Mental Illness Policy Development or Gobbledygook?

By Dr David Laing Dawson

In the late 1960’s at UBC we replicated a social psychology experiment. The focus was the study of human behaviour in groups. In this activity two groups are formed numbering 6 to 8 people per group. One group sits in a circle discussing the subject or problem presented to them, the other group sits in a larger circle observing the inner group for later discussion.

Three kinds of tasks are given, one at a time, to the inner circle. One of the tasks is straight forward and concrete, such as “Can you name all the birds native to Canada?”

The second task is more abstract, difficult. Today it might be, “How should Canada help prevent war between Russia and The Ukraine?”

As one might expect, with the simple concrete task, someone quickly volunteers to take notes, someone quickly takes the lead and organizes the task, everybody offers names of birds, discussion ensues. Nobody challenges the person taking the lead.

With the more difficult task, some leadership conflict often occurs, people lean in, talk, struggle, lean back, go silent, argue, challenge.

Then the third task: The group is asked to discuss a grammatically correct sentence chock full of feel good words that ultimately make no sense whatsoever. This would be something like, discuss how “The optimization of inclusive democracy could be achieved by the utilization of a scoping and realist review targeting human capacity and technology.” (I borrowed that last bit right from the Mental Health Commission of Canada)

Given this third task the group struggles, leaders arise and fall, opinions are given and challenged, members get active and fall silent, body language speaks volumes. But nobody, at least during the twenty minutes the group is asked to discuss this topic, ever says, “Wait a minute, this sentence simply does not make any sense at all. It is a bunch of gobbledygook. It is nonsense.”

A little twist on this can be added at the twenty minute mark: A stranger is brought in and introduced as an expert on the subject visiting from Harvard. You can guess what happens. The group immediately turns to the “expert” and listens attentively to whatever the “expert” has to say on the subject, nodding agreement. (one maybe hopeful sign for humanity in all this is that each of these subject groups appeared to accept the expertise of the designated expert no matter their age or ethnicity or gender).

But I am writing about this because the Mental Health Commission of Canada’s Report titled “Towards Better Mental and Physical Health: Preventing and Managing Concurrent Mental and Physical Conditions – A Scoping and Rapid Realist Review” offers us dozens of sentences that could be used as fodder for the third group.

What a waste of time and money.

Pencil Pushers and Bureaucrats Should Have No Say in Mental Illness Treatment Strategy -Part Two

By Dr David Laing Dawson

I agree with everything Marvin has written but I don’t think the CEO of the Royal Ottawa Mental Health Centre has written her op ed with any serious thought, or consideration, or understanding of the public import of her words.

Her writing (and I have listened all too often over the years to similar expressions) is a nicely constructed assemblage of warm, fuzzy, good feeling words, meaning, ultimately, nothing. Nothing except self-congratulation and virtue signalling.

Nobody can argue with such feel-good words organized in any way on a page:

“patient centred, patient driven, patient choice, personal freedom, democracy, equality, fraternity, self-determination, team approach, holistic, wellness, life-style, autonomy, transformation, best outcome, radical change, given a voice, client-centred, gold standard, seamless, engagement, thriving, options, normalcy, convenience, independence……”

I think these kinds of writings or speeches are fairly harmless in the committee room, the board room, and within the task force designing the mission statement for the institution, (And they do continuously remind us of some ideals to pursue) but as an op-ed they contribute to the imprecision, the fuzziness of our thinking, the Orwellian world in which the words alone, no longer just signifiers, become realities, or are then treated as realities. It has been said and therefore it is. But not only are the words now a form of reality, they allow us to ignore, if you will pardon the redundancy, real reality. In this case the jails and prisons filling with the mentally ill, the burgeoning homeless population, and the horrific struggle families go through trying to get psychiatric treatment for a family member who is mentally ill.

And they obscure the very troubling, always difficult, always stressful, social, ethical, legal, medical, and often necessary choice to make a decision for someone else, to decide when someone else is incapable of making such a decision for themselves. Or, left to make such a decision for themselves, they will choose a course of action that predictably will end in poverty, homelessness, jail, or death.

