Psychosis is Not Normal – A Psychiatrist Responds

By Dr David Laing Dawson

This morning I witnessed a taxi pull up to a doctor’s office stopping as close to the entrance as possible. The cabby got out, went around to the passenger side and gently helped an older woman ease her way to the pavement. He then took her by the arm and slowly helped her up six stairs to the front door. He opened the door for her and only left when he was sure she was safely inside. All of this in a cold rain with remnants of snow and ice on the blacktop.

My despair for humanity is momentarily lessened.

But I must go back to a brief history of mental illness treatment as a response to Ms Nanos’ guest blog and some of the comments that it received.

When Medicine had only a few potions and surgeries that actually worked on any illnesses (let’s start somewhere in the early 1800’s) the severely and persistently mentally ill were hidden by their families, left to die in the streets, jailed, banished, punished, or they found their way to Asylums created by religious groups (Quakers, Sisters, Brothers).

Though Medicine had little to offer at the time, doctors were invited into the Asylums to help. These doctors became known as Alienists. (I’m not sure if it was a term of endearment or prejudice)

Fast forward through revolutions, civil wars, the industrial revolution, urbanization, massive population growth, the State taking over the Asylums, and the age of science. Scientific medical advances (the disease model) eventually led to the successful treatment (more importantly the prevention) of many things, of many illnesses other than mental illness, though a scientific approach did lead to a delineation of specific mental illnesses still quite valid today. And of course the Asylums grew along with the urban populations.

All that was tried to treat severe mental illness (from rotating chairs and cold baths to insulin coma and numerous varieties of work, rehab and talking) failed. Though at least through this time (about 1870 to 1950) there were some kinder periods when the Asylums lived up to the meaning of the word, and other less kind periods (wars, economic depressions) when the Asylums (evolving through titles of Asylum, Hospital for the insane, Provincial or State Hospital, to Mental Hospital and Psychiatric Hospital) at least provided three square meals and a bed to sleep in for many who would not otherwise survive.

With so many advances in scientific medical treatment developing, academic medicine (with some exceptions) lost interest in the untreatable population inhabiting the mental hospitals. Religious explanations for their existence (demonic possession for example) no longer sufficed, so it is no wonder, through the 1930’s, 40’s, 50’s, and 60’s, a plethora of psychological, sociological, familial, genetic, and conspiracy theories developed to explain psychosis, mania, depression and insanity. The new Medical specialty, Psychiatry, remained aloof. Academic and private practice psychiatry focused on the worried well, the neurotic, the anxious, the despairing and moderately depressed. They stayed clear of the mental hospitals, with a few exceptions when they brought and applied a variety of psychological and psychoanalytic theories to some wards of these Asylums and failed dismally to make a difference in actual outcome of illness, though probably bringing some improvement to many lives.

But then quite suddenly (1950’s and 1960’s), and mostly accidentally, medications were discovered that actually work: Medications that calm severe anxiety, obsessions and compulsions, that overcome severe depression, that level the profound mood swings of manic depression, that quell delusional grandiosity, and that actually work for the most puzzling and debilitating mental illness of all, schizophrenia.

The second world war was over, good economic times had arrived, our medications worked and we all looked forward to an era when mental hospitals would no longer be needed.

Paradoxically as the medications worked, and many people who otherwise would be living within the shrouds of psychotic illnesses were now functioning as independent citizens, the causality conflict between nature and nurture intensified, as did the calls to abandon the disease model.

Now I should note that Medicine (Doctors) have always over reached. When we have something that works on one problem we try it on another. At least we do this until the studies prove that it doesn’t work for the second problem.

But I think the real reason for this intense anti-psychiatry movement is two-fold: on one hand pharmaceuticals that work to change mood and thought, plus more and more sophisticated ways of watching the brain do what the brain does, undermine that last vestige of hope and desire that each of us is more than “a sloppy bag of mostly water with a limited life span”.

And professional aspirations and jealousies of status and turf.

