Failed Suicide Prevention and What is Really Needed

By Dr. David Laing Dawson

Our approach to suicide prevention over the past 30 years has been tiresome, costly, and futile. Through this period the incidence of suicide did not decline. In fact, it increased among teens and youth.

Our Suicide prevention programs can so far be summed up as:

1. Public awareness (let’s talk)
2. Getting every doctor, counselor, teacher to ask every patient, client, student if they have been thinking about suicide.
3. Attempts to de-stigmatize suicide (“dying by suicide” rather than “committing suicide”).
4. Omnipresent media advice to not do it but call this number instead. And in case dialing 7 digits was daunting we will shorten it to 3.

This has not made the slightest dent in the incidence of suicide over those thirty years. It may even have caused an increase in the impulsive suicides of youth, and distracted mental health workers from the job of identifying and treating mental illness. And a negative answer to the question “Are you planning to kill yourself?” has become the dominant reason many mentally ill people are being prematurely discharged from hospital.

Imagine applying this approach to death from heart failure or cholera.

Instead we might take a close look at medical, epidemiological, sociological, historical, and cultural data to devise a far more effective approach. Let me give this a start:

1. Culturally the stronger the stigma against killing oneself the lower the incidence of suicide. So let the stigma remain. It is a nasty thing to do to your family. (This does not preclude compassion or empathy)
2. Some suicides have always been rational choices to end suffering from untreatable, terminal illnesses . Our acceptance of MAID indicates most of us agree with this statement.
3. We have extensive data on the demographics and causes of suicide. Let us use this to devise specific programs targeting specific populations, while acknowledging that some suicides will remain unpredictable, surprising, or the consequence of complex social problems and not easily amenable to intervention or prevention.

Let me look at a few of these high risk demographic groups.

1. People who have been recently discharged from emergency, short term and long term mental health and Psychiatric inpatient care.
A possible intervention: the development of transitional care teams, able to provide treatment and support within hours of discharge rather than the current long wait for an outpatient appointment. And involvement of family caregivers in every phase of hospitalization, treatment and discharge.
2. Schizophrenia, bipolar disorder, and depression. People with these illnesses are at a ten fold risk of suicide.
So instead of the emphasis on suicide prevention in the whole population let’s put our energy and resources into good, thorough, comprehensive, and long term treatment of these illnesses. (note that a significant study post-mortem of bipolar people who died by suicide found that all, all of them had stopped taking their medication)
3. A subset of 2 consists of males age 35 to 65. These are men who develop (usually) depression (often associated with losses and alcohol) who, unlike females who seek help or let their distress be known, suffer in silence or anger. I’m not sure how we can target this group other than trying to make male health care and mental health care for men more acceptable and accessible. Note that while many women’s health studies and programs have been initiated in recent years, the males of this world are, with a few exceptions, far less healthy than the females – we have higher rates of everything except where it is anatomically not possible. Identification of, and treatment for depression in this gender and age group could reduce the incidence of domestic violence, murder/suicide as well as suicide.
4. Though teens and youth are not the highest risk demographic, a suicide at this age is always tragic. And the  suicide incidence at this age has been creeping up. It has gone up rather than down despite (or because of?) an abundance of awareness programs. We already know that when anti-smoking campaigns were introduced in our High Schools the percentage of teens smoking increased.
Some of the suicides in this age group are the result of the serious mental illnesses listed in point 2 above. So a focus on detection and treatment of these illnesses in this age group is warranted.

The adolescent brain is susceptible to catastrophizing shame, particularly within a peer group. It also is short on perspective and an awareness of a future when present concerns will become unimportant. Hence teenagers are prone to terrible impulsive decisions and terrible reactions to temporary failings and passing slights.

The safety railings for this are not phone numbers for helplines, suicide or mental health awareness programs, or once a week appointments alone with counselors, but rather the means of impulsively inflicting great self harm not being immediately available (guns of any kind, potentially lethal pharmaceuticals, father’s Mercedes, bridges without safety nets), involved, available parents, time away from peers and social media, and for teachers, family doctors, psychiatrists, therapists, and counselors to always include parents.

The adolescent brain needs a parent to provide perspective, relief from the onslaught of peer opinions and social media distortion, a sense of a different time both past and future, some boundaries, as well as safety, love and support.