These feel-good words are also an assault on medical and psychiatric treatment, and science, and paradoxically they increase the public stigma for those who suffer from severe and persistent mental illness.

The stigma and fear that added to the burden of those afflicted with cancer has been dramatically alleviated between 1960 and today. This was not accomplished by renaming cancer as “cell health issues”, calling cancer patients self-determining clients, and the institutions that serve them, The Princess Margaret Holistic Cell Health Centre and the Sloan Kettering Cellular and Substance Issue Center.

Terry Fox did not run halfway across the country to raise money for bone health issues but for bone cancer.

Calling severe mental illness a “mental health issue”, and addiction an “issue with substances” is ridiculous.

I have severe osteoarthritis in my deformed left knee (?knee health issues). The internet tells me I could choose (for a sum of money) a bunch of capsules that will magically transport new cartilage to my left knee, or (for a sum of money) a strange exercise program to strengthen my glutes to fix the problem in my knee, or attend a chiropractor who will charge me for weekly massage and stretching, or get some strange smelling medicine or a bunch of needles stuck in me by a naturopath or acupuncturist, or I could become a patient of an orthopaedic surgeon who will fulfill his or her role in the doctor-patient social contract by examining my knee, diagnosing the problem, and recommending the best and safest solution or help that science has demonstrated to date. I will be fully informed. I will make the decision, but my wife, who is tired of shoveling snow, will be there with me. And I trust the medical and surgical care will take place in a hospital and not at a “Client Driven Joint Health And Addiction Issue Holistic Centre”.

Pencil Pushers and Bureaucrats Should Have No Say in Mental Illness Treatment Strategy -Part One

Marvin Ross

I don’t believe I have ever seen the CEO of an oncology facility suggest how doctors should treat those with cancer but the CEO of the Royal Ottawa Mental Health Centre just did in an op ed in the Ottawa Citizen. If the CEO was a psychiatrist I would not object but the author, Joanne Bezzubetz, has an MBA and a PhD in Applied Management and Decision Sciences from Walden University. She has a history of admin positions in mental health but no education in mental health treatment.

She begins by saying that “It is time to put clients (patients) at the centre of their own care, to let them make choices about their therapies, and to give them the resources they need to lead independent and happy lives.”

She is clearly an advocate for patient centred care whereby the health care system puts the needs of the patients first. No one can disagree with that but my question is why is that such a big deal. Without patients, health care personnel have no jobs so what did they do before someone came up with this concept? I hope the system always put the needs of the sick up there at or near the top and always provided them with the treatment and resources they needed to overcome their illnesses, pain and suffering.

None of that should be radical. Where I have a problem is to allow them to make their own choices about treatment. Imagine going to the doctor with an infection and the doctor asking what would you like to do? That doesn’t happen. What the doc does is to present the patient with possible solutions, the pros, the cons, the side effects and then decide on a course with the patient. The choices might be wait and see if it resolves on its own or start antibiotics now.

In oncology, the same process would take place and if the patient decides to not accept conventional treatment but wants to go to Tijuana for alternative therapy, I would expect the doctor to have a long talk with the patient and try to dissuade them. If the patient is adamant then there is not much the doc can do. The patient has the capacity to make that decision and does so.

Under common law, as Justice Robins of the Ontario Court of Appeal explained:

“The right to determine what shall, or shall not, be done with one’s own body, and to be free from non-consensual medical treatment, is a right deeply rooted in our common law. This right underlines the doctrine of informed consent. With very limited exceptions, every person’s body is considered inviolate, and, accordingly, every competent adult has the right to be free from unwanted medical treatment. The fact that serious risks or consequences may result from a refusal of medical treatment does not vitiate the right of medical self-determination. The doctrine of informed consent ensures the freedom of individuals to make choices about their medical care. It is the patient, not the physician, who ultimately must decide if treatment — any treatment — is to be administered.”