Fast forward again (2000 to 2020) and we find our fear of psychiatry, plus the aspirations of growing numbers of psychologists, plus politicians jumping on ways to save money, (or shift costs to other jurisdictions), plus identity politics, plus changes in societal attitudes that are hard to fully understand from inside…..have left us in the disheartening position of having a mental illness treatment system worse than it was 40 years ago.

Or, as a colleague warned 30 years ago, we are heading for a time “when the good schizophrenics will get good treatment and the bad ones get none”. By that he meant, if I must translate his words into today’s reality, people with mental illnesses that respond to medication and who remain compliant with treatment and develop enough stability and insight, and have sufficient family and community support will get good treatment and helpful counseling and rehabilitation services, while those who don’t will be left to the streets and the jails.

And he wasn’t even considering the “Recovery Movement” and the plague of euphemisms that give cover for this disgrace.

The other night we had an Opening at the gallery: Live music, glasses of wine, a table of food and a growing crowd of art lovers. Then two young men wandered in. The leader was bundled in bulky parka over a hoody, drooping pants, multiple sweaters of varying length, with wild hair flailing beyond his parka. He was also carrying a very large rock partially wrapped in plastic. The second young man was gaunt, undernourished, stiff in his movements and vacant of eye.

They gravitated to a sitting area and a small bowl of chocolate bars. Others left the area and I got them sitting on a couch and I sat with them, between them. They quickly demolished the chocolate bars, dropping the wrappings on the floor. The thin young man slipped in and out of a catatonic state staring blindly and hearing nothing, unaware his nose was dripping, his face immobile, flat and blunted. He did tell me when I asked that he lived on this same street many blocks away. The other man babbled nonsense, making connections between the glass shards embedded in his rock and insects, spirits, goddesses and aliens. I offered him ten dollars for his rock but he said he wanted a quarter million. He said he has a house in Kingston, another in Mississauga, and a car somewhere in Hamilton. And his grandmother’s name is Olanzapine.

I took them to the food table but the lean one stood immobile over the cheese tray dribbling from his nose and the other bypassed the toothpicks and forks to stick his hands in the pickle bowl so I sat them down on a bench and brought them a plate of cupcakes.

And then I saw them on their way. The gaunt one headed for the door but the other held him back to choose a coat off the rack. I was satisfied the coat they chose was theirs and not that of a guest because it exuded the same odour that they did. And I wished them a good night.

But, ahh I thought, how much they would benefit from a month or two at the old Hamilton Psychiatric Hospital, or any other 1985 psychiatric hospital, with a warm bed, food, shower, activities, routine, the right medication, good counsel, and seamless follow up with regular outpatient care.

And here are two women with schizophrenia who talk about their difficult journey

And these are families asking how to help their ill relatives

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Donald Trump and Marshal McLuhan

By Dr David Laing Dawson

Marshall McLuhan’s phrase “The medium is the message.” is often quoted glibly. I am sure I have done this myself. It means, I think, that the medium through which we receive messages alters, itself, the way we view the world, the way we receive these messages and understand them.

I think we quote Marshall glibly because as white rats in the experimental lab we are not often able to see how the medium, or media, are changing our perceptions. And Marshall said this before the internet arrived, and certainly before Twitter.

I have never thought of Donald Trump as a clever man, a man of deep thought and consideration, but damned if he doesn’t appear to understand Marshall better than the rest of us. I assume this understanding comes from being a creature of the media, a man without an inner life of doubt and shame and empathy and consideration.

And within all the noise in the past few weeks and months about Trump, Zelensky, the phone call, the quid pro quo, one minor point seemed to go unnoticed. Trump asked Zelensky to open an investigation into the Bidens, father and son, and to announce this “in a public box”. He didn’t say “invent some dirt on the Bidens”, or “charge them with something”, he asked that an investigation be announced in a public forum. He knew that such an announcement on TV, cable news, Facebook, Google, and Twitter can, in and of itself, blossom into a fixed perception of guilt. It is the world we live in today.

Trump has also intuitively understood that the medium of Twitter and its daily onslaught can make the unacceptable acceptable, can deodorize something putrid, can make the irrational seem rational, and a lie seem plausible, through copy, assertion, and repetition.

