The concept of recovery for serious mental illnesses has been somewhat controversial but a new research study sheds more light on the issue and confirms what has always been known for schizophrenia. Historically, it has always been understood that about one third of those who have had a first psychotic episode never have another. An additional third manage to cope with some symptoms but do not gain complete recovery and the final third do not do well at all.
Both Dr Dawson and I have written about recovery a few times in this blog before. In one, I pointed out that the concept of recovery is more emotional than rational.“Many people cannot recover to the point where they have no deficits and need no medications. Anyone who can’t (and they are in the majority to varying degrees) are made to feel like it is their own fault that they are not better.”
Dr Dawson pointed out that as doctors “We would all like our patients to recover, to become well, to be able to live full lives with minimal suffering. Fine. But the “Recovery Model” with its emphasis on hope and prayer and peer support and its mantra that everyone can “recover” (with hard work and a little help from his friends) provides a foundation of easy denial for our politicians, our civil service, and our managers.”
The most recent study on recovery comes from Norway where researchers followed a cohort of people diagnosed with first episode psychosis for 10 years. A total of 142 people were followed and the researchers defined recovery as personal and clinical. Personal recovery was defined as “a process of finding subjective quality of life regardless of symptoms” versus clinical recovery defined as “an observer-rated outcome of symptomatic remission and adequate functioning for a given duration.”
The percentage of people in clinical recovery was 31.7 but those with bipolar spectrum disorder achieved a 50% recovery while only 22.9% of those with schizophrenia spectrum disorder achieved full clinical recovery. As for the rest of the sample, the majority did manage to achieve adequate functioning personal recovery in that they were able to live independently at least. Most in the schizophrenia group were not employed even part-time which the researchers suggest may have been the result of systemic problems. Norway lacks adequate work placement programs as does Canada and likely the US.
Another barrier for those with schizophrenia spectrum disorders is the presence of social withdrawal and anhedonia, negative symptoms which impede social activity. Weekly socializing becomes difficult and takes away from recovery.
The bottom line for me in this study is that recovery is complex and can mean different things to different people. It is gratifying to see that some can attain clinical recovery but most cannot. Those who can’t can still improve and hopefully live reasonably happy lives with their deficits thanks to improvements in treatment. The one thing that should never be done or implied is to blame them for not achieving full clinical recovery. Emphasizing full recovery while ignoring the majority who cannot achieve that does nothing but ignore the true reality of this disease. It stigmatizes the majority.
A trial was recently concluded in this Okanagan town in which a young man was given a short jail sentence and then a short probation for a plea of guilty to manslaughter. I know nothing of the case except for that which has been reported in the local paper.
But it is clear from the reporting that the boy in question used a knife to stab the other boy to death in the middle of a melee, an altercation involving several boys. I have no idea what the original beef was about but given the demographics it would undoubtedly have been about girls, drugs, money, or “respect”.
Specific and treatable mental illness did not seem to be a factor.
But I am writing about this because of the judge’s, and the reporter’s, and the family’s focus, emphasis, on redemption, remorse, turning one’s life around, promises to be good from now on, and forgiveness.
Our courts are stuck in some Judeo-Christian morality play. Crime, punishment, remorse, redemption, forgiveness.
The young man in question committed murder/manslaughter. I have no problem with the short jail sentence – to be effective as punishment it needs to be long enough and difficult enough for the young man to not want to return, yet not so long as to engender hopelessness/bitterness and to be thoroughly socialized as a con within a prison culture.
But the question the court should be asking is: short of full incarceration can we ensure that this man never kills again? And this question should not rely on a display of remorse. Remorse can be easily faked. And even when it is genuine it still has a very short shelf life.
The court should instead rely on what we know about human behaviour: we seldom change in any fundamental way, though we can redirect our passions, energies and fears. We humans tend to maintain or fall back into established patterns of behaviour. We do not keep promises. We lie. We lie to ourselves. Displays of remorse are entirely unreliable.
And in this case some general elements and some specific elements were causal. The boy grew up in chaos, addiction, homelessness, maybe abuse, certainly neglect. And at the time of the murder he was very drunk on alcohol and high on cocaine and he was carrying a substantial knife. He claims to not remember the incident and this could be true.
He also did not have a criminal record at the time.
So there were very specific elements involved in the cause of this crime. Elements that can be monitored outside of prison.
These are consumption of alcohol.
Use of illegal stimulant and potentially psychosis-inducing drugs.
Carrying a lethal weapon.
Forget the remorse, redemption, punishment, turning one’s life around.
Rather help this young man get some education and/or employment and housing and monitor abstinence from alcohol and drugs and weapons for the rest of his life – or at least until he reaches that age when violent crimes become statistically negligible.
Though triple vaccinated, and abiding by all international conventions, I have been invaded by the coronavirus. And now in the sixth day of invasion I have concluded that my immune system is not Ukrainian. It is NATO.
