Boris, Donald, and Elizabeth

By Dr David Laing Dawson

We recently passed through an interesting social experiment from which we should learn.

Boris Johnson is a better educated, more articulate, smarter version of Donald Trump. Both men, to the surprise of many, managed, using the same populist tropes fashioned to rouse and focus the anger of their respective populations, to achieve the top political positions of their countries. Both “ruled” with flamboyance and flim flam. When Boris took one too many liberties with the truth his political career ended simply and quietly. There was no backlash, no outpouring of grief and anger, no seeking of revenge, no denials, no marching in the street, no violence, no groundswell of support and demand to reinstate Boris as Prime Minister.

On the other hand Donald Trump kept piling on the lies, the outrageous behaviour, the cons and grandiosity. He did lose the election for a second term but we all know what happened next.

We humans, many of us for sure, retain a trait that once provided genetic Darwinian survival value. Projection, identification, thoughtless loyalty, unquestioned fealty. Some commingling of our need for reassurance, a God, guidance, the embodiment of all we hope we are and could be, a protector, a symbol of unity, of past, present and future.

The people of the U.K. and the Commonwealth have the Crown for that, Her Majesty, and now His Majesty, a Royal Family. It is anachronistic, silly, fantasy and fairy tale stuff. But then so are we. The viewership of Game of Thrones rather exceeds that of Question Period in the House of Commons.

Because we have the Crown, our Head of State, our (actually powerless) symbol of all that we hope we are individually and collectively, Boris Johnson and Justin Trudeau are just politicians who have or had important jobs, who cannot get away with the outrageous behaviour of Kings and Potentates, and who can be removed from those jobs without much disruption at all. Without weeping and wailing and threat to democracy. Because we have a separate, symbolic Head of State, and a Royal Family, that provides, without threat to our democracy, sufficient fanfare, intrigue, scandal, and a few good deeds to keep us tuned in.

We need to keep the Crown.

Guest Blog – ‘Nowhere to go’: Homelessness and mental illness create a ‘revolving door’ of admissions

By Nicole Naimer from Healthy Debate Sept 7,2022

The following article shows the lack of humanity in the treatment of marginalized groups in Ontario. What has been done to the mentally ill is now going to be done to the frail elderly who, under just passed legislation, will be removed from hospitals against their will once they are stabilized. If their long term care or home care preferences are not available, they will be sent to whatever openings exist. Some of those facilities may be miles away from home and family but if they do not move, they will be charged a per diem. This is what Ms Naimer says about the usual condition for the mentally ill which is now being extended to the elderly. What group will be tossed out next? – MR

When Jane was asked if she was excited to leave the psychiatric hospital, her first reaction was:  “Where do I go?” Jane, still in her teens, had been sexually abused and was battling addiction and homeless. She wasn’t aware of an alternative discharge option besides sleeping on that same stoop on a busy street.

Homelessness at hospital discharge for those with mental illness/addictions is an issue for more than just Jane. Across Ontario, more than 1 in 50 adult patients from psychiatric hospitalizations are homeless at discharge.

Vicky Stergiopoulos, who recently stepped down as physician-in-chief of the Centre for Addiction and Mental Health (CAMH), recalls that when she worked at St. Michael’s Hospital in downtown Toronto, one in five of her patients was homeless.

“It was very hard to feel good about the care you provide … and (that) the care you provided can have a positive impact. But how can you when you see them being discharged to go back to the pavement on the street, or in a shelter setting with no support?” asks Stergiopoulos. “And the moral distress associated with that, it’s very uncomfortable.”

Psychiatrist Sarah Levitt has seen that distress in her inpatient practice. “There’s a lot of pressure on the staff, in terms of bed pressures, and making sure that when folks don’t absolutely have to be in hospital, they are discharged,” she says. “And at the same time, from a compassionate perspective, it feels so awful to be discharging people with nowhere to go.”

Homelessness at discharge in psychiatric settings comes with significant cost to our health-care system and, more importantly, to those with lived experience. Homelessness at psychiatric discharge nearly doubles mental-health related emergency department visits and increases readmission rates by 43 per cent within 30 days of discharge compared to those with housing.

“If people think that their best housing option is to stay in hospital, then there’s something really wrong with our system,” Levitt says.

And it doesn’t just end with one readmission. Says Melonie Hopkins, a social worker who manages Alternative Level of Care (ALC) at a mental health hospital: “(For) those individuals who are homeless upon admission, and they return to homelessness, you can get this revolving door.”