Evidence that he intuits this rather than fully grasping it lies in the letter he sent Erdogan. As a series of tweets this might have passed. As a letter, the ignorance, grandiosity, and adolescence of the message was clear.

Then Trump goes back to his favourite medium and he tweets a bizarre accusation and clear intimidation while the witness, Yovanovich, is testifying in the impeachment hearing. And we find ourselves again pondering Marshall’s words.

Written on paper and delivered as a letter, or overheard and recorded on a wire tap, Trump’s words would be perceived and understood as clear evidence of witness tampering. The same message in the medium of a Tweet? Is it just Trump being Trump?

And where on earth are Twitter, Snap Chat, Whatsapp, Tumblr, Instagram, Facebook, internet forums, texting, and blogging for that matter, taking us?

Psychosis is Not Normal – A Guest Blog

By Lynn Nanos author of Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry

Image by 3D Animation Production Company from Pixabay

As I was selling copies of my book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, at a National Alliance on Mental Illness (NAMI) conference in Albany, NY last month, I had an interesting conversation with someone which reminded me of the dangers of the antipsychiatry movement, which promotes the notion that mental illness doesn’t exist.

A man approached me at my booth and asked me about Breakdown and then shared his experience with bipolar disorder with psychotic features. He emphasized that he’s recovered.

I empathized with his experience and happened to mention “illness.”

Immediately upon hearing this, he interrupted me mid-sentence with “I do not have an illness. I don’t like the use of that word so please don’t use it. I have a condition. I’m not defined by my condition. We need to stop stigmatizing this.”

I thought, “I’m not sure how this conversation will end, but I have to educate this guy. Otherwise, he’ll continue to spread the façade that stigma is an enormous issue and the only way to mitigate it is by not accurately describing what he really has – an illness.”

So, I said to him, “According to several dictionaries, ‘condition’ means ‘illness.’”

His eyes and mouth widened with “What? That can’t be true. Are you sure?”

“I’m sure. Check it out yourself. I’m sure you’re a lot more than your bipolar disorder, but not accurately defining what you have is stigmatizing, not the other way around.”

After a few more minutes of him working through his shock about my challenging him, he eventually said “Thank you for pressing me to change for the better. I’ll look this up.” Smiles and relief.

∞∞∞

Earlier this year, I attended the National Alliance on Mental Illness’ national convention in Seattle, WA. The event was kicked off with pomp and circumstance involving a ceremonial military march beside the United States flag on stage before me. As I looked around at a sea of thousands of guests, I couldn’t help but think, “NAMI is huge, important, and powerful.”

Most of the week was filled with lectures and workshops. The “Cognitive Behavioral Therapy (CBT) for Psychosis” workshop I attended reminded me of the benefits of this therapeutic modality for a variety of mental illnesses, but also left me alarmed at some of the messages NAMI has been sending to mostly family members of those with mental illness and some professionals. CBT teaches people to think about, describe, and respond to the environment accurately. It persuades people to behave in healthy ways in response to thoughts. The underlying presumption of CBT is that when either one’s thought, emotion, or behavior changes, the other mental components change.

As I vigorously took notes in the workshop led by psychologists Kate Hardy and Sarah Kopelovich, my review was mixed. Should CBT for psychosis be completely disregarded? No. I’m grateful to the late forensic psychologist Robert Powitzky who extensively directed services for prison inmates, for his educational reminders. He wrote to me, “CBT can have several benefits other than making observable changes in positive and negative symptoms…is often effective for patients with schizophrenia who are stabilized on medication in conjunction with supportive housing.” 

CBT for psychosis can be useful, especially once the psychosis has been stabilized and well-managed. The psychologists said that CBT has shown moderate effectiveness in reducing the negative symptoms of schizophrenia – social withdrawal, poverty of speech and thought, apathy, anhedonia, loss of motivation, and inattention to social or cognitive input. I credit the psychologists for pointing out, albeit briefly, that per psychologist Xavior Amador, one of the greatest predictors of successful treatment is awareness into illness. But this was as far as they got regarding insight.

