decision to act or not, with the anxiety of predicting human behaviour, in this case with a lethal outcome if they get it wrong.

Let me share with you what both good and bad experiences have taught me:

Rule 1: Be present when seeing a patient, be there, in the room, focused and attentive.

This may require, in many situations, a clearing of the head before entering the room, making sure other loose ends have been taken care of and are not nagging you. It requires an ability to be present in that room no matter how slow, painful, distasteful, or even boring the encounter is, or how many distractions  insinuate themselves . And it requires you to stay away from your computer screen, not take notes, and be quiet.

Rule 2: Talk less. Empathy, the ability to experience what the other is experiencing requires silent observation, watching the eyes and mouth, the movement and posture, listening to the tone, the cadence, the intensity, the timbre, the intention of the spoken word as much as the content.

Rule 3: Without directly asking, listen for the presence or absence of future references in your patient’s words, something he or she plans for next week, next year, tomorrow.

Rule 4: And lastly, watch for, listen for, let yourself experience, the presence of two emotions, the congruence of these two emotions if they are present:

Despair/hopelessness plus  dread/anxiety.

If both of these are present this patient is high risk for suicide. And to know these are both there, residing in your patient today, you have to be there yourself, attentive, present, open, receptive.

Family Day, Serious Mental Illness and Murder

By Marvin Ross

I’m posting this on Family Day in Ontario. This is a new statutory holiday promised by former Premier Dalton McGuinty during the election campaign of 2007. It was, of course, part of his platform so that he could win re-election by giving people an extra day off between New Year and Easter and sold as an opportunity for people to celebrate family.

Unfortunately, families with serious mental illness in them lost out when the recommendations of an all party Select Committee on Mental Illness and Addictions Report of 2010 was largely ignored by that government. There is little for many of these families in Ontario to celebrate as you will see from my Huffinton Post blog that follows. It was published on February 9 and I will update it at the end.

Was Ontario Complicit in a Father’s Murder?

Last Spring, I mentioned the problems that a Richmond Hill, Ontario family was having with acquiring adequate service for their son with schizophrenia in one of my Huffington Post blogs. That was one of the many blogs I write on the pathetic state of care that we have for the treatment of those with serious mental illness.

Sadly, the father in this case, Bob Veltheer, was murdered on Sunday evening February 7 and, the next day, his son Jacob was arrested. Bob and his wife talked to me before I wrote the blog wanting to reveal just how badly people with serious mental illness are treated by the health system but decided to remain silent other than what I reported then.

Before I outline what I know of the care their son received, I should mention that Bob was the founding member and president of Home on the Hill, an agency set up to try to get housing for the mentally ill when their families could no longer keep them at home. I had been invited to speak at their monthly meetings a few times as had my blogging partner in another blog we share, Dr David Laing Dawson.

Last year, Jacob, who suffers from schizophrenia, was found sitting on a bus at the end of the line in Newmarket, Ontario presumably having failed to get off when it passed through Richmond Hill. He was suicidal, so the police were called and he was taken to South Lake Hospital. After a week and still suicidal, according to the family, he was discharged against the wishes of his family and that is what I reported.

Upon discharge, he ran off, as do many people with schizophrenia, and the York Regional Police went looking for him. He was found after three days and returned home only to disappear again. This time, when he was found, he was admitted to MacKenzie Health in Richmond Hill. After a brief stay, he was discharged with a community treatment order to a residence. A community treatment order is a legally binding order that the individual must accept regular medical help and medication. If they fail to abide by this, they can be returned to hospital by police.

Jacob, it seems, was too sick for the residence to cope with (but not sick enough to be in hospital) and was evicted from the residence. What should the parents do but what all parents do and that was to take him home. Just recently, the team that supervised his orders (the South Lake Assertive Community Treatment team), wanted him discharged to the care of the family doctor. His mother had just made contact with a local Richmond Hill psychiatrist and was waiting to hear back to see whether that doctor would see him.

Friday night, Bob had a meeting with a member of Home on the Hill executive at his house and I was told that Jacob was so distraught that he was pacing about the house talking to himself (or his voices or demons) in a loud voice. That Sunday night, the police allege that Jacob murdered his father.

This horrific tragedy could probably have been prevented had Jacob been kept in hospital long enough to stabilize him properly and, if that was not possible, to give him a secure place where he could live. The number of psychiatric beds in Ontario has been declining considerably over the past few decades but the total extent is not available since statistics on that can’t be found. And I’ve tried. The most recent Ontario report released in December of 2015 called Taking Stock found that access to services varies across the province and is inconsistent.

Late last year, the brand new psychiatric hospital in Hamilton closed a ward because of budgetary problems although that hospital has 6 vice presidents, 31 directors, a medical director earning $500K a year and a CEO making $750K a year. And, as I wrote a year ago, Ontario has had 17 reports on the sad state of mental health care between 1983 and 2011 but little has been done.

