Thoughts on Addictions and Illness

By Dr David Laing Dawson

One of the foundations of a civilized, organized society is the assumption that each member is personally responsible for his or her behaviour and will be held accountable. Then, over time, we cautiously make some exceptions through our laws and courts.

Before the western disease model developed as a way of understanding illness, most cultures, in different ways and to different degrees, held individuals morally responsible for their illnesses, especially, of course, mental illness.

Though we understand the western model of disease as an assumption of biological causes and pathways, of equal importance historically was the removal of moral culpability from the sufferer. (the illness was no longer ascribed to moral lapses that allowed the devil in).

Even so, if the sufferer committed a crime he or she was still held morally and legally accountable until the M’Naghten trial in 1840. Since then each western country has developed variations of the three factors that could, through due process, allow a judge or jury to arrive at a finding of not guilty by reason of insanity or mental defect, or, now in Canada, Not Criminally Responsible. These are: labouring under the influence of a defect or illness of the mind, and did not appreciate the nature or consequences of his actions, and could not distinguish right from wrong.

It is also a relatively recent development that we do not hold children accountable for crimes they commit, or some mentally handicapped or demented citizens, and adolescents are given a modified pass.

It is certainly compassionate to consider an established addiction an illness, and at least from that point, not consider the addict’s seeking and using of drugs a moral failure, quite apart from the assumption of biological determinism. But as for crimes an addict might commit he or she would have to satisfy all three of the precepts listed above for a finding of “not criminally responsible”.

The assumption of free will and personal responsibility is in itself a determinant of human behaviour. What happens when we remove that responsibility?

I think it fair to say that the incidence of schizophrenia or serious depression would not increase. But what about addiction? No matter how you slice it, the addict must do something (seek out, ingest, inject, snort) to continue being addicted. Of course not doing that thing brings about illness and suffering as well.

The general wisdom often voiced in the therapy world is that addicts and alcoholics will only change or engage in a rehab process when they are ready to, or have decided to. But that wisdom has always struck me as too generous. Experience indicates they will enter treatment and try to stay clean when they have to. When they have to or else face some serious legal, employment, medical, or social consequences. As I have written before this is not a particularly strong condemnation of addicts, for all humans mostly engage in the hard work of changing behaviour when they “have to”. (the wake up call of a heart attack eg)

Addicts also have certain striking personality traits. They are not tolerant of delayed gratification. They tend to ascribe cause and responsibility to someone else or some factor beyond their control, and they lie. True of all humans I suppose but definitely traits that make helping addicts problematic.

Now before you think I am being harsh on the illness of addiction please note that the treatment, rehab, and recovery programs for alcoholism and addiction all tacitly acknowledge these traits. They do so in their forms of group therapy that all emphasize taking personal responsibility, in the lie detector urine test before methadone is handed out, in the AA twelve step program.

It is definitely more compassionate to think of addiction as an illness rather than a moral failing deserving our scorn and condemnation. But to do this naively will help no one.

We have already made the mistake of administratively blending addiction services with those for the mentally ill with the consequence of attitudes toward each, models of care toward each, models of security and protection for each bleeding both ways, helping neither.

More on Homelessness and Mental Illness

By Dr David Laing Dawson

With seemingly intractable social/medical problems we tend to rant about them or offer sweeping, global, feel better (they make us feel better) but useless proposals such as “talk about it” for suicide, and more affordable housing or shelters for homelessness.

And we forget history.

In the seventies our community psychiatry teams (at least the ones I was involved with) made home visits, ensured patients stayed on their medication, intervened with landlords, and one team member was official liaison with all, what was then called, second level lodging homes.

In the eighties our Psychiatric Hospital formed a special team to help prepare patients for discharge and settle them in appropriate housing, and connect them with all the treatment and support they would need.

And this is the moment to intervene and to focus resources: preparation for discharge. Discharge from hospital, addiction treatment centers, and from jail. This is the moment to spend resources and money, finding, securing, settling in with all necessary supports. And those supports can include intervening with landlords, attendance at AA daily, a sponsor, a visiting nurse with anti psychotic medication in a syringe, community treatment orders, help with shopping, budgeting, ADL’s, peer support etc.

Many factors have combined to produce the current problem: loss of low skill jobs, epidemic of opioid addiction, lack of affordable housing, psychiatric treatment shifting to short stay general Hospital treatment and specialty outpatient clinics, and a well-intended but damaging shift to protection of individual rights at any and all cost, and an institutionalized denial of mental illness combined with a paradoxical acceptance of addiction being an “illness”.