On another note, I confirmed that NAMI was doing two dangerous things: marginalizing those whose psychosis interferes with the ability to engage or benefit from CBT and minimizing mental illness.  A mother stood up and said to the psychologists, “All I could think of while watching this was ‘bullshit!’ Employing these techniques was impossible when my son was too agitated and unable to listen because of his psychosis.” 

Below is a detailed account of exactly what these psychologists said in the “CBT for Psychosis” workshop accompanied by my impressions.

• Psychosis is a temporary condition. It is usually permanent.

• Everyone is susceptible to psychosis. Not quite. An extremely small percentage of the population is far more susceptible to developing psychosis than others.

• Trauma and stressors make someone more susceptible to becoming psychotic than genetics. False.

• There’s a correlation between creativity and psychosis. I don’t know whether this is true, but I’m not compelled to research it because it seems mostly irrelevant to treatment goals. Even if it were true, how could this possibly be used to help people with psychosis? Should psychiatrists and social workers offer painting materials instead of medication and psychosocial rehabilitation to people suffering from psychosis? Yes, this is a rhetorical question.

• Psychosis is often part of PTSD and can be part of borderline personality disorder. Untrue.

• It’s not helpful to tell the person with schizophrenia, “You need specialized treatment.” Psychosis is a special illness requiring specialized treatment. Treatment providers help their patients by telling them the truth.

• Expect recovery. If you get good treatment, recovery is the norm. Hundreds of NAMI blogs are ridden with happy endings, but everyone with psychosis does not recover. Telling families that recovery is the norm inappropriately sets them up for huge disappointment when good treatment does not work. There are many factors that can interfere with recovery even when the best treatments are tried.

• Intrusive thoughts, which everyone has, can be compared to delusions and hallucinations. Are you stating that psychosis is normal? It sure seems like it.

• CBT inherently normalizes psychosis, because we all have negative thoughts, engage in unhelpful behaviors, and use unhealthy coping strategies. Thus, CBT normalizes psychotic symptoms. Psychosis is normal. The psychologists asked the audience, “How many of you ever felt others were trying to harm you?” There is nothing normal about psychosis!

With all of NAMI’s grandeur and influence, speaking out against its marginalizing those who are most ill and spreading the notion that mental illness is less than important is paramount if we want to alter the status quo. Let’s destigmatize mental illness by defining it accurately. It’s a condition, but more accurately, it’s a brain disease.

How Do You Find a Good Psychiatrist?

By Marvin Ross

From left to right Jude Mersereau, Dr David Dawson, Lindsay Thompson, Kathy Mochnacki (chair) Along with a police officer from the York Regional Police Force who often come to learn about mental illness

And that is a rhetorical question as I have no idea. It was a question raised the other evening at a presentation I was at with fellow blogger Dr Dawson. The presentation was put on by the group Home on the Hill Supportive Housing in Richmond Hill Ontario as part of their ongoing Robert Veltheer Lecture Series.

At this presentation, two women with schizophrenia talked about their experiences with the disease and how they coped. Dr Dawson answered questions about the nature of schizophrenia and the video will be available soon which I will post. Both women received standing ovations from the audience when they finished describing their struggles and their successes. I have to admit that I was very moved.

The question of a good shrink was raised and people struggled to answer it so I would be most interested in how the readers of this blog might answer that question.

Dr Dawson, if I remember correctly, talked about the need for all doctors to focus on their patients. Evidence based plus Electronic Medical Records (EMR) allows for the efficient input of great quantities of data gleaned from a q and a with the patient. But, while inputting, so much if not all of the appointment is spent with the doctor staring at the monitor or back and forth between patient and monitor. This strict adherence to evidence based medicine is unsatisfying for the sufferer and thus probably a reason more and more, in this era of science and information, are turning to acupuncture, naturopathy, chiropractors all of whom provide some comforting magic and the promises we all want to hear.

Another important component of psychiatric support is ongoing support for the patient at fairly frequent and regular intervals. This can actually be done (and is often done in good programs) by case managers. The case manager will meet with the patient and discuss successes, failures and activities. If there are problems, then the psychiatrist can be brought in.