What Ms Bezzubetz is espousing is something that already exists and is well entrenched in the legal statutes and in case law. I did highlight With very limited exceptions because it is those exceptions that she may be talking about and those are serious mental illnesses and dementia. It is not unusual for these two groups to be unable to understand that they are ill and to be able to make rational decisions about their care. When it comes to dementia, we mostly understand this and allow a substitute decision maker to make those care decision.

Granny has advanced Alzheimer’s and does not know what day it is, how to make a cup of tea safely but refuses care that will keep her safe. With compassion and understanding, we guide her into the care she needs which may be into a long term care facility where she can be looked after. We do not allow her to wander the streets and to live in the park or at a street corner.

In contrast, a young person with untreated schizophrenia is allowed to refuse treatment because he or she insists there is nothing wrong with them. And the longer their condition is untreated the worse it gets. Their family cannot cope and they end up living on the street, getting in trouble with the law and ending up in jail or dead. Society does not care and seemingly those like Ms Bezzubetz feel that is fine because they were “at the centre of their own care” and were allowed to “make choices about their therapies”.

In Ontario and most other jurisdictions, if these individuals become dangerous to themselves or others, they can be incarcerated in psychiatric facilities. Unfortunately, in Ontario they can still decide upon their treatment which usually is to refuse treatment. As a result, we have patients locked up for years who are dangerous but refuse treatment and the chance to recover and be released. How sensible is that?

If Ms Bezzubetz had more knowledge about psychiatry she would be aware that close to half of all patients with schizophrenia and bipolar disorder do not realize they are ill which is why they refuse treatment. The term is anosognosia and it is not just denial of being ill but a symptom of being ill whereby you are not capable of understanding. The following video by Xavier Amador is a perfect example of this condition.

In addition to or as an extension of this characteristic, people with schizophrenia “experience the world differently. And many have a relatively unique set of cognitive impairments, or problems with their intellectual functioning.” Those with schizophrenia have poor memories, trouble shifting between tasks, making bad judgement calls and failing to predict consequences.

None of this bodes well for them to be able to make rational decisions about treatment or no treatment or the best treatment. At least, of course, in the acute early phase of their illness. In that circumstance, consultation should involve family or those who are closest to the patient and know them best. Once treated and stable, the ill person is capable to discuss refinements in treatment. Physicians should pay attention to potential side effects and be willing to change medications to other drugs or to rationally discuss the choice between oral versus injectable forms of drugs.

Those providing treatment have to have the knowledge and the compassion to treat their patients with the appropriate respect and to act in their best interests.

What I’ve written reflects the frustration of a family member experiencing a health system governed by what I consider the harmful ideas expressed by Ms. Bezzubetz. Part Two tomorrow reflect the experiences of a psychiatrist working within that system.

Guest Post People With Mental Illnesses are Not Culpable for Those Illnesses

Joseph M. Bowers

A blog I follow regularly is Mind You usually written by Marvin Ross or Dr. David Dawson. In a recent blog Marvin pointed out that society has more compassion for and better treatment of elderly people with Alzheimer’s or other forms of dementia than for people with schizophrenia. A person who commented on this blog believed that many people feel that somehow people with schizophrenia are culpable for their illnesses.

In a later blog Dr. Dawson speculated that this may be in some part because of mental illness and substance abuse being to such a degree lumped together. There is choice involved in substance abuse. There are many reasons why people become addicted to cigarettes’, alcohol, opiates and other addictive substances. Often it doesn’t feel like much choice is involved, but people can and sometimes do choose to get clean and stay clean. One can not choose to try mental illness or to recover from it. Some can with help learn how to keep symptoms at bay and deal with them effectively. Some can not improve much with any currently available method of treatment.

I think there are more reasons for many feeling little compassion for the severely mentally ill.

The thought of one’s brain seriously malfunctioning is very scary. Some assuage this fear by telling themselves that they are better than those with severe illnesses. They have more will power, stronger character. A coworker whose job was in jeopardy once told me that I had never experienced anything as bad as what he was going through. When I mentioned being institutionalized with severe mental illness, his comment was that he had never let something like that happen to him.

Many of these superior people will never experience a challenge as daunting as what many with severe mental illnesses deal with every day.