This is not the first preventable death, nor will it be the last unless we finally start to care. In my book on schizophrenia, I describe a case where a family in Mississauga, Ontario desperately tried to get help for their son. They could not and he ended up killing both his parents. I met the son a couple of years ago and found him to be a very pleasant and sane individual. But that was after years in a forensic psychiatric hospital where he has been getting treatment. Imagine if his family were able to get that when they first tried.

I am not Emil Zola nor was Bob Veltheer, but I accuse the complacency of the Ontario government for his death. Government bureaucrats have been informed repeatedly both verbally and in writing about the need for accountability, program evaluation, transparency regarding mis-spending, mis-use of privacy legislation and the historical resistance to partner and collaborate with families. The Central Local Health Integration Network where Bob resided, I’m told, had recently been notified about the profound need for hospital beds by Home on the Hill.

Home on the HIll has been attempting to meet with the new Health Minister, Jane Philpott, whose constituency is near Richmond Hill but have not heard back yet.

I would like to see either a Coroner’s Inquest or a Royal Commission into the circumstances that led up to this horrific event. And I would like to see Ontario finally do something other than commission studies which they then ignore.

Update

This blog received a great deal of attention as it was distributed widely and to a number of politicians where the Veltheer family live. I attended the funeral on February 13 along with politicians from the all three levels of government. The local town councillor who is a supporter of the work of Home on the Hill plans to bring this to the attention of the Ontario Minister of Health as is the local representative in the Ontario legislature. The representative who sits in the Canadian House of Commons is planning to raise this event in the House of Commons and a meeting has been arranged with the Federal Minister of Health.

We all hope that Bob’s death and the pain that his family is going through will result in some positive changes. Ontario which has direct responsibility for providing health care needs to get off its duff, stop generating reports which they ignore, and start providing the services that have been recommended so many times by so many reports.

The Federal government needs to take the money they are wasting on a Mental Health Commission that has no direct authority and does nothing but generate its own reports and put it to providing funding programs in the provinces. And just maybe, Prime Minister Justin Trudeau whose mother, Margaret suffers with bipolar disorder, will understand and do something.

Doing something would be a welcome change and would honour the memory of Bob and all the others who have been sacrificed by our lack of resources.

Exploring Delusions

By Dr David Laing Dawson

Well, let’s talk about delusions. The word, as a verb, is used in common parlance as “You’re deluded.” or “He is deluded.” referring to a mistaken belief, often one that will soon be proved wrong.

Much time is spent in undergraduate psychology, philosophy and medicine discussing, arguing about the concept. Could one man’s delusion be another man’s truth?

One could probably find more evidence to support the notion that the earth was populated by visiting spacemen a million years ago than the notion God created everything in seven days 4,000 years ago.

I suspect one would be hard pressed to find any man or woman out of our seven billion who does not hold to at least one irrational belief. Ghosts, lunar influences, karma, fortune tellers, telepathy, vengeful Gods, and ….. this list could go on and on.

So when is an irrational belief a delusion? More importantly, when does this phenomenon indicate illness, mental or neurological? When is it a symptom of illness?

And how does one decide this?

I suspect that the anti-psychiatry movement is partially fuelled by this fear. The fear that this group of professionals, working within a medical model, goes about arbitrarily deciding what belief is delusional and what belief is not. And each psychiatrist, being a member of one culture or another, will hold some irrational beliefs of his or her own, acceptable in that culture.

Karl Jaspers, psychiatrist and philosopher, defined delusions in 1903 as beliefs that fulfill these three criteria:

• certainty (held with absolute conviction)
• incorrigibility (not changeable by compelling counterargument or proof to the contrary)
• impossibility or falsity of content (implausible, bizarre or patently untrue)

All well and good until we come to the third criteria. Who decides, and upon what basis, the belief is implausible, bizarre, or patently untrue?

On the other hand, it is a very rare event for a psychiatrist to find out later that what he diagnosed delusional was actually true. And the reason for this is that Jaspers has ignored one other criteria for a belief to be considered part of an illness, an aberration of the mind/brain. And that is the manner the delusional conviction overrides all social realities and drives behaviour to destructive and self-destructive pathways and actions.

When talking with a psychiatrist a sane person, whether patient, friend or colleague, might preface a conviction with, “You will probably think I’m crazy but…”. Whatever the belief (astrology, karma, ghosts), this person is aware, at the same time, of the present social reality, the possible or probable response of the other. He or she is sane.

But there is no preface for the delusional person. He or she will launch right into the conviction, either oblivious to the current social reality or unable to read it, or (delusionally) convinced that this idea he or she has will over ride, or somehow dominate this other reality.

Hence the young man, with both parents in the room with me, announces that he is “the illegitimate son of Adolf Hitler”. (I wondered at the time why this delusion included the unnecessary word, ‘illegitimate’, but as with most delusions, the phrase, the words, often carry more reality than the inferred physical reality. Which is why, I think, that I have often over the years, been able to admit such a patient to hospital voluntarily. As long as I don’t challenge the assertion with countering words, he will come with me to the ward and stay awhile.)

It is one thing to harbour a belief that perhaps you could survive on oxygen, water and the word of God alone, without food, but not mention this to your family doctor, your dietician, or test out this theory. It is quite another to wander into the woods, or travel to Alaska, to put this theory into practice.