(in this strange world of ours a man who believed he was born of the stars and a professor was deemed by the Supreme Court of Canada to be competent to refuse treatment though it meant he would be incarcerated the rest of his life, and another court reinstated a nurse who stole opioids from her patients to feed her addiction on the grounds that “her addiction was an illness”

Emergency shelters, delivering blankets and food to the homeless, clean injection sights, mental health teams working with the police, street homeless watch, a differently designed clothing donation box are all worthwhile band aids but if we want to actually make a difference over a long period of time we need to focus resources to help people through that difficult transition from hospital, treatment center, or jail into a settled housed life within a community including all necessary support to remain housed and stay on the medication that prevents depression, psychosis, or mania.

Some years ago while giving a talk in The Netherlands about treating “borderline personality disorder” I was told it was illegal for Dutch hospitals to discharge someone to the street. I don’t know the details of that illegality, and it is a bit extreme for our social contract in Canada, but we certainly could keep patients in hospital a little longer while a special team ensured successful housing and compliance with treatment post discharge.

Band Aids are not a Solution to Homelessness

By Marvin Ross

It’s winter in Toronto and, as can be expected, there is a cold snap. Not surprising of course but with every serious drop in temperature, the medical officer of health announces a severe cold weather alert so that agencies can look after the homeless.

The city opens special shelters so those poor souls do not freeze to death as often happens in the winter. The number of homeless in Toronto and other Canadian cities is a blot on our supposed safety net. Our solutions to homelessness are totally inadequate.

This past week, a poor woman sleeping in an alley in an attempt to keep warm was run over and killed by a garbage truck backing into the alley as the driver did not see her. As a consequence, one charitable group is handing out visibility sashes to protect the sleeping souls from this happening to them as well.

https://globalnews.ca/video/embed/4865296/

Shortly before this event, another woman died when she was trapped in a charity box used to collect clothing items as she had presumably gotten into it to keep warm . I find it totally disgusting to see the numbers of homeless in downtown Toronto sleeping on sidewalk grates in the financial capital of the country (Bay St) with all their possessions piled around them. They are invisible as humans as the bankers, stock brokers and other business types walk around them failing to see the human beings hidden under the blankets.

One year, driving into Toronto for a meeting, I watched as I was stuck in the rush hour traffic as a van pulled up blocking the curb lane. The driver got out with breakfast for the just waking up homeless on the sidewalk.

It is nice to have breakfast in bed wherever you are but this was and is a totally useless exercise. In 2018, the number of homeless in Toronto was 6000 but today it is 9000. Project Winter Survival (one of the many aid groups in Toronto) has been besieged with requests for survival kits this year: homeless aid groups sought 21,000 kits, up 60 per cent from last year. Jody Steinhauer, the founder of Project Winter Survival was quoted in the Toronto Star stating that “we need to put the pressure on the city of Toronto: open up 1,000 shelter beds, get people into housing long-term with support solutions so that next year at this time, we can be indoors and being proud.”

According to the Homeless Hub at York University in Toronto, “30-35% of those experiencing homelessness, and up to 75% of women experiencing homelessness, have mental illnesses. 20-25% of people experiencing homelessness suffer from concurrent disorders (severe mental illness and addictions). People who have severe mental illnesses over-represent those experiencing homelessness, as they are often released from hospitals and jails without proper community supports in place.”

One study carried out by McGill University in Montreal, found that it is costing over $50,000 a year to provide support to one homeless person without resolving the problem. These costs were comprised of services such as supportive housing, treatment for substance use, emergency department visits, ambulance trips, hospital admissions, police and court appearances, social assistance and disability benefits, and incarceration.

Matthew Pearce, the head of Montreal’s Old Brewery Mission, told the CBC that “homelessness is not the problem. It’s a symptom of a problem” and that “It’s a symptom of inadequate services for people with mental illness. It’s a symptom of inadequate options for affordable housing for individuals.”

The researchers said that there is a “need for a comprehensive response” to the problem, and the importance of preventing vulnerable people from finding themselves in that situation in the first place.

Yes, the homeless need to be kept warm and safe but they also need to have treatment for the conditions that allow them to become homeless in the first place. Until we start to do that as a society, we will only be putting band-aids on the problem not solving it.

Books Based on Mind You Blog Now Available

By Marvin Ross

We are pleased to report that you can now get Mind You the Realities of Mental Illness: A Compilation of Articles from the Blog Mind You and Two Years of Trump on the Psychiatrist’s Couch in either print, kindle or Kobo versions.

Both print editions are distributed by Ingram which supplies almost all bookstores everywhere. The print editions are listed in Amazon world wide, Barnes and Noble, Books a Million, Chapters/Indigo. Kindle editions are, of course, available in all Amazon websites internationally and Kobo is also sold internationally.

A tip for Canadian purchasers. Amazon is selling the books at the US price of around $17.95 whereas Chapters is charging $23.95 for each of the books.

All reviews welcome.