It warned of the coming invasion, though COVID denied this and claimed they were merely training. My immune system then gave speeches decrying this unprovoked aggression by COVID. My T cells levied sanctions against COVID leaders, their daughters, and their mucous banks. My lymphocytes asked what sanctions actually do, and called for expulsion of COVID from the general assembly. My mRNA sent some of their members to each afflicted region of my body to record, interpret and broadcast back to the command center. The command center then interviewed retired macrophages for their assessment of the situation.
Some young antibodies with no previous experience volunteered to fight COVID, but retreated when they found WiFi was not available.
My command center suffered from energy blackouts and depletion of sustaining fluids. My NATO immune system railed against this deplorable state while noting the heroism of my command center getting out of bed each morning, albeit later and later.
COVID then alternated its attacks between day and night, between centers of industry, intelligence and metabolism.
And then the atrocities began. They started with an unprovoked attack on my sense of taste, specifically the center for coffee excellence. COVID claims an arms depot was hidden in the basement. Portions of my NATO immune system boldly stated this was a war crime. Other portions of my NATO immune system warned that the definition of war crime was complicated and evidence had to be collected.
My command center asked where all those macrophages and antibodies promised by NATO and Pfizer were hiding. Pfizer offered a fourth vaccine. NATO immune system responded that it was a long process, that my body had to pass many governance tests first, and besides, they did not want a direct confrontation with COVID. Such a direct confrontation might cause an even worse mutation to emerge. But we are 100% behind you, they said.
My immune system feared COVID had even larger ambitions beyond being the simple pandemic of the 21st century, but wanting to return to the glory days of The Black Plague, provoking fear in every shriveling, decaying, blackening organ of my body.
Some members of my NATO immune system suggested I concede a direct passage to the southern port, in return for sparing my command center. My southern port was already under attack and unlikely to achieve safe passage.
My NATO immune system prognosticated that this was going to be a long siege. COVID then pulled back from some northern organs leaving a trail of carnage, to regroup and plan an assault of alternate organs. My command center pleaded with my NATO immune system to increase their support. One of them offered to fly my command center out of my body. I don’t need a ride, I need antibodies and Tcells and neutrophils, eosinophils, basophils, mast cells, monocytes, macrophages, dendritic cells, natural killer cells, and lymphocytes, I yelled back. This seemed to impress them.
At least send me a few courageous macrophages, I said.
But they weren’t listening. Tiger Woods was back on a golf course and though walking with a slight limp and putting badly, he commanded their attention.
Why are we surprised when war leads to atrocities?
I suspect lying behind or beneath this is our continuing delusion that there can be a good war, a just war, a war in which everyone participating behaves according to a set of rules.
We arm young men with serious weaponry and send them off to hunt and kill other young men.
I would assume a few are very comfortable hunting and killing other humans. And another few are content to follow orders whatever they may be. Yet most must find or develop for themselves, a justification, an excuse, a rationale, an explanation for the actions they are about to take.
Some of this may come from the leaders, the propagandists, the generals, and the language they use: “de-nazification, cleansing, eliminating poisons, devils, vermin, Untermensch, and races and nationalities that have no “justification” for existence, repairing historical anomalies….”
Once in the field the “band of brothers” will bond and protect one another.
But they must also see “the enemy” as less than human, not their brothers, as a scourge, not other young men with jobs and families.
To do what they are asked to do they must perceive their enemies as less than human. They must find a way of vanquishing any empathy that might arise unbidden, to view the enemy and his family with contempt.
We are fond of telling stories about those rare moments of kindness, empathy, heroism and compassion that can occur during a war, but they are rare and speak more about a need for reassurance of our basic human goodness, than about our reality, about the reality of unfettered human nature.
So why are we the least surprised when tired, cold, angry, hungry Russian troops slaughter civilians as they retreat from a village?
In fact, I think, viewing this as an anomaly, a war crime, reinforces that delusion our leaders seem to share: that their can be a war without crime and atrocity.
I recently sat in for part of a webinar on human rights and mental illness put on by the Empowerment Council at the Centre for Addiction and Mental Health (CAMH) in Toronto. The Council is a psychiatric survivors group funded in large part by CAMH which is the largest psychiatric teaching hospital in Canada. I do find it rather strange that a teaching, research and treatment facility would fund a group that mostly opposes what they do. The Council is an active opponent of Community Treatment Orders (CTOs) and even launched an unsuccessful legal challenge to CTO’s whereas the hospital sponsors continuing education courses for staff in how to use CTO’s.
I raised this contradiction with the hospital and was told that the webinar had nothing to do with the hospital but was being put on by the patient and family group at the hospital. The hospital, however, did provide the platform so that they could disseminate their views. I have to wonder if cancer hospitals facilitate information sessions for Tijuana cancer clinics or if infectious disease facilities give covid deniers space. I doubt it!
