Monthly Archives: August 2022

A Memorial Tribute

By Dr. David Laing Dawson

Image by Kanenori from Pixabay

An old friend of mine died yesterday.

Today in the early evening I sat on the covered porch watching the clouds move over the mountains on the east side of the lake. They ranged from the whitest of white, through mauve and purple to a dark brown grey. Most were organized horizontally, moving slowly from right to left, from south to north, but some were vertical. They swelled and expanded down the mountain until all was obscured by mist. There was rumbling in the distance, that deep throated growl, and flashes of light.

The older dog went inside. The younger one sat up against me in the wicker chair, watching intently, startling with each noise.

Then the jagged limbs of lightning struck, one across the sky, another on an angle from sky to ground on the left, then the same on the right. I counted slowly waiting for the thunder. A flash lit up the sky above us with a loud crash on its heels.

Then it poured, loudly, then settled into a steady light rain. The jagged bursts of lightning continued on the other side of the lake.

The young dog pulled closer. His name is Max.

On the west side of the lake just over the mountains behind me the clouds parted a little and let the setting sun send a shaft of light across the lake, diffracting in the raindrops. A full spectrum rainbow appeared, its pot of gold on the western shore.

I took Max inside.

My friend died yesterday. He will never again get to see, feel or hear the glory of an August storm.

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Giving Delusional Disorders a Bad Name- The Queen of Canada

By Dr David Laing Dawson

There was a time a couple of generations ago when itinerant preachers and snake oil salesmen had to work hard to make a living. Set up a wagon or tent outside a village or small town, find ways to entice some of the citizens to come out to see the show. Put on a show with charm and colour and oratory and promises of health and happiness, perhaps perform a bit of sleight of hand, a little magic, an instant healing. And move on to the next small town when the well runs dry or the promises fail to come to fruition.

Television allowed a few of those preachers to vastly broaden their audience and their wealth, and to travel by private jet. But the selling of snake oil became the purview of large corporations, now regulated to the point the particular cure being peddled was usually, at least, safe.

And then the internet. Individual snake oil salesmen and women are back with us with slick presentations and one time only offers, working in the comfort of their production offices.

And the internet has also re-birthed a host of itinerant preachers selling everything from mental health and sovereign citizenship to a seat at God’s dinner table. And they have revealed for us students of behaviour, that there are no limits to the gullibility of human beings. Ahh, we so desperately want to believe in something other than the big bang, the expanding universe, quantum computing, global warming and the fact our sun will die in a few billion years.

Enter the Queen of Canada (whom I gather is now the Queen of the World), HRH, her majesty, one Romana Didulo, resident of Victoria, B. C., aligned with Q’ANON but willing to borrow from a host of wacky conspiracies and new age jargon.

But in reference to the title of this piece, over the years I have met a few queens, women suffering from psychotic disorders whose delusions told them they were Queens. One actually Queen of Canada, and a couple of Queen Victorias. And these women suffered from psychotic disorders, delusional disorders, treatable mental illness.

The Romana Didulos of this world do not. They are the descendants of the itinerant preachers and snake oil salesmen of past centuries. Con men and women. And they prey on the gullible, the not-so-bright, the lost souls, and the mentally ill.

Salman Rushdie

By Dr David Laing Dawson

In a classroom annex of the United Church on Quadra Street in Victoria, the Sunday School teacher was presenting the story of God parting the Red Sea for Moses to lead the Israelites fleeing from the Egyptian soldiers and their chariots, and then letting the sea swallow up the soldiers, their horses and chariots, once the Israelites were safe.

A boy in the class, no more than 12 years old, raised his hand and asked, “Sir, is there any archaeological evidence that this actually happened?”

I remember it well because of the very uncomfortable meeting the teacher had with my parents and myself. He suggested perhaps I was ready for full-on church rather than Sunday School.

Writing this I realized today that 12 year old boy could simply put his question to Google. And so I did. And discovered the perils of the internet. There are dozens of tracts, essays, and videos of “scholars” setting out to prove this happened exactly as described in the bible. Their proof is thin gruel indeed: animations, paintings of the event, maps, speculation about which Pharaoh was in charge at the time, and a bit of coral found in the shape of a chariot wheel, with one expert announcing as a final word on the subject, “Science cannot explain miracles.”

Of course it is as easy to explain miracles as it is to explain Uri Geller’s spoon bending or Harry Potter’s dragons.

But it is very difficult for me to imagine living in a country or culture that would not allow that 12 year old boy to ask his question.

Prime Minister Trudeau called the assault on Salman Rushdie a “cowardly attack” and “a strike on the freedom of expression.”

No Justin. This was simply a deluded and tragic young man seeking meaning in his empty life, carrying out what he had been told by religious leaders would be an act of justified murder that could bring him martyrdom and a place in heaven.

But this was, Justin, your chance to condemn Fatwas, the concepts of heresy, infallibility, apostasy, extremism, absolutism, and any faith that forbids questions, investigation, criticism, satire and humour.