5. Indigenous and first nations

The rate of suicide in this population is generally higher than the general population but varies dramatically between reserves and communities. Much research, study and suicide prevention programs have been initiated. Reading the literature one finds conflict between an individual mental health emphasis vs. a more sociological and historical emphasis. Colonialism, loss of land, loss of culture and language, and inter-generational trauma are often blamed.

But overall, what is clear to me is that those reserves and populations that have become more economically independent, relying more on generated income than government grants, have lower suicide rates. The more successful and independent the reserve, the lower the suicide rate.

People need activities, purpose, and future possibilities. Young people need activity, purpose, and future possibilities, within an organized structured community.

It is all well and good to blame colonialism, residential schools, and loss of culture, and to advertise “trauma-informed” crisis lines of 7 digits or 3, but high rates of suicide will persist among the youth on reserves until those reserves develop, achieve, some economic (work, capitalism, enterprise) independence, and thus create a foreseeable future for their adolescent population.

Guest Blog Interview With The Author of The Suicide Magnet: Inside the Battle to Erect a Safety Barrier on Toronto’s Bloor St Viaduct

Lembi Buchanan with author Paul McLaughlin

The Suicide Magnet follows the heroic advocacy efforts by two extraordinary men, Michael McCamus and the late Al Birney to erect the Luminous Veil on the Bloor Viaduct that has saved countless lives since it was completed 20 years ago. As a journalist, Paul McLaughlin was compelled to tell the whole story, not only the challenges to build a safety barrier to prevent further loss of life but also to raise public awareness of major improvements in crisis services for people struggling with mental health issues, providing hope and saving lives.

LB What inspired you to write about the book?

PM All of the credit goes to Michael, who approached me a few years ago and suggested that I write the story to celebrate the 20th year anniversary of the installation of the Luminous Veil on the Bloor Viaduct. I had known Michael since he took a journalism course that I had taught at Ryerson University (now Toronto Metropolitan University). We became friends and stayed in touch even when Michael moved to Vietnam in August 2012, where he teaches English. While I didn’t think that a publisher would see it as a notable anniversary, I did think that the story itself was worthy of being told.

LB What wasthe tragic allure of the Bloor Viaduct that it became a suicide magnet second only to the Golden Gate Bridge in San Francisco, claiming more than 400 lives since it was built?

PM I don’t know for certain. I’m guessing that it’s because it’s such a wonderful structure, a great architectural accomplishment and engineering masterpiece, spanning 494 metres (1,620 feet) over the Don Valley. Perhaps also because it was such an important addition to the city when it was completed in 1918. It literally bridged the downtown and west end of Toronto with what was then the burgeoning east end.

LB Why was there so much controversy about erecting a safety barrier on the Bloor Viaduct?

PM Many people, politicians included, believed that a jumper, if denied the chance to end their life off the Viaduct, would just find another location. I understand that concern. But Michael and others in the mental health community convinced me that that was not going to happen with all of them. Another major concern was the aesthetics of the bridge, and that a safety barrier, if it was a chain-link fence, would destroy a beautiful and important monument. Others worried about the cost, an estimated $5.5 million for the award-winning design of the Luminous Veil by architect Dereck Revington.

LB Can you talk about the importance of your research including interviews with families who had lost a loved one to suicide?

PM I am very dogged in my research. The Toronto Reference Library had a wealth of online archival material, especially, for me, past issues of The Globe and Mail and the Toronto Star. I was on those archival sites for nearly a year gathering information for my book. Michael was also an amazing resource and he shared his impressive archives with me. We engaged in numerous Zoom calls and countless emails. I am also indebted to the many people who agreed to talk to me, often about painful memories.

LB Your book contains detailed descriptions of people’s experiences with mental illness, psychosis, suicide, murder-suicide, and child sexual abuse taken from news media reports and your own interviews with survivors and their families. Are there specific guidelines or ethical standards to follow when writing about suicide?

PM Suicide is the last taboo in our society. We have seen so many changes in social policy, from smoking, drinking, and domestic violence, because of the public outcry that discussing such topics generated. What we really need to do is to be able to talk about suicide openly. We need to stop pretending that suicide doesn’t happen. We also need to address the fact that the resources are not always there when people need them. The inability of hospitals to admit and keep suicidal persons under their control was a common complaint of many families with a loved one dealing with mental health issues. I write about Martin Kruze, who was taken to the Toronto East York Hospital by the timely intervention of a constable who prevented him from jumping. But he was released against the wishes of his family and jumped off the Bloor Viaduct six days later.