It is one thing to harbour a pet belief that you are a descendent of royalty, while shopping, working and playing Canasta with your friends. It is quite another to introduce yourself as Queen Victoria.

So a delusion as a symptom of illness is all that Karl Jaspers described, but it is also a conviction that over rides current social reality, that obsessively dominates all thought and interactions, and puts self and others at risk.

Reply to I am Too Smart to Have Schizophrenia

By Dr David Laing Dawson

I was in my early 30’s when I first met Robert. He was just twenty but had already been hospitalized three times. He had schizophrenia. He became my patient for the next 10 years, and indirectly my patient for 25 years after that. He did well with reasonable doses of anti-psychotic medication, monitored and adjusted over the years, though his paranoia, his ‘ideas of reference’ and his anxiety would resurface in socially stressful moments.

I saw him through group programs into employment, steady employment with good sick benefits and a pension at the end. He kept this job throughout his working life though several times he came close to losing it when his symptoms surfaced at work.

And I saw him through his first dating experience, then engagement and marriage. Their honeymoon ended abruptly when he became paranoid at the luggage carousel upon landing at their destination. They flew back, we talked, I adjusted his medication, the marriage lasted. His new wife came to me for genetic counseling and I told them what we knew. They agreed to have no children, she worked as a primary school teacher, and with two incomes and later an inheritance they did well financially. He always had more savings in the bank than I had.

At the end of those ten years I worked out of town for five years and I did not see him but I knew he regularly attended a nurse at the clinic I left. Over the next 10 years I was psychiatrist-in-chief at the mental hospital where he had once been a patient. His medications were now being looked after by his family doctor but he came to see me occasionally to talk something over.

After those 10 years as medical director of the hospital I left to work clinically part-time and devote the other half of my time to artistic pursuits. This included being co-owner of an art gallery with my wife. Robert started coming to every art opening. He would find me, often tending bar, and fill me in on his struggles and successes, his medication, his work. He wrote poetry he shared with me, and he began to write a book about his life, his illness, his hospitalizations. He was conflicted about this; his wife wanted him to keep it as a private journal but he wanted to share his story to help others. By this time both his father and mother had died but his life with this wife was solid. He gave me copies of each chapter and asked for my advice.

Neither of us were young anymore. I was now in my sixties, Robert in his fifties.

Then one Sunday afternoon at the gallery I received a phone call from Robert. My wife answered and told me it was Robert but “he doesn’t sound right”.

On the phone Robert said he needed to see me. He needed to talk something over. He didn’t have schizophrenia after all. The police really are watching and following him. And for the same thing as years before. The same crime. It was all real. Not a delusion at all. A major mistake had been made. He did not have schizophrenia. Out of character he also suggested we sit down over a beer to discuss this. We talked some more and I learned that his family doctor, after seeing Robert symptom free and well for the past many years had taken him off his Olanzapine. It was not an entirely unreasonable clinical decision for he had put on more weight than is healthy. But the same delusion returned. The same guilt, fear, and belief that the police were after him for once owning, hiding, and then throwing away, a small pile of pornographic magazines that had so troubled him in his late teens.

I asked him how I could help. He asked if I knew the police chief. I assured him I did. He asked if maybe I could influence the Chief, to get his men to stop harassing him. I told him I would certainly do that. I would get the Chief to call off his men. But in return I wanted him to go back on his Olanzapine and come in to see me the next Saturday morning. He promised he would.

When Saturday came he had been back on his medication for 5 days. He looked a little sheepish. He asked if I had spoken with the Chief. I told him I hadn’t gotten around to it. He said, “Thank goodness.”

—————

It cannot be that often that a psychiatrist has the privilege of observing the course of a psychotic illness over 35 years, especially that of a patient who remains symptom free for many of those years. But I write this story as counterpoint to the courageous blog by Erin Hawkes.

A delusion is a delusion. It is not a moment of misunderstanding; it is not a passing thought; it is not an odd experience that we check out with others (“Did you hear that?” “I’d like to see what you think of an idea I have.”); it is not an ‘issue’; it is not an idea or even a conviction up for debate; it is not assailable by either reason or evidence, and it is certainly not a spiritual experience preceding moral growth. And Erin, despite her training in and knowledge of science, and neuroscience at that, when ill is ill, when delusional is delusional, and when in that state she, like all the people who suffer from that illness that I know, seeks evidence to prove the belief, the delusional idea, the hallucinatory experience, and disprove the diagnosis, no matter the illogic of the quest.

And, away from treatment, off treatment, five or thirty-five years later, the delusion that returns is the same.

This latter phenomenon I have always found fascinating. Why the same delusion? Ultimately, I think, this is further prove of the illness being a brain problem. For surely if it were the mind, the open-source software, changing, growing, adapting with every input over those many years of life-experience, a delusion would refresh itself, would become more topical, more age specific. But it doesn’t. Which makes it, to me, more of a hardware problem, an illness for which the only effective treatment is medication. Offered of course within a family inclusive humane care system.