Sean Kidd, psychologist and senior scientist at CAMH, says health-care workers have little choice but to discharge patients.

“We are really underfunded. We cannot meet the demands and needs of the people we’re trying to serve,” says Kidd. “So, it’s not like any hospital or any provider of any kind is thinking it’s a good idea to discharge somebody into no fixed address or to a shelter. It’s just a matter there’s no choice …”

Jesse Jenkinson, postdoctoral fellow at the MAP Centre for Urban Health Solutions, points to the shortage of shelter beds as a major barrier.

“There literally aren’t any spaces for people to go. A shelter space is already a suboptimal discharge destination for someone leaving the hospital. But it’s the only option that exists for most people,” says Jenkinson. “And now… we don’t have that option either. So, it’s very bad.”  At the time of writing, the shelter bed occupancy in Toronto ranged from 94.5 to 100 per cent.

Currently, there is no provincial strategy for discharging people experiencing homelessness from hospital settings. Though there are best practices outlined by the Ontario Hospital Association to confirm with provincial legislation and funding, Stergiopoulos “doubt(s) there is close attention across the province on what happens at discharge.”

Says Jenkinson about those best practices: “It doesn’t include the word homeless in any of the documents … I think that gets very tricky.”

Hopkins’ ALC clients have a diverse set of care needs in addition to mental illness. Her clients stay in hospital for “even years just waiting for housing.” And that, says Hopkins, “reduces our capacity to serve individuals who are more appropriate (for treatment) and more acutely ill at that time.” While Hopkins would not say how many people are on the ALC waitlist, she said “it’s very, very long.”

Levitt, Hopkins and Kidd emphasize the urgent need for more affordable and supportive housing. But, “it’s not enough just to give a person a key,” notes Kidd. “Giving a person a key is just one part because if you want that person to move forward in meaningful areas of life and stay out of hospital. You need other supports in place.”

There are initiatives like Housing First, in which housing is granted before treatment along with supports like assertive community treatment or intensive case management. Though the program showed promise during pan-Canadian trials, Kidd says “it has really lost momentum in Canada, and it’s become quite watered down.”

Under the previous federal homelessness program, there was mandatory investment in Housing First but it was removed in 2019. Tim Aubry, professor of psychology and co-lead of the Moncton site in the trials, says “there was some growth (with Housing First), but it has kind of stalled since that time.”

Another initiative that has shown promise is CATCH (Coordinated Access To Care from Hospital), which helps people who experience homelessness, with or without mental health or addiction problems, connect to services in their community. CATCH Translational Case Managers work in three of Toronto’s hospitals and with referred clients in the community.

The lack of funding has been “the main barrier” to upscaling CATCH, says Stergiopolous, leaving us at risk of falling behind other jurisdictions.  “Critical Time Intervention Models, like CATCH, are expanding internationally,” she says.

The rapid transformation of hotels into shelters during the height of the pandemic, while a temporary solution, makes Jenkinson optimistic.

“We’re at a point right now where there’s a window of opportunity to make that shift,” she says. “It’s going to require some evidence and advocacy on everyone’s part to push for some of these changes that we know are really important and could improve people’s lives.”

Kidd mentions that changing perceptions means seeing through the stigma of homelessness and mental illness. “Ultimately, what’s going to change perceptions is (to) see people’s humanity.”

Contrary Thoughts for September 2022

By Dr. David Laing Dawson

• Banning books in 2022? Genius. What better way to get teens interested in books, actual physical, printed on paper books.

• Don’t prosecute Trump. Just let him get more and more ridiculous and outrageous. For every ten percent increase in depravity he loses about 1% of his people. If you prosecute you will make him a martyr for several armed militias.

• We humans are not capable of switching off fossil fuels in time to save the planet. It is not in our nature to give something up until we have to. Until we feel sufficient personal pain. Just ask any addict. Please take a harder look at all the technologies for capturing carbon and either using it or sequestering it.

• The principal demographic of drug addiction (non college educated males between 20 and 50) is the same demographic displaced by robots in the work force. Coincidence?

• Can’t we just acknowledge that there is a biology of gender as well as a social construct of gender expectations?

• Economic growth is accepted as a good thing, a goal. How about we change that ideal in the developed world for economic stability with better distribution of wealth?

• I just read an article about Fuller Torrey having Parkinsons and calling it a “weird disease”. But what struck me was the author mentioning that Torrey was a “proponent of anti-psychotic treatment for schizophrenia”. And in 2022 that read as anachronistic as labelling someone a “Proponent of anti-biotic treatment for bacterial infection.”

