More on Vince Li and Absolute Discharge

By Dr David Laing Dawson

Let me give a little background to my previous blog on Vince Li.

I have had many patients over the years (50 years now, actually) who have done well with treatment, who recover, who have insight, who promise to stay on their medication. They are good people. I like them. We become friends. With some it can involve an ongoing dialogue about needing or not needing to stay on medication.

But at some point most of them stop their medication, at least once. Their lives have changed. They have been well for 20 years. They meet a family doc who doesn’t understand why they are still taking Olanzapine. They fall in love. They move. They get ill in some other way. The pharmacy changes hands. Their doctor moves. They come under the influence of one of any number of cults, including Scientology. They read the bullshit of the anti-psychiatry crowd, or the homeopaths. Someone offers them cocaine.

So at some point most of them stop their medication at least once.

With psychotic illness the illness returns, and it always returns in the same way. With some my relationship is good enough that I can cajole them into going back on their medication. With some I have had to spend hours offering it while my patient tries to decide if I am a friend or the devil. With others it means a complete relapse and re-hospitalization.

And in most cases, the only ones hurt by this relapse are my patient and his or her family. That is no small thing though. The social, emotional, vocational, educational, and sense- of-self cost is huge. Often a year or more of progress is lost.

Lack of insight may be a good predictor of human behaviour, but insight itself is not. An equally poor predictor of future behaviour is remorse, or a display of remorse. “Good behaviour, model patient or prisoner” has also little to do with what will happen in a different context five years from now. I will agree, however, that a good support system is a good predictor, but we need that support system in place for 40 years.

We clinicians are further hampered by our natural empathy, our natural sympathy that flows toward anyone nearby. It is not special; it is just human. At least twice a week during commercials I see on the television screen an emaciated fly-covered child. I get up and refill my glass. But should that child and his mother be in the room with me, my response would be quite different. Hence, as I have seen many times with CCRB cases over the years, the staff actually caring for and treating the patient are very poor at predicting future behaviour.

Now, I have not examined Mr. Li. It is possible he had a psychotic episode that will never reoccur. In my 50 years experience I know this to be only possible if the initial psychosis was caused by a brain injury, a stroke, toxic substances, or withdrawal from toxic substances, or very severe acute trauma within the time-frame of the psychosis. But from what I have read Mr. Li developed a schizophrenic illness with hallucinations and the specific delusion that resulted in a very specific horrendous crime.

So, from my 50 years of experience, I would say the people who know Mr. Li, who have spent time with him, are the last people who should be making predictions of future behaviour. Secondly, insight, remorse, promises, even absolute statements of conviction are not good predictors of distant future behaviour.

We know this man, when well, is a very nice man, and could be a good citizen of any community. We also know when ill he is capable of committing a horrendous crime.

Would it not be reasonable to use the tools we have to keep him well for the next 40 plus years? To protect Mr. Li and any future community in which he resides? They are not overly constrictive or intrusive considering the possible consequences of a relapse.

By allowing even a remote chance of a repeated homicide by Mr. Li you are doing everyone else diagnosed with a psychotic illness a great disservice.

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8 thoughts on “More on Vince Li and Absolute Discharge

  1. Again an excellent article. i agree with all of it and i am especially impressed by the fact that you dealt with the issue of being overly involved and thus losing objectivity. Losing site of facts and wanting to believe that things are better than they are ( forgetting the reality of the disease) can lead to trouble. The only time i got seriously clobbered in a mental hospital ward when I temporarily forgot what the poor patient was up against re: hallucinations.

    As a former professional SRN RMN ( UK)in this area of nursing/medicine, I was sometimes tempted ( as were others)to pretend that all was better than it was, ( even though I should have known better ) Yes the same delusions will return if there is slippage for whatever reason. Using words like “hope” and “usually” do not cut it . i am given sometimes to slip into sloppy usage but I am not guilty of politically correct nonsense ( lived experience and the like),but I think i am kind as are the majority of professionals Alas, Schizophrenia and allied conditions are not “mild” they are profound illnesses. And though some people do well when treated, we have quite a way to go before can declare progress. Untreated and treatment resistant psychoses often give rise to violence.

    In 1980 while volunteering …giving out information in a shopping mall… trying to dispel stigma ( Table for FOS) I remember once being told firmly by a family that they would not join the Schizophrenia Society ( At that time the Friends of Schizophrenics ( FOS) because we avoided the violence issue. WE must tell the truth be true advocates and educate ourselves and the public with facts and real information. Thank you again Dr. Dawson you obviously have compassion through understanding but are speaking out responsibly. Thank you.

    Liked by 1 person

  2. were i him, i would want to know that someone was watching and keeping others, hence myself, safe from a repeat. whats the big harm? what else does he have more important to do with his time than to stay on top of his situation?

    Liked by 1 person

    1. I agree, but the law has allowed this loophole to happen. ” unconditional discharge”

      There is too much hope that there will be “recovery” i.e disappearence of illness i.e will get rid of the underlying condition. Stabilization is quite different from cure. Though stabilization ( thus reduction or removal of vexing symptoms ) can restore good function it does not mean that there will not ever be a relapse . Hence some kind of safety net is required to ensure safety for us all including the person who has the condition..

      Sad to say some of the organizations that are supposed to speak the truth and kindly , including an organization I used to belong to… don’t. quite do that I recently received a letter from a key person in such an organization. It began ” Recovery from mental illness is possible but it takes the support of a caring community” To that person i say, I am supportive, caring and I will do much to encourage to push for necessary timely medical services . But I will speak truth to power especially when there is so much hype which does not benefits the patient.

      Many patients would enjoy a better quality of life if their condition had proper followup services. This was addressed honestly with compassion.

      Liked by 1 person

      1. “Alas, Schizophrenia and allied conditions are not “mild” they are profound illnesses.”

        “Many patients would enjoy a better quality of life if their condition had proper follow up services.”

        Thank you

        Like

  3. Thank you Dr. Dawson! The article (this one and the first one) are excellent and should be must reading for our lawmakers. I have very limited experience with SMI, but I too have seen the same delusions come back during relapse. – each time worse, in my opinion. The delusions became even more terrifying and bizarre during relapse.

    Liked by 1 person

  4. I read both of your excellent articles with great interest and can only agree absolutely with everything. We have a son who has SZ and despite an extended period of medication compliance he stopped taking his clozapine about 18 months ago without any obvious explanation and certainly none that he can provide. So off to hospital yet again. Whilst he has never been violent he has self harmed on more than one occasion. He is not dangerous as far as the public is concerned but clearly ongoing medication compliance is a challenge, which is why he now lives with us again. As far as I can tell medication compliance is a challenge for all who have SZ and thus it is hard to see how someone with a clear history of violence when psychotic can be considered anything but a serious ongoing risk. Those who permit unconditional discharge don’t pay the price if they get it wrong!!

    Liked by 1 person

  5. Thank you for your thoughtful article. I have three questions.

    1) What do you think should have happened? Here in BC we have something called “extended leave”, meaning that a person is free to go about their business as long as they meet certain conditions, e.g. check in with a psychiatrist every X-amount of weeks. Is that what you had in mind?
    2) What ARE good predictors? E.g. is there evidence that once a person committed a homicidal act during psychosis, they are prone to do that again? Is there evidence of progressive violence (like we have in sociopathy) among people with serious mental illnesses such as schizophrenia or bipolar disorder? Are violent acts tied to a person or to circumstances?
    3) What do you think of the competence of the board giving him an absolute discharge? Is there something they need to know more of/study, or does there need to be a different mix of people/experts sitting on the board?

    Liked by 1 person

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