Monthly Archives: June 2019

Involve Parents, Involve Parents, Involve Parents.

By Dr David Laing Dawson

At the other end of the spectrum of care (from Marvin’s blog on Monday) we seem to be equally devoid of common sense, and strangely enamoured of something we call “privacy rights” for teenagers. This at a time when teens themselves are withholding very little on their snapchat and facebook posts. This at a time when a contemporaneous news report referred to a study finding teens who SEXT one another at higher risk of anxiety, depression and suicide. This at a time when we have a better understanding of the delights and limitations of the teenage mind/brain than we ever had before. This at a time when the parents themselves are not Victorian but grew up in the 60’s, 70’s, and 80’s.

In this article a doctor is quoted as saying that often “teens are uncomfortable talking about birth control and abortion” in front of their parents. Of course they are. But that discomfort lasts mere seconds, like getting a vaccination, whereas the consequences of unprotected sex and illicit drug use can last a life time, and by life time I mean the life time of the teenager and his or her parents and sibs.

And by and large they want their parents to know what they are doing (unconsciously at least) because then their parents may be able to protect them. And I myself find it easier to get the truth out of a teenager when a parent is in the room. Alone he or she can easily lead me astray, can sell me on his good school attendance, his abstinence from drugs, his many friends he hangs with. With a parent in the room when the question of drugs is asked, the boy glances at his mother, she raises her eyebrows, and then he sheepishly tells the truth. And then the mother may tell me that he hasn’t been to school, and he hasn’t seen his good friends in two months. And now we can talk about what is actually happening, and not about the very limited (and instinctively self-protecting) world view of this teenager.

Note that from the teenage perspective words and phrases that denote time spans, frequency, and quantity are used randomly. (forever, never, all the time, every day, like once a week maybe, pretty much, mostly, basically, sure, I guess, whatever………)

If the teen suffers from an actual mental illness it is imperative the parent(s) be involved, for the understanding, acceptance of treatment, and the outcome will be much better.

If the problem is addiction or being on the pathway to addiction, parents are the strongest tool in the treatment tool box; I would go further, for alcoholism and addiction in adolescence, parents are the only effective tool in our tool box. Perhaps not parents alone but parents working with the counsellors and doctors and teachers to bring about a change in behaviour of the adolescent who lives in their house and eats from their refrigerator and pilfers from momma’s purse.

Editor’s Commercial Note: For more parenting wisdom for raising adolescents, see David’s book, The Adolescent Owner’s Manual

Political Correctness and Medicine

By Marvin Ross

I always thought that the only area of medicine that applied absurd political correctness concepts to the detriment of those needing help was in the treatment of those with serious mental health illnesses. I was wrong. And note that I am not being politically correct when I say mental health illnesses rather than mental health issues and problems.

Readers of this blog probably need no introduction to one of the main deterrents to treatment for people who are ill and do not know they are ill. In most jurisdictions in North America, it is hard to hospitalize someone against their will when they are very ill because we bend over backwards to defend their rights to not be hospitalized. Better to let them live on the street or be in jail than to force them into a medical institution.

Sadly, Ontario goes even further by allowing someone who is hospitalized involuntarily because they pose a danger to themselves or others to then refuse the treatment that will enable them  to get well. Consequently, there are people in hospitals for years left sick and untreated because we respect their right to not take medication.

It turns out that we apply the same stupid rules to those with Alzheimer’s. In Ontario, at least. A number of years ago, I arranged for my mother to go into a nursing home because she had dementia. She had been assessed at a geriatric facility in Toronto described as “a global leader in geriatric residential living, healthcare, research, innovation and education, with a special focus on brain health and aging”. She did not have Alzheimer’s but dementia which was visible on MRI studies of her brain.

As a result, I had no difficulty finding a suitable nursing home for her. She was not happy going into it but she did become a long term resident for probably well over 20 years, enjoyed her stay and was well cared for. It was probably the mid 1980s when she went there.