Then there is the belief among some that people get what they deserve in life. Good things happen to good people and vice versa. Wouldn’t that be nice! When going through more than twenty years of recurring psychotic episodes, I sometimes wondered if I was being punished for doing something just God awful in a previous life. I couldn’t think of anything I had done in this life to deserve what I was going through. Most of us I suspect have seen people get undeserved good or bad fortune.

I maintain that those of us with severe mental illnesses are not culpable and deserve as much compassion and care as the elderly with Alzheimer’s and other forms of dementia. Both conditions are tragic and undeserved.

New Years Resolution for 2022 (A scientific approach)

By Dr David Laing Dawson

Diet and Exercise

Recent scientific studies have demonstrated conclusively that my current diet along with a vague plan to become more active once the good weather arrives, is perfect. Not that scientists would ever use the word “perfect” but rather they use the word “optimal” which really means perfect.

Specifically one Nobel laureate has declared that my occasional over-indulgence in Buffalo style chicken wings is fine as long as it remains occasional. (The statisticians define occasional as more than “sometimes” but less than “often”.)

Similarly many large studies have shown that my current consumption of 3 cups of coffee per day is optimal. To make that better than optimal they suggest drinking both tea and coffee, though that suggestion is ridiculous because we all know you are either a tea drinker or a coffee drinker and cannot be both. Nutritional science does occasionally flounder on the shores of reality.

When it comes to consumption of alcohol, calculated as the average number of “drinks” per week, I do what everyone does when asked that question: I conduct a complex mathematical equation to determine an S number rounded down to account for heritage metabolism (mine being Scottish and possibly Venetian). This produces a range of 14 to 21 drinks per week, which the majority of drinking scientists agree is quite acceptable.

One important study that pleases me shows that moderate drinkers who stop drinking fare more poorly (dementia) than moderate drinkers who continue imbibing into their dotage.

I am already a proto-vegetarian and thus doing my bit for health, climate, and the happiness of cows and pigs. WHO scientists define proto-vegetarianism as the absence of red meat in the diet for at least 3 days per week.

Exercise is a more complex issue. Social scientists all agree that a sense of failure, guilt, self-recrimination, and hopelessness is very detrimental to physical and mental health. Thus, as one NIMH scientist espoused, “Making plans to exercise regularly and failing to do so is terrible for your mental health and thus plans to exercise should be expressly avoided. On the other hand a “vague notion” of becoming more active in the good weather is easily fulfilled and thus not detrimental to health.”

Besides, in my life time I have had two friends who died while jogging, and to call this anecdotal evidence would be insulting to their memory.

Thus, in keeping with the latest scientific evidence, I resolve in this third pandemic year of 2022 to continue eating and wait for the good weather to occasionally (or quite often actually) stroll outside.

When it Comes to Vaccinations, I Stand with Macron

By Marvin Ross

French president Macron upset many when he announced that he wants to “piss off” the unvaccinated by making life difficult for them and forcing them to vaccinate. He is so right as the statistics show at least in Ontario and likely elsewhere as well. Austria has made vaccines mandatory, Greece is fining the unvaccinated over age 60 $114 a month and Italy is planning to prevent the over 50 unvaccinated from going to work.

The Omicron variant is spreading rapidly while, in Ontario, 81.6% of those over the age of five have already had two doses. Our problem is with the 12.6% of people who do not even have one vaccination. Even though you need a vaccine passport to go out to dinner, to a movie or a play, all has been shut down to help prevent the collapse of our hospital system. All elective surgeries have been cancelled which will not hasten death but will increase the suffering for those whose procedures have been delayed.

The anti-vaxers point to the fact that both the vaccinated and the unvaccinated are getting Omicron but they ignore the crucial bits of data that tell a compelling story. According to the science table that has been advising the Ontario Government since the beginning, covid cases among the unvaccinated are 1600.9 per million versus 1292.0 per million among the vaccinated. The vaccinated with two doses are 19.3% less likely to get the virus which is a reduction but not that great a reduction.