Most of the time, we do not get to chose the psychiatrist but have one assigned to us by the hospital or agency based on who is available. There is little room for choice given the shortage of those in this specialty. If I get referred to a cardiologist by my family doc and I do not like that person, I can always go back to the family doc and request a referral to someone else. This is not a luxury open to psychiatric patients.

Another problem, in Ontario at least, is that if you are hospitalized, the treating outpatient psychiatrist is replaced by whichever psychiatrist is responsible for that unit. Most of the time, the in patient doc will consult the chart and talk to the regular psychiatrist and caseworker but not always. I’ve seen that happen with disastrous results. And, like a crap shoot, you may actually get an exceptional psychiatrist which, thankfully, I’ve also experienced.

So from my perspective, a good psychiatrist is one who understands the disease and its treatment, listens to the patient and interacts with them, the family and provides regular and frequent support from a qualified and empathetic case worker.

I’d love to hear what you think.

For Remembrance Day 2019

By Dr David Laing Dawson

I grew up thinking my grandfather fought at Vimy Ridge, though he never talked about his war experiences. I have a memory of one funny story he told of being on leave in London, and throwing his filthy underwear into the street from a hotel window, and another moment when he told his grandchildren that he had a metal plate in his head. But that is all. Years later I visited Vimy, saw the trenches, the killing grounds, and the Memorial, and signed the visitor book. Perhaps my memory told me he fought at Vimy because in my mind at that time Vimy Ridge and Canada and the First World War were conflated.

Now, with the wonders of digitization and the internet I have access to all my grandfather’s war records and his medical documents from the field hospital to the Canadian Forces Hospital in England to the Convalescent facility. I have the doctors’ notes and even an X-ray of his skull. I even know he enlisted in 1915 after three of his children were born and when the Canadian Government removed the requirement of spousal approval.

He trained in England with the Canadian Expeditionary Forces and then fought in Belgium, in the muck and mud and horror of the battles for Ypres. Twice he was taken from the front lines to the Field Hospital sick with fever and dehydration. He survived the charges, the bombardments, the cold wet trenches through the fall of 1915 and the winter of 1916. But on a spring morning in that year upon the whistle to charge he stepped up from the trench and was hit by both a bullet and the shrapnel of an exploding mortar. The bullet hit his left arm; the shrapnel struck the left side of his face and head.

He was carried to the Field hospital again, and then shipped to the Armed forces hospital in England.

The bullet wound in my Grandfather’s left arm healed quickly. The doctors cleaned his head wound and removed all but one piece of shrapnel still visible on the X-ray 100 years later. But in the hospital and the convalescent ward through the summer of 1916 he continued to suffer dizzy spells, and when he had these he usually fell to the ground. He was eventually given a medical discharge and sent home via troop ship to Halifax and then train and boat to arrive in Victoria in the winter of 1917.

In the hospital they had searched for an explanation for his dizzy spells and concluded, in the terse medical writing of the time, that the cause was mostly “functional”.

One would have to have practiced medicine and psychiatry in the 20th century to understand all the implications and nuances of the diagnosis “functional”. It meant no underlying structural or physiological mechanism has been detected. It also implies the symptoms may be goal directed, but the degree to which the patient is conscious or not conscious of the goal may be implied by the overall tone of the report. In black and white terms, malingering or conversion reaction.

With a little more knowledge today (I do mean little) I know my grandfather’s falling-down spells could have been caused by post concussion syndrome, by PTSD, by a conversion reaction, or by a very conscious decision to fake illness to avoid going back to the trenches.

I am writing this because I read an article in my local paper recently by Thomas Froese. I am sure Mr. Froese is a good Christian and a good person, but I would like to tell him he is wrong. There is no glory in war. There is no heroism. There are no lessons to be learned other than we must never let it happen again. Mr. Froese also says he “doesn’t believe in war” which makes as much sense as saying you don’t believe in rape and murder.

We do not need to teach children (as he recommends) about the moments of courage and spiritual awakening, and acceptance of mortality and powerlessness that can occur in war. At least not unless we are preparing them to enlist for the next conflagration.