Fast forward to today and I am the power of attorney for someone with Alzheimer’s as his family is spread around the globe with no one locally to look after his needs. The disease has robbed him of his ability to have any insight into his diagnosis much like anasognosia for those with serious mental illness. His Alzheimer’s was diagnosed by a leading Toronto hospital affiliated with the Faculty of Medicine at the University of Toronto. He has been assessed countless times with the standard mini mental status exam and it is obvious talking to him that he has dementia.

But here is the thing. He is not capable and while he lived alone, he had to have substantial support at home and he was going to a day program for those with dementia. When a spot opened for him at a very good home for dementia patients, we arranged for him to be admitted. He refused, of course, and as his power of attorney, I was worried about moving him and selling his condo. I spoke to the social worker at the geriatric unit who told me that his test scores were bad and that if I listened to him and did not have him placed, I would be remiss in my duties.

Two members of his family flew to Toronto and had him placed there. He got used to it and is happy and safe.

The problem for the future is that the home is not capable of providing intensive nursing care so their residents will eventually need to be moved to a nursing home. With the aging population, there is a shortage of these beds and a long waiting list. Beds in acute care hospitals and dementia homes are held by people who need nursing home but are occupying beds until a place opens up in a more appropriate setting, As this individual is starting to deteriorate, I tried to fill out an application for a nursing home to prepare for his future needs.

Turns out that is now complicated. Ontario has a bureaucracy called the Community Care Access Centres which co-ordinates home care and placements. It is a huge bureaucracy which no longer exists by name as it was merged with another large bureaucracy but the functions are there. My charge has a case worker who authorized some minimal home care for him and did periodic assessments. I called her to get an application and left a voice mail.

Next day, I received a call that they cannot send me an application because his file is inactive and I have to start intake all over again. It will only take a few minutes and I was transferred to someone else who took down the information they already have. I was told I would get a call to arrange a new assessment. Another one.

I then got a call from someone who I could not understand on my my voice mail but I did get the phone number and extension. I fully expected the person who called to answer but no, I got someone else. She had no idea who called me or why but found the name of the case manager who would call me. When I did get to talk to the case manager, I was told that she must do an assessment because his last assessment was a year ago and his status might have changed.

Of course it has, I told her. He has Alzheimer’s which does not go away and is progressive. In the past year, he has gone to living alone with support to needing a home. He now has a small GPS device in case he gets separated from his caregiver while out which did happen. And he will continue to deteriorate and will eventually need a nursing home. I wanted to put in the application because it can take 2-3 years to find a good one. Regardless, she said, I have to test his competence and tell him we are applying for a nursing home.

But if you tell him about a nursing home, it will set him off and he may not recover from that. He denies he has the disease and he thinks he is employed at the day program he goes to. His competency can be assessed without the need to tell him. I have to tell him she said. It is only fair and I cannot hide it from him.

As a result, I told her no. I will wait until he deteriorates to the point where his placement is an emergency and he will remain in a bed that someone else could use until the system finds him a place that is more appropriate. This is a problem that is happening throughout Ontario. Patients blocking beds in acute care hospitals they do not need because they need a nursing home and can’t find one. And the blame for all this goes to the bureaucrats.

Since this encounter, the Canadian government announced a $50 million dementia strategy that includes prevention and anti-stigma. Sound familiar to the mental illness advocates? How does one prevent Alzheimer’s and other forms of dementia when the causes are not known? What does stigma have to do with anything. As an aside, I wrote a book on Alzheimer’s in the late 1980’s and nothing has changed from then. Same with our treatment of schizophrenia. My 10 year old book on Schizophrenia is pretty much as relevant today as it was in 2008 when it came out.

Mueller, Trump and Some Shameless Self Promotion

By Dr David Laing Dawson

When Robert Mueller finished his 8 minute presentation I felt vaguely heartened. Here was a man choosing words and phrases very carefully in order to convey exactly what he meant. And here was a man adhering strictly to the rules of law, of propriety, of the constitution.

He had not found sufficient evidence of “criminal conspiracy” to pursue this issue further, though his report documents many instances of the ill defined, and not illegal, activity of collusion. And he had not entertained the possibility of guilty of obstruction of justice because a sitting president could not be charged, and had his official report proclaimed guilt, this in itself would be unconstitutional for it would be the same as accusing someone of a crime without allowing him his day in court, and the opportunity to defend himself – though the report itself documents many instances of obstruction of justice, or attempted obstruction of justice, or as Mueller put it, “If we had confidence that the president clearly did not commit a crime, we would have said that.”