The huge difference is in severity. Those who have not been vaccinated are 5 times more likely to be in hospital than the vaccinated (532.7 per million vs 105.9 per million). That differential becomes even greater when intensive care need is looked at. The rate for unvaccinated in the ICU is 135.6 per million compared to 9.2 per million for the vaccinated. That’s a reduction of 93.2%

These are the stats for January 5 from the Science Table

We are all being made to suffer because of a small element of people who value their personal freedom over the good of all society or because of their inability to grasp science. If we required people to show their vaccine passports for travel on public transit, shopping and even going to work in addition to the already required restaurant and other places of entertainment, they will either get vaccinated or sit at home alone.

The issue is the right to make decisions and choices about your own medical treatment (and to hell with everyone else) versus the impact that right has on the health and safety of others in society. It has been suggested to me that the case of Typhoid Mary is one that is comparable now. Mary Mallon was an Irish American cook who was an asymptomatic carrier of typhus. She denied being ill but, as a carrier, she infected many and some of those whom she infected died. She continually denied that she was ill and was twice quarantined to North Brother Island for a total of 26 years. Isolating people in quarantine to protect the majority of society is not something new but dates back to Biblical times when lepers were isolated in colonies.

Today, we are not suggesting the unvaccinated be quarantined on remote islands but that they simply accept a fairly benign injection. How terrible is that?

We should not be allowing this small minority to dictate to us and to clog up our hospitals. The other day, I saw Dr Paul Offit, an American pediatrician and expert in vaccines interviewed on BBC News. He stated that at his hospital, the Philadelphia Children’s Hospital, the Covid wards are full of kids whose families are not vaccinated. Watching families sob when he is forced to intubate their kids makes him want to go and shake some sense into them to vaccinate he told the BBC. He added that a parent’s job is to protect their kids and not vaccinating is not protecting them. Today, in Ontario, babies are ending up in hospital with covid acquired because many pregnant women are not vaccinating.

Maybe Macron’s strategy and the measures being taken in some European countries will work.

A Look Back and A Wish For 2022

We have been writing blogs since October, 2014 and while we weren’t sure how much we could generate, we have somehow managed to put out 573 of them on at least a weekly basis. While the vast majority of our readers are in Canada and the US, we are read in a total of 167 countries. According to feedspot, we rank as number 76 in the top 100 blogs and websites worldwide dealing with mental health. We are number 6 out of the top 15 in Canada.

In the past year, our ten most read blogs are:

Yes, Involuntary Committal and Treatment Does Work

The World Health Organization Joins the UN in Attacking the Mentall Ill

The Decline of Mental Illness Treatment from the 1980s On

Guest Post – Dealing With the Mental Health bureaucracy

Things a rural doctor has in his iPhone during Alberta’s COVID-19 pandemic – Reblog

Going Off Schizophrenia Medication – A Real Life Example

When the Involuntary Option is Ignored – Tragedy Follows

Discrimination Against the Mentally Ill by Medical Professionals

The Reality of Involuntary Treatment

Lived Experience and Peer Support

Our Top Ten Blogs of All Time:

The Decline of Mental Illness Treatment from the 1980s On

Donald Trump’s Mental and Emotional Age?

Belief Systems, Mad in America and Anti-Psychiatry

A Psychiatrist Critiques Open Dialogue

Involuntary Treatment and British Columbia

I Thought I Was Too Smart for Schizophrenia

Why I’ve Been Prescribing Psychiatric Medication For 47+ Years

Time to Re-evaluate Clozapine Use for Improved Schizophrenia Outcomes

A Psychiatrist Discusses Hearing Voices

The Unfiltered Mind of Donald Trump – A Tentative Psychiatric Evaluation

Some of the above were written by guests and we did receive over 2000 comments to what we wrote. My personal favourite is one of the latest for the blog post Anti-Psychiatry in British Columbia – The Need for Continual Vigilence. Someone by the name of John posted “The world would be a better place if the author of this diarrhea were to stop living in it.” One fan responded with “It’s not diarrhea. It’s shite! The guy needs to get his terminology straight!”

To all our loyal followers and readers, thank you and may 2022 prove to be an improvement over 2021. Stay safe, healthy and happy