Guest Blog – Ontario’s mental health laws must change to protect our most vulnerable patients

By Drs  Angela Onkay Ho Lyndal Petit Kashif Pirzada Karen Shin

This article first appeared in Healthy Debate on July 18, 2022. I found it refreshing that more psychiatrists are now entering the debate and arguing for better legislation that I wanted to share it with our readers. This is what they had to say:

When people begin to show symptoms of psychosis, they are facing a crucial and vulnerable moment when timely treatment can prevent needless suffering and death.

Yet, Ontario’s current mental health laws make it difficult for front-line physicians like us to provide evidence-based treatments to people in crisis.

Psychosis is a condition that is widely misunderstood, misrepresented and stigmatized. Illnesses that can cause symptoms of psychosis, such as schizophrenia and bipolar disorder, affect about three per cent of the population. Symptoms often begin in one’s early or late 20s. Psychosis may manifest as delusions, which are false beliefs maintained despite rational evidence to the contrary. It can also appear as hallucinations, like hearing voices that are not there. Other signs include social withdrawal, disorganized behaviour or disorganized speech.

When a person shows symptoms of psychosis, maintaining a job becomes difficult or impossible; family relationships become strained; physical health suffers. Tragically, people with psychosis can become homeless, victims of violence or incarcerated.

Early intervention and treatment can mitigate the severe impacts of psychotic illnesses and provide individuals with the best chance of returning to their pre-illness levels of functioning.

However, two aspects of our mental health laws not only create barriers to treating our most vulnerable patients but are harming them.

First, many patients with psychosis are unaware of their symptoms and their symptoms’ impact. Consequently, they can’t appreciate treatment benefits or options. Such individuals are considered incapable of directing their own mental health care and frequently refuse psychiatric treatment unless it is forced in hospital during an involuntary admission with their substitute decision-makers’ consent.

But in Ontario, despite their mental deterioration, patients cannot be involuntarily hospitalized unless there is a safety risk to themselves or others, or have experienced a response to treatment in the past and a substitute decision-maker consents to treatment in a psychiatric facility.

Ontario should make involuntary admission accessible to people needing treatment that can only be provided in a psychiatric facility when they are at likely risk of substantial mental or physical deterioration, are incapable of consent to psychiatric treatment and consent from their substitute decision-makers has been obtained.

As it stands, those experiencing psychotic symptoms for the first time, or who have never engaged in treatment, cannot receive psychiatric care through involuntary hospital admission in Ontario unless they are a danger to themselves or others. In other words, for individuals with no insight into their condition, and who are undergoing mental or physical deterioration, the law does not allow for involuntarily hospitalized treatment without evidence of past effective treatment, regardless of the severe mental and psychosocial repercussions of the untreated illness.

This chicken-and-egg scenario is harming our most vulnerable patients.

This chicken-and-egg scenario is harming our most vulnerable patients: We can’t compel you to get treatment unless we have proof it has worked before, but we can’t get proof because we can’t compel you to get treatment unless you are a danger to yourself or society.

People are then left untreated for years, indefinitely debilitated by psychotic symptoms, resigning families to burn-out or risk losing loved ones to a marginalized existence and homelessness.

The majority of Canada’s provinces and territories permit involuntary admission to prevent substantial mental deterioration when other criteria are met. However, Ontario is the only jurisdiction that limits involuntary admission for incapable persons with a likely risk of substantial mental or physical deterioration only to those with past documented responses to treatment. Thus, Ontario’s laws discriminate against people without a history of response to treatment.

The second issue is that once admitted to hospital, incapable patients can legally decline treatment consented to by their substitute decision-makers, meaning they remain untreated while they challenge their finding of incapacity to the Ontario Superior Court.

This appeal occurs after the patient has already exercised a right for legal representation at an independent review board (consisting of a lawyer, a community member and a health professional) that has reviewed the facts. These appeals take months, even years, to clear the protracted court systems.

Untreated patients are either held in hospitals – detained but untreated – or discharged to the community while their untreated symptoms continue to erode their lives. Patients can incur social and financial risks, become suicidal or agitated, and suffer legal consequences for causing harm to property or others. This process is not the case in most of Canada, where treatment pending appeal is the law.

In these jurisdictions, treatment can start after a review board confirms a patient’s incapacity while the patient simultaneously fulfills a right to appeal the decision in court. In Ontario, data collected by the province’s Consent and Capacity Board has found that the majority of appeals are withdrawn, dismissed or abandoned before they reach court. Thus, the appeal process only interferes with effective treatment rather than its intended purpose of facilitating patient rights.

The appeal process only interferes with effective treatment rather than its intended purpose of facilitating patient rights.

All Ontarians are entitled to timely and publicly funded psychiatric treatment.

A defined group of people with specific needs should not be denied care because their illness interferes with their capacity to fully engage in treatment decisions. This is the opposite of prudent, evidence-based care. Legislative changes will align Ontario with the majority of Canada to facilitate psychiatric care for those who need it the most, creating a more equitable and effective mental health system.

Psychiatric Hospital Design and Security Part Three

By Dr David Laing Dawson

I was going to write about my continuing search between (1970 and the present) for the answer to Marvin’s question but I decided to cut to the chase. I worked in Fulbourn Hospital for about 8 months in 1970 and 71. Yes, the Therapeutic Community idea is not effective treatment, but it is a way of returning to psychiatric inpatients at least some sense of power and control over their own lives.