Thoughtful and commendable. And clearly passing the problem on to the legislative body that can investigate the criminality of a president.

But then I realized Mr. Mueller had brought not even knives, but a rule book, to an active gunfight. And it was probably as effective as waving the Marquis of Queensbury Rules at Wyatt Earp and Billy Clanton in the middle of the OK Corral.

Meanwhile an emboldened Donald Trump coyly suggests in his twitter feed today that the American People, after his next 6 years in office, may not want to see him give up the presidency.

Congress, Mr. Mueller has handed you the torch.

Here is the plan: Start impeachment proceedings. A major narcissistic injury to a person like Donald Trump will cause him to recklessly lash out and impeach himself.

As for the self promotion, Two Years of Trump on the Psychiatrist’s Couch just received an excellent five star review on Amazon. The review was entitled “Not an Ordinary Book About Trump”. Mary Ann who wrote the review said “I’m finding it hard to put down!” She added “The author is a Canadian psychiatrist, so offers a refreshing “outside” point of view. I’m not only finding his comments about Trump to be worthwhile, but am also just enjoying his comments about the world and life in general.”

She highly recommends it. And you can buy it in print or in e-book format not only at Amazon but wherever you prefer to get your books.

Later this month, the book will be at the annual conference of the American Library Association in Washington, DC. It is already in a number of libraries worldwide including the Institute for Defense Analysis Library in Alexandria, VA, and libraries in the United Arab Emirates, Germany, the UK and the Netherlands.

Celebrating the 75th Anniversary of D-Day to Neo-Nazis in Detroit

By Marvin Ross

The western world has just finished celebrating the 75th anniversary of D-Day – an event in history described by Barrack Obama at the 65th anniversary as the struggle for “a slice of beach” that changed the course of history. A somewhat more elegant statement than the comments made by Trump about whom one paper said the D in D- Day does not stand for Donald.

Obama was correct. Post World War II, we had the Marshall Plan to rebuild Europe, the establishment of the UN, NATO, the development of the UN Peace Keeping Force thanks to Canadian Prime Minister, Lester B Pearson followed by the European Union.

The post war period saw tremendous economic growth in North America and Europe along with growing civil liberties and progressive policies. Abortion became legal in the US and Canada, human rights advanced as the result of sit-ins in the US, the advocacy of Martin Luther King, the creation of Human Rights Commissions in Canada and non discriminatory policies in rentals and acceptance to universities.

I don’t mean to discount the problems like the absurd War in Vietnam but that war was met with great opposition not only in the rest of the world but in the US as well.

Having grown up when the war ended as a child of working class immigrants, my own opportunities were greatly expanded. Quotas against minorities in universities were ended as well in hiring practices and rental. My fellow students at a working class immigrant high school had an opportunity to pursue post secondary learning in a variety of professions without burdening our futures with debilitating student loans.

But we are doing a disservice to the men and women who sacrificed so much during that war to ignore our recent and rapid descent from that progress and idealism.

What is happening in the US is scary. Women’s rights are under attack, violence against African Americans is increasing and while there are no lynching, there are police shootings and beatings. Election boundaries are being jigged to disenfranchise African Americans. The US has become a bully wrenching children from mothers, picking fights with various countries and I could go on.

But the US is not alone. The UK has its Brexit, Italy a right wing anti-immigrant party gaining in popularity along with similar groups in France, Germany, Hungary and Poland. Germany has just announced that it is dangerous for its few remaining Jews to wear the kippa.

Canada has a growing populist movement with a number of provinces electing right wing governments attacking the environment, poor people, workers and others. The upcoming Federal election in October will be a test of our ability to withstand the populist movement.

And then there is bigotry. Racist ideology is growing with attacks against Jews, Muslims, Blacks, immigrants, the gay community and others. The Province of Quebec is at it again with its proposed policy to prevent people from wearing religious symbols and the renewed antisemitism is infecting the left as well as the right.