• Most recent scientific reports on the dangers of drinking alcohol have the maximum number of alcoholic drinks one should imbibe down to 2 per week. I shall have to shorten my week.

• I no longer have a medial meniscus in my left knee. Why does it still hurt?

• When Putin started the war in Ukraine the news was full of the horrors, the death, destruction and pain caused by this war, and any war. Six months later as this same war grinds on the little news there is, is dominated by pundits, retired generals, discussing war tactics and weapons, and ground being, possibly, won or lost. I can find more information on Pete Davidson’s short affair with Kim Kardashian than the war in Ukraine. We are doomed.

Meaningful Work – A Labour Day Rant

By Marvin Ross

In my anti-woke rant, I referred to having disabilities as a burden and one reader wrote that she did not find hers a burden. She also said that people with disabilities can work to some extent either in paid or volunteer positions. I was making a somewhat blanket statement when I used the word burden but having a disability does mean that you have limitations. The extent of that limitation will vary depending on what the disability is and how well we adjust to it.

I find my newly developed L5 stenosis a burden as I can no longer walk far but it does pale in comparison to other disabilities.

Dogs manage to show us how we should deal with infirmity as they quickly adapt to what has been thrown at them. My vet once told me that dogs have three legs and a spare. If you have seen a dog who lost a leg, you will notice that they manage quite well without (seemingly) depression. I have a neighbour dog with a wheelchair and she is as happy as can be. Her back end is paralyzed and she gets around with a couple of wheels on her back end.

Dogs can teach us a great deal about coping.

How much work someone with a mental disability can do varies but it is an important issue. Some people can work part-time but that becomes problematic when the condition is episodic and you never know when you are going to have a relapse. It takes a very understanding employer to cope with that. A few years ago, I met with an agency that trained and tried to place those with mental disabilities into paid jobs and they refused to deal with people with schizophrenia for that very reason.

On a psych ward with my son a number of years ago was a professor of medicine who was having a relapse of his bipolar disorder. It seems he went off his meds periodically and would end up in the hospital which was in the same building as the medical school. When he wasn’t locked in the isolation room, he would have the nurses go to his office to pick up his mail. A university employer can manage with an employee who is unreliable but most employers cannot.

I remember interviewing the late Dr Fred Frese a number of years ago and he made the comment that he kept going to school to collect degrees because no one would hire him or others with schizophrenia.

In Ontario, any work you do while on disability has to be reported and after a certain income, 50% is clawed back.

Volunteer work can be rewarding but my son’s experiences have been not that great as many positions have been very badly organized and often there is really nothing to do. In one position, he was ignored because the person who hired him did not tell anyone he was coming so they thought he was a client.

What is important and mostly totally overlooked is providing meaningful activity for people. That is something that is rarely done as the medical system medicates and stabilizes people and then says go away and fend for yourselves. How do they do that? They have no money and few resources so many turn to drugs to amuse themselves and gain some amount of pleasure from getting high. Now we have a bunch of people who are mentally ill and addicted.

Part of our advocacy must be to demand vocational rehabilitation or meaningful and rewarding activities for people as part of their treatment and ongoing support. A livable disability allowance or a a universal basic income (UBI) would be a step in the right direction. During the worst of covid, the Canadian Government provided a $2000 a month allowance to people who had lost their jobs. That was the minimum amount that they felt was needed to get by but we expect that the disabled can get by on around $1200 a month (once the added 5% is included for Ontario). That is barely existing.

It has long been recognized that the ability to work improves outcomes for the mentally ill, improves their self-esteem, alleviates psychiatric symptoms, and reduces dependency and relapse. In the days of asylums, patients worked on farms on the grounds of the hospital and in other meaningful jobs. “As asylums closed down, work experience played an important role in the preparation of patients for discharge. Patients who performed well on graded tasks within the hospital were gradually reintroduced to working in the community, often through special arrangements with local employers. As community care developed, these arrangements evolved into enterprises or workshops providing sheltered employment within a segregated work setting.”

Gradually, in most North American jurisdictions, these functions disappeared and degenerated into allowing discharged patients (and those who do not even get hospitalized care or any medical care), to fend for themselves with little community support or money.

Europe, and especially the Netherlands from what I can gather, does make an effort through individual placement support to help patients.

The cost of not paying attention to this aspect of care is likely far greater than the cost of helping people to have meaningful activity in their lives. What we have instead is the cost of arrests, incarceration, revolving doors in and out of emergency rooms and hospital stays and public nuisance – let alone the moral bankruptcy of our current policies.