LB Why was it important to include a chapter about suicide attempts by people jumping off the platform in front of a subway train coming into a station?

PM I felt that it was a powerful adjunct to the bridge. I knew it was a big problem even though the TTC had a policy of not releasing any information for fear of copycat incidents. However, the Ontario Information and Privacy Commissioner ruled in 2009 that it had to release some of the contentious statistics. Also, there was almost no reporting of the trauma experienced by the drivers and first responders even though the TTC operators have PTSD four times the rate of police officers. Some of them never recover. I came across a video of a husband and wife, both of whom had experienced someone jumping in front of their train as they drove into the station. There has been talk of installing platform edge doors (PEDs) to prevent people from jumping in front of a train but the cost is prohibitive, at least $1.5 billion. So, I think that the chances of that happening soon are pretty slim.

LB I found the anecdotal sidebars throughout the book very interesting as well as informative. One of them is about the1999 study, “The Cost of Suicide Mortality in New Brunswick.” Were you surprised by the results?

PM I was blown away by the dollar amounts. The authors of the report offered the financial cost of a suicide, including not just the dollars but also the cents! I have no idea how they calculated that the mean total cost estimate was $849,877.80 per suicide for the 94 deaths reported in 1996.

LB Has the Luminous Veil been successful as far as reducing the overall number of suicide deaths in Toronto?

PM Yes. When you prevent someone from carrying out their plans by erecting a safety barrier, then you save lives. There are no longer suicides at the Bloor Viaduct and no meaningful increase in deaths at other Toronto bridges. And for every life that is saved, that is something to celebrate.

Paul McLaughlin, the author, is an award-winning freelance writer, broadcaster, and teacher of professional writing at York University in Toronto.

The Suicide Magnet: Inside the Battle to Erect a Safety Barrier on Toronto’s Bloor Street Viaduct 247 pages Published by Dundurn Press , November 7, 2023 ISBN 9781459751408, $24.99 paperback and $9.99 in e-book format.

Lembi Buchanan is the author of An Accidental Advocate on fighting the tax man for the mentally ill, Beresford Press, ISBN 978-1738947621 Distributed by Ingram and available from your favourite bookstore.

Coming next week, Dr. David Laing Dawson on Failed Suicide Prevention and What is Really Needed

Guest Blog Effectively Utilizing Family Caregivers of those with Severe Mental Illnesses

By Kathleen Mochnacki

Background:

The process of deinstitutionalization of severely mentally ill individuals over the past decades has led to families shouldering the psychosocial burden of care and informally adopting the role previously provided by professionals in healthcare services. Fifty to ninety percent of people with mental illness live with their family caregivers. (Chan B. M.Y, O’Brien A-M., 2011). Furthermore the average length of stay in psychiatric hospitals has also dropped about 60%, from approximately 250 days in 1994-1995 to a100 days in 2005-2006 and from 35 days to below 20 days in general hospitals (Canadian Institute of Health Information, 2008). The number of long-stay psychiatric beds in the GTA has dropped from 3857 to 761 beds between 1960 and 1994 (Davis, 2004). By 2001, the Ontario government had closed 500 of the provinces 2900 beds (National Union of Public General Employees, 2004) with no compensating increase in the funds for community-based mental health services (Maxwell,2009).

Fast forward to today, the pressure experienced by the family caregiver has increased with longer wait times for their family member to receive psychiatric care according to a report from the Fraser Institute entitled “Mental Health Care: How is Canada Doing?

https://www.fraserinstitute.org/studies/mental-health-care-how-is-canada-doing?language=en

This report noted that, “From 2003 to 2005, the wait time for seeing a psychiatrist on an urgent basis after GP referral averaged 2.0 weeks, and grew to 2.6 weeks between 2020 and 2022. For non-urgent patients, the wait time averaged 8.0 weeks from 2003 to 2005, and deteriorated to 9.2 weeks between 2020 and 2022. For treatment on a non-urgent basis after an initial consultation, Canadians could expect to wait an average of 10.4 weeks between 2003 and 2005, and an average of 15.5 weeks between 2020 and 2022. Overall, the total wait time from GP referral to treatment by a specialist deteriorated from 18.3 weeks between 2003 and 2005 to 24.7 weeks between 2020 and 2022.”

Despite the onerous responsibility and unique perspective coming from the direct experience of caring for a family member with a severe mental illness, health care legislation, program planning, and funding decisions are generally prepared without the input of families. Consequently, poor patient outcomes, ineffective practices, mismanagement of resources and inadequate legislation continue despite their obvious failures.