I am posed with a dilemma now I have my grandfather’s war record. He was not a hero of Vimy Ridge. He was a decorated soldier who fought at Ypres. He arrived home before the battle of Vimy Ridge. And his medical discharge? How am I to think and feel about that? Well, I have concluded that I would be most happy, proud even, to think he faked his dizzy spells. It would mean that he was a sane man, not delusional, that he was rational and mature, that he simply said NO to returning to the horror and insanity of war, that it was more important to remain alive for his wife and children. That he had had enough. That he knew there was no heroism or enlightenment to be found in war, no grand purpose, just death and life long damage to body and mind. That he understood that he had enlisted because he had succumbed to the propaganda of heroism, duty, king and country, manliness, the great adventure. That he now had the courage, the real courage, to say, simply, “No more.”

From Asylums to Recovery -A Critique of a Mental Health America Documentary

By Marvin Ross

I just recently came across a documentary on Youtube put out by Mental Health America called From Asylums to Recovery – a celebration of the so called consumer survivor, anti-psychiatry movement in the US and beyond. After showing some images of the horrific conditions that people were forced to live in in asylums, we are greeted with the statement that in the late 1950’s and early 1960’s, there were 550,000 people locked up in asylums. Many, the documentary goes on to say, were locked up by their families and the courts because no one believed that those with mental illness could recover.

Horrific conditions did exist and no one can deny that but people were in the institutions because they could not usually recover in those days. Recover isn’t even the right word which really should be that their symptoms could not be dealt with appropriately. Recover really means to be cured and that is not possible for illnesses like schizophrenia and bipolar disorder.

The doc then states that today there are about 50,000 people in psychiatric facilities and that the system has improved. This reduction, they claim, is the result of 100 years of patient/consumer/survivor advocacy. The documentary then goes on to try to explain how this reduction in patients and improvement came about by interviewing many of those who were involved in the consumer/survivor movement.

What is missing, of course, is that from the early 1960’s on, new medications came along that, for the first time, could treat the worst of the symptoms of schizophrenia, bipolar disorder and major depression. In fact, the first anti-psychotic, chlopromazine, was discovered in the 1950’s and its first North American use was in Montreal in 1954.

That was the beginning and over the years, more anti--psychotics were developed so that doctors now can experiment to find the one that works best for a particular patient.

Lithium, the gold standard treatment for bipolar was first used in 1954 but not introduced into the US until the 1970’s. The US was late to the game as it was the 50th country to start using this agent to treat bipolar disorder.

Anti-depressant drugs to treat major depressive disorder began about 1957 with the appearance of the MAO inhibitors. This class of drugs had their problems with interactions with some food products such as cheese. However, other classes of drugs such as the tricyclic anti–depressants, the SSRI’s and now other agents like ketamine are in use.

Those in asylums were able to have the worst of their symptoms treated successfully and to be released from hospital. Mental Health America fails to mention any of this and attributes the emptying of hospitals to the works of the consumer survivors and anti-psychiatry advocates. The problem, however, was that governments were too anxious to release people without first setting up proper community resources to aid and assist those being discharged.

Known as deinstitutionalization, the process has resulted in sick people being left in the community to fare for themselves. As a result, many of the homeless and those incarcerated are suffering from untreated mental illness. Is being homeless or in jail an improvement on the asylums of old? I think not!

All of this (drug development and deinstitutionalization) is ignored in this documentary designed to celebrate the 100+ years that MHA has existed. It began life in 1909 as the National Committee for Mental Hygiene. An organization that has been around for that long I would hope would have more understanding of mental illness than displayed in this documentary. The popular media, in my opinion, displays a greater understanding.

If you are a fan of the TV series Homeland, and have not seen season 7 then stop here unless you want the ending. The protagonist, Carrie Mathison, is a CIA agent with bipolar disorder. In this season, she is captured by the Russians and held prisoner before eventually being exchanged for a Russian spy held by the Americans.

As part of her torture, the Russians withhold her bipolar meds. After a significant time without medication, Carrie is returned to the US in the state that anyone who understands mental illness and the role of medications would understand. She is an incoherent mess and basket case. If Hollywood can understand this, why can an agency involved in the mental health field not understand it?