Time to Relegate Anti-Stigma to the Garbage Heap – Part Two

By Dr David Laing Dawson

There is a moment for most of us sometime in second year University studying linguistics, humanities, philosophy, psychology when questions of truth, reality and delusions become quite interesting. Is there really a difference between the man who believes the CIA is watching him (assuming they are not) and the man who believes Jesus turned water into wine without the aid of grapes and fermentation.

Is what we call a delusion just a lived experience no different than a thousand other unfounded beliefs the rest of us live by? Is it just a social judgment by which we differentiate?

The answer is no. Though it may not be readily apparent to other than a family member or someone who has spent years treating schizophrenia.

First of all the delusion, the false belief of the schizophrenic is almost always tormenting: being watched, controlled, denigrated, persecuted. And when it is not that, when it endows the schizophrenic with a power to right these wrongs, it is dangerous.

And secondly, most clearly differentiating a delusion from an ordinary unfounded belief is the accompanying cognitive deficit.

This is not a cognitive deficit that shows up on an IQ test. This is rather a more subtle and complex social information processing deficit. It is a deficit in the ability to stay grounded in this social moment including having a governing awareness of the effect we are having on others and of the consequences of what we say and do. It is this deficit that differentiates the disheveled man ranting about God on the street corner and the Jehovah’s witness knocking politely on my door.

Schizophrenia is a brain illness for which we have effective treatment.

And as Marvin points out, stigma is not reduced by railing against it. When the subject of the stigma is a frightening illness, stigma is reduced by naming that illness, understanding that illness, and ensuring that it is treated.

Time to Relegate Anti-Stigma to the Garbage Heap

By Marvin Ross

I am so terribly tired of all the effort and money spent on fighting the stigma of mental illness. I don’t really think it is that much of a problem. What is a problem is discrimination – the fact that mental illness does not get the health funding that it should when compared to other illnesses. There is a lack of beds, a lack of community supports, a lack of support for family caregivers and I could go on.

I feel a bit like Howard Beal did in the classic 1976 film written by the brilliant Paddy Chayevski and I am mad as hell. His famous line can be seen here

A couple of things have set me off. The first was the appointment to the Order of Canada of Professor Heather Stuart who holds the Bell Mental Health and Anti-Stigma Chair, the world’s first anti-stigma research chair at Queen’s University in Kingston, Ontario. I’ve met Heather, have corresponded with her a number of times, and years ago I backed her getting a grant from the Schizophrenia Society of Ontario to conduct a study of stigma by health professionals against those with schizophrenia so I’m pleased for her to win recognition. Sadly, her efforts to promote anti-stigma do not improve the treatment for anyone.

As an advocate in Kingston Ontario continually tells me, the streets of downtown Kingston are filled with ever increasing numbers of obviously untreated mentally ill. Maybe Heather should get off her endowed chair and try to get them some help.

The other event this week was told to me by a Toronto advocate who notified me of a bioethics lecture at the University of Toronto entitled Reflection on Mental Health Stigma, Narrative, and the Lived Experience of Schizophrenia (you have to activate Adobe Connect to see it). The presenter was a PhD candidate in philosophy at York University in Toronto.

To his credit, the lecturer admits the existence of anasognosia and that people with schizophrenia do have cognitive deficits. However, he suggests that many people fear those with schizophrenia. I think many of us do if they are not treated and are in active psychotic states. He does seem to suggest that doctors should accept the delusions that people have and not ignore their lived experiences. He also suggests that people are told that there is no recovery.

What he did not seem to differentiate between was treated versus untreated and that is crucial. It is true that recovery to a totally healthy state is not normally possible but many people can and do recover to live as reasonable lives as possible. And some don’t. That is the reality.

The notion that people fear those with schizophrenia and distance themselves needs to be qualified. Maybe some do but they are not in the majority. Those people will also fear and distance themselves from people diagnosed with cancer or some other serious and chronic ailment. They are not in the majority. Most people are sympathetic and many will tell you of relatives or friends who also suffer. Despite some tragic examples involving the police, the majority are incredibly sympathetic and understanding.

I remember one case years ago when a man with schizophrenia took off (as often happens) and the police found him miles away from his home. As he was over 21 and not declared incompetent, the police could not take him back to his family but the officer phoned his father 3 hours away and told him he would keep an eye on his son till the father got there. He did, provided cell phone updates and kept it up even when his shift ended so the family could be reunited.

When David Dawson was shooting his feature film on schizophrenia, Cutting For Stone, we needed a police cruiser in the middle of the night for one scene. Two cruisers showed up for us and one of the cops commented that if any group needed more exposure it was people with schizophrenia.They were happy to accommodate (available on Amazon for streaming) and I got a chance to ride in the front with the sirens blaring.