While Pat F. recounts a couple of escapes from the unlocked wards of Fulbourn, they are chaotic and frightening events but not tragic. I have been there.

What research there is on the subject actually shows that suicides and escapes leading to tragedy are actually less frequent in unlocked wards. The act of locking the ward does enhance the urgency of fight or flight.

Anecdotally I have been very convinced of this. The very modern hospital of which Marvin writes, with all its high tech security, has a vastly poorer record of suicides and violence than its old mental hospital predecessor, the Hamilton Psychiatric Hospital, with mostly unlocked doors, at least between 1985 and 1995.

Even when psychotic we respond to the messages of our physical and social environment. In the development of the programs at the UBC hospital in 1969 we argued at length about the wisdom of carpets during those years everybody smoked everywhere, having seen the marks on old linoleum floors. And we found nobody ground out a cigarette on carpet. They used the ash trays provided.

But there are complex forces at work, especially today. Societal expectations pushing in conflicting directions: On one hand expecting absolutely no risk and complete safety for the public, on the other hand idealistic about individual human rights to the point of denying the existence of mental illness and incapacity.

With most mental hospitals, including HPH and Riverview, there were expansive grounds to walk upon, to sit in quietude, to blow off steam, after prematurely leaving a ward. In fact sitting parallel on a bench under an oak tree is a fine and safe place to conduct a therapeutic and de-escalation intervention.

On the other hand a patient running from the locked or unlocked psychiatric unit on the fifth floor of a general hospital can create much havoc and fear going through a surgical or pediatric ward before getting to the front door.

And lawyers. And risk management committees. And unions. And more lawyers.

But Ill fated de-institutionalization may have made the issue partly moot. In 1954 the largest mental hospital in the U.S. housed 13,875 patients. Today the largest mental health facility in the US is actually a wing of a county Jail in Los Angeles. You can be sure its doors are locked.

Psychiatric Hospital Design and Security – Part Two

By Dr David Laing Dawson

Century Manor built in 1876 as the Hamilton Asylum for the Insane

There have been many reformers in the history of mental illness treatment: Phillipe Pinel cutting the chains of the insane locked in Bicetre in 1796. William Tuke, 1792, founding The Retreat, in York. Benjamin Rush and the Moral Treatment pioneers from the late 1700’s. Dorothea Dix actively promoting more treatment facilities through the same period. And long before that Ahmed ibn Sahl al-Balkhi (850-934) within the Islamic Faith.

More recently the publication (1963) of More for the Mind by the Tyhurst Committee of the Canadian Mental Health Association on psychiatric services in Canada: “Mental illness should be dealt with in precisely the same organizational, administrative and professional framework as physical illness”. Tyhurst is the same psychiatrist who contributed to the design of the Psychiatric wards of the new hospital on the UBC campus, opened in 1969.

But it also becomes clear, looking at the realities of institutional psychiatric treatment over the past 300 years, that how we view and treat people suffering from severe mental illness, and the design and function of our institutions, ultimately depend more on economics, politics, the preoccupations and social forces of the time, than on any single person’s ideas.

The reforms of Pinel and Rush coincide with the ideas fostered by the French and American Revolutions. As our cities grew in size, roughness and clamour, the Moral Treatment era sprung from a combination of new psychological thought, religion, and nostalgia for the rural life.

Unfortunately the industrial revolution sealed the fate of those Moral Treatment Institutions, which started as large Manor Houses, built in the countryside where the inmates and staff and the Superintendent ate together, prayed together, followed healthy routines of sleeping, working, prayer, rest, and eating.

With the industrial revolution immigrants arrived, cities grew, workhouses and poor houses proliferated, and the small buildings of the moral treatment era were expanded and expanded. With the same architectural inspiration as prisons, wings were added to left and right, and then from those corners to form a U shape and often then finished at the back to form a rectangle with a large courtyard in the middle. As these institutions grew conditions deteriorated and security became a prime motive. By the turn of the century (1900) the number of patients who were discharged from any American Asylum, dropped to a tiny percent. To be admitted to an asylum was often for life.

After the First World War public interest in the conditions inside our mental hospitals increased, at least in part because of the number of hospitalized veterans. In the mental hospital in Hamilton, Ontario, “airing courts” and vocational programs were added for the patients. These reforms and more humanitarian attitudes coincided with suffrage for women and child protection laws being enacted.

With the depression and the “dirty thirties” into the 40’s the mental hospitals are forgotten once again, and in many, conditions deteriorate. The only effective treatment available is the newly discovered ECT. It actually works for severe depression and psychosis but as with all medical discoveries it becomes overused. On the other hand, as a colleague once pointed out to me, these asylums with their own farms and kitchens were some of the few places in those years where one could be guaranteed a bed and three meals a day.

After the Second World War, again with many veterans being admitted to mental hospitals, public interest in the conditions in these hospitals increased. And finally, medications that actually work for psychosis, mania, and depression are introduced in the late 50’s. These are good economic times, and new attitudes evolve with a renewed interest in human rights and human dignity.

To be continued