After this was drafted, I read a report from a left wing source on Facebook that armed neo-nazis in Detroit showed up at the Pride Parade. Wary of fake news, I googled this to verify it and found very few references in the US other than Fox News. It was carried by papers in the UK and by the Jerusalem Post. In DC, there was a gun threat for the Pride Parade resulting in a panic and seven people were injured. Poland, however, was peaceful although the LGBT community there is under threat.

So, while we should honour those that served in World War II, and relish the progress that was made in the world after the peace, we should guard against slipping back into the conditions that precipitated that conflict as we seem to be doing.   If we do not reverse course, we are screwed!

More on What Families Need and Don’t Get

By Marvin Ross

This original  blog post on what families need and don’t get seemed to have touched a nerve with many as it was shared far and wide and received a number of interesting comments. I thought I would reply to some of them.

The first comment stated that family involvement that I wrote about bears no resemblance in the US because of the privacy legislation under HIPPA. That very same situation exists in Canada as each province has its own privacy legislation. Doctors on both sides of the border hide behind that as an excuse to avoid dealing with families but, if they do, they should be challenged. Any good psychiatrist will ask if the family can be involved but the problem arises if the patient gives a blanket no.

The doctor should not leave it as no and the family should insist that further questions be asked of the patient. Quite often, there are issues like drug use or sexual activity that the patient does not want revealed but is willing to allow other information such as diagnosis or treatment options to be revealed. A doctor who refuses to include the family some way even when the patient says no is, if I may, an idiot and it should be challenged by the family.

We only went through this once and the reason for the no  was uncharacteristic. The patient feared that if the family had information, the government would find out and steal all his money. Had the doctor asked why, he would have realized that the paranoia was extreme. The damage caused by this was rectified and the doctor was reprimanded by the hospital.

A retired psychiatric nurse pointed out that nurses today are inundated with paper work and reports that take time away from their ability to interact with patients. Bureaucracies are in the cover your ass mode and require that all this be done in order to defend themselves from angry family when something goes wrong. Nurses spend too much time sitting in front of computer screens entering data or, as I’ve often seen, wandering the halls with a computer pad recording patient activity.

They do their best to interact with their patients but the system is designed against that. As an older retired psych nurse trained in the UK pointed out, nurses in the 1960’s engaged with patients far more than they do now. Talking to patients, having coffee with them and walking with them can have a beneficial effect but there is just not enough time for them to do that. Hospitals really need to reduce the cover your ass paper work and get back to basics.

Another comment pointed out the propaganda that many health professionals spout such as the mentally ill being the victims of violence rather than being violent themselves. That is true for those who are stabilized and not actively psychotic but it is not true for those who are psychotic. Families want to know the truth and deserve to be told the truth and not lied to as if they were little children. Mental health staff need to be more honest with families and so families should question and press the staff on what they are told. Demand evidence and sources from what they tell you.

Finally, it was suggested that the family meeting was deficient because there were no patients involved as required by the Strategy for Patient-Oriented Research (SPOR) policy of the Canadian government. That policy pertains to identifying “gaps in treatment and care, provide the best evidence to fill those gaps and conduct new research when existing knowledge is incomplete”. This meeting had nothing to do with research but I do agree that people who are “recovered” are a good source for families to see and hear.

Families of newly diagnosed are raw and hurting with little idea of what the future holds for them or for their relative. Being able to see someone who has done well with treatment can give them hope and allay their fears. The family education program that I referred to in the original blog did have one session with someone who was doing well. The most impressive example we saw was that of a young mother who was hospitalized. The woman had schizophrenia and was receiving ECT in hospital when we met her. Some time later, I was in line getting coffee in the hospital coffee shop when this attractive and well dressed woman said hello to me. She realized that I did not recognize her and introduced herself as the woman from the inpatient unit who was undergoing ECT. “This is the post ECT patient you met before” she explained.

At that same time, one of the patients on the unit who was in and out of the seclusion room was a professor emeritus at the medical school the hospital was affiliated with. He would send the nurses to his office to pick up his mail as the faculty was in the same building.

So yes, families do need to see some successful people and to realize that mental illness is an equal opportunity disease. It does not discriminate based on gender, income, education or race/ethnicity.