Sitting in on that webinar gave me some insights into the obsession of the psychiatry deniers but since I mentioned CTOs let me digress for a minute as opposition to CTOs continues. The Empowerment Council did challenge CTOs as a violation of the Canadian Charter which I wrote about at the time. The judge must have been scratching his head in disbelief when he ruled that CTOs are constitutional. The one witness put up by the council on the evils of CTOs actually demonstrated their effectiveness.
Their witness was involuntarily committed in 2004 for showing violent behaviour. In 2007, while hospitalized, she kicked her mother in the back and hit her repeatedly. Then, in 2009, she grabbed a large kitchen knife and marched upstairs toward her mother after discovering a magazine about schizophrenia. In another incident, she kicked and punched the emergency department psychiatrist. By the time she was given a CTO in 2009, she had five hospitalizations.
She was then put on a community treatment plan which included monthly appointments with her psychiatrist, meeting with her case manager every three weeks, and orally taking a low dose of antipsychotic medication. Since being placed on a CTO, she had not been admitted to a psychiatric facility, either voluntarily or involuntarily. She maintained her housing. She volunteers with community organizations, has a job, and takes yoga and acting classes. While she believes that the CTO is restrictive of her “liberty and autonomy” and is “an attack on [her] personal dignity,” she prefers the CTO to involuntary hospitalization.
Having a CTO is a fairly benign form of ensuring compliance and good mental health. It worked for this opponent and research has shown that it works for others as this follow up article I did at the time demonstrates. There is considerable evidence on the efficacy of CTO’s but ignored by this group and others. With this background, I sat in on the first part of their webinar which began with a recitation of the historical ills of psychiatry beginning with Charcot.
Why Charcot I have no idea but we were shown an 1887 painting of a doctor with a female patient presumably being treated for hysteria. Charcot is considered to be the founder of modern neurology and he did a great deal of work with hypnosis and hysteria. How he is relevant to human rights is beyond me. The lecture then went on to talk about how psychiatric patients contributed to human rights as they were never treated well. Examples were given of insulin shock, lobotomies, experiments with LSD and ECT.
But, here is the thing. Early psychiatry was barbaric because of a lack of understanding of illnesses and the absence of effective treatments that arise from that understanding. As scientific and medical knowledge improved, so did treatments. The history of psychiatry is no different than the history of other branches of medicine. Migraines, mental illness and possibly epilepsy were treated by drilling holes in the heads of patients to let the evil spirits out and yet I know of no one who berates neurologists today for that practice of yesteryear. Surgery was even more brutal. A newly published book on the history of surgery called Empire of the Scalpel talks about how patients were often tied down screaming in pain while the gloveless surgeon covered in blood cut out parts.
When anaesthesia was first introduced in the mid 1800’s, many surgeons refused to accept it. Doctors would deliver babies without washing hands until Dr. Semmelweis suggested washing might reduce maternal fatal infections. He lost his medical license because no one believed him and yet despite all those barbaric practices, there are no groups of angry people opposed to surgery and surgeons because of the past.
So why are some people so vociferously opposed to psychiatry for historic failures while no one is for the failures in other branches of medicine? Maybe someone can enlighten me but I do also want to address the claim that psychiatric patients contributed to human rights as the rest of the webinar dealt with the human rights protection in Canada in the various Human Rights legislation and in the Charter of Rights.
Human rights involves more than just treatment of disabilities but also involves racial and gender equality. When it comes to medicine, it was the Nuremberg Code created after World War II to prevent future abuses like those inflicted upon concentration camp inmates in Nazi medical experiments . The key for human research is the requirement of voluntary, competent informed consent. All research proposals must be approved by an ethics committee to ensure that the experimentation is based upon valid hypotheses and that subjects are given the opportunity to consent.
That is research but the same principles apply to medical treatment. Patients must give consent to treatments recommended by doctors and patients have the right to refuse treatment. This basic concept applies in most if not all jurisdictions even though my example comes from Ontario.
Courts have reaffirmed repeatedly a patient’s right to refuse treatment even when it is clear treatment is necessary to preserve the life or health of the patient. 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.”
No one forces patients who are competent to subject themselves to unwanted treatment even if it is in their own best interests. I did, however, put in bold the statement with very limited exceptions. Those exceptions refer to cases where an individual lacks competence to make an informed decision and is detained in hospital. Different jurisdictions have different criteria for what qualifies but the reasons would be that the person is a potential danger to themselves or to others so they are detained.
While the anti-psychiatry types consider this to be a horrible violation of a persons’ rights and oppose it, every jurisdiction has a set of safeguards determining how someone gets detained, for how long and there is always a process to appeal. It may on the service sound horrific but it is not. It is not our version of Cancer Ward by Solzhenitsyn describing the locking up of dissidents in Stalinist Russia.
People do benefit from involuntary treatment as Erin Hawkes-Emiru described a few years ago. Today, Erin is married, the mother of a young daughter, the author of two books and a peer counsellor in Vancouver.
It is time for the opponents of modern psychiatry to learn a little of medical and scientific history.
Mind You Reflections on mental illness, mental health and life 