Many people with schizophrenia are willing to expose themselves to the public by telling their stories in books. Many of them I’ve published thanks to the willingness of people like Sandra Yuen MacKay, Erin Hawkes-Emiru, the late Dr Carolyn Dobbins, and Sakeena and Anika Francis. Others have done the same in books and blogs like Christina Bruni, The Unashamed Schizophrenic and others. Some have exposed themselves in documentaries like the ones in the film The Brush The Pen and Recovery directed by David Dawson (available on Amazon for streaming).

The same goes for those with bipolar disorder like Victoria Maxwell and many others including a new book called Mad Like Me. This one was originally submitted to me but I turned it down for a number of reasons. The author, however, did take some of my suggestions, rewrote it and had it published. Or, a book that I reviewed in these pages called Shatterdays Bipolar Lives

I often receive requests from people with schizophrenia offering to tell their stories as I did last night from a gentleman in California. His e-mail to me stated “I have been contemplating writing this manuscript for several years,and have decided to now ,because I feel there is no shame in having a mental illness, as it is no different than having a disease such as Epilepsy. I wrote this book to be in an advocate/activist position to be able to speak for those who cannot. If my book, my story, can help just one person, one family, it will have been more than worth the effort of writing it.”

I think it would be well worth it for mental health agencies to run writing workshops for people with mental illnesses.

But, let me circle back to the issue of stigma. Who in their right mind would not be fearful of a dishevelled ranting, untreated schizophrenic wandering down the street. I almost hit one the other day when he suddenly walked out into the traffic of a busy street impervious to the traffic.

The best solution to this stigma was offered by Dr Stuart’s partner, the psychiatrist Julio Arboleda-Flórez, He wrote:

The lesson to be drawn from these papers is simple: helping persons with mental illness to limit the possibilities that they may become violent, via proper and timely treatment and management of their symptoms and preventing social situations that might lead to contextual violence, could be the single most important way to combat the stigma that affects all those with mental illness. While most myths about mental illness can be traced to prejudice and ignorance of the condition, enlightened knowledge does not necessarily translate into less stigma unless both the tangible and symbolic threats that mental illness poses are also eradicated. This can only be done through better education of the public and of mental health service consumers about the facts of mental illness and violence, together with consistent and appropriate treatment to prevent violent reactions. Good medication management should also aim to decrease the visibility of symptoms among patients (that is, consumers) and to provide better public education programs on mental health promotion and prevention.

The Perils of Data Mining

By Dr David Laing Dawson

Allowing computers to search through large medical data bases may one day discover a link, an association of great importance and one that stands up as actually a causal link. It is really the headlines associated with the reporting of these studies with which I have a problem.

These headlines appear on Google searches, Google news, newspapers, and trade epublications such as Psychiatry Times. I suppose the purpose of a headline or lead is to make the reader want to read the article, or in these cases, the research findings and the methodology.

If I read that eating bacon is going to double my chance of a heart attack I am compelled to read the actual study. In that case (an example from a few years ago) I concluded, after reading the actual study and juggling statistics with reality, that I would have to increase my bacon consumption from occasional to every day to increase my chance of dying from cardiovascular disease within the next ten years from 14 percent to 16 percent.

You can’t make good carbonara without bacon or prosciutto.

Butter is good, butter is bad, and now butter is good again.

These data mining exercises can never account for all variables, and they certainly don’t prove cause. In fact they are quite dumb in the sense of ignoring the obvious, and they seem often to be initiated with a prejudice, with the prejudice informing the headline but belied by the actual results of the study.

Others have pointed out that there is a very strong correlation between the presence of an ambulance and a road side accident. My satire on the subject would compare the rate of death from cancer in people who have taken anti cancer drugs with people who never have.

But I am writing this because of a Psychiatric Times headline that implied a causal relationship in the elderly between antidepressant treatment and hip fractures. Forcing me to read at least the synopsis of the study.

Comparing the elderly population (mean age 80) who were not taking antidepressants with those that were found that more of those taking antidepressants had suffered hip fractures. In the details of the study they found peak incidences of hip fracture 30 and 90 days before the initiation of antidepressants. Yes, before the initiation of antidepressants.

This throws the notion of antidepressants causing hip fractures out the window and hints at a much more complicated relationship between hip fractures, falls, osteoporosis, and depression. Depression is, after all, an illness that affects the body as well as the mind: (diet, life style, exercise, concentration, isolation, sleep, carelessness, memory, awareness, along with low mood).

Of course with the elderly all drugs need to be prescribed with added caution, often lower doses, and closely monitored. But if not newspaper editors at least the medical and science writers should refrain from writing headlines that are actually not supported by these data mining exercises.

But more often today all the other interpretations of the data, the cautions, the caveats, the list of missing variables, and the call for more research is added at the end. But few readers today, as we know, read more than the headlines and first paragraph.