Collaboration with families:

This situation would improve if clinicians, service providers and healthcare legislators were willing to work with family caregivers. The advantages of working with families are documented in research (Ong H. S., Fernandez P.A., Lim H. K., 2021). According to these researchers, family engagement involving individuals with mental illness can lead to better health outcomes such as fewer relapses, longer duration between relapses, reduced hospital admissions, shorter inpatient stays, and improved compliance to medication and treatment plans. For individuals with schizophrenia, family engagement has also been shown to lessen residual psychotic and deficit symptoms, as well as helping with earlier detection of warning signs of relapse. Family engagement is associated with better self-reported quality of life and reduced general social impairment. There is evidence that these benefits endure over time if family engagement is actively maintained. Families can also help patients gain access to mental health services during times of crisis. The benefits of family engagement do not merely help the individual with the illness, but extend to the family and caregivers as well. Studies have shown that family engagement helps to ease family burden and family caregiver stress.

Communication with family caregivers:

Privacy laws impede communication between family caregiver and clinician. Individuals who are capable have the right to not have family members involved in their care if that is their wish. There are strategies, however, which would ensure that the family caregiver receives needed information without compromising the privacy rights of the family member with the illness. Where a relative chooses not to involve family caregivers, clinicians need to ensure that the reasons are explored, discussed and documented, and that they provide general information about the trajectory of the illness, common symptoms and management of symptoms so that the caregiver has the basic information required to support the family member without compromising confidentiality. (MacCourt P., Family Caregivers Advisory Committee, Mental Health Commission of Canada. 2013).

Clinicians have a duty to their patients’ relatives, although they regularly fail to take available practical and legal steps to ensure that families receive the information that they need. Professional training programs should place greater emphasis on cooperation with family caregivers and clinical services should develop protocols to ensure the involvement of family when appropriate (O’Reilly R.,Gray J.E.,Jung J.,2015). The stress of barriers on families of not being able to provide information or not being taken seriously by clinicians, is considerable. Most Mental Health Acts are silent on this issue so that providing information is not a problem. However, many family caregivers do not know this, so efforts need to be put forth by the clinician to get needed information from the family caregiver.

However, stress also can be caused when information about the patient’s symptoms or behaviour is offered in confidence but then provided to the patient. This can cause significant disruption to the family patient relationship. It is suggested that family caregivers ask the clinician what they will do if information is given to them in confidence. Families need to be told if clinicians keep it confidential, or believe they must tell the patient, and or that they must record it in the file. The file can be released to the patient on request, so it would be important to ask that anything the family caregiver gave them in confidence be redacted.

If the family caregiver believes that privacy legislation is suspected as being fraudulently used as a means of shielding a clinician/service provider from accountability, then the family caregiver may consider filing a complaint with the appropriate Provincial Privacy Commissioner.

The family caregiver’s role in system design

Health care administrators are notorious for tokenizing the input of the family caregiver of those with severe mental illnesses in program design. Often the voices of family caregivers of those with severe mental illnesses are overshadowed by those from the consumer survivor movement who diminish the severity of severe mental illnesses and broadcast their message that “people can and do recover” from the euphemistically termed “mental health challenges”, The fact that governments fund those services provided by the consumer survivor movement gives the impression that their message is legitimate.

Government, and Health Care Administrators have the moral duty to acquire more education about the severity of mental illness, the symptoms such as anosognosia or lack of insight before making funding decisions. Acquiring such knowledge would motivate them to include the input from family caregivers whose unique perspectives allows them to see gaps in services where needs are not being met.

The family caregiver’s role in developing realistic mental health legislation.

Families and their loved ones experience the devastating consequences of our current health legislation which does not accurately reflect the effect of symptoms upon the individual’s behaviour. For example, the symptom of anosognosia where the individual is not aware that he or she has an illness, prevents the individual from accepting life saving treatment.

What is Needed:

• Families must continue to sound alarm about the inadequacies of the system until the decision makers listen.
• Families are a key stakeholder in the design and maintenance of healthcare systems that provide for their loved ones and consequently must have a seat at all tables where decisions are made about services and legislation for individuals suffering from severe mental illnesses.
• Mental Health Clinicians, and community agencies must receive evidence-based training and guidance on how to prioritize and maintain therapeutic alliances with families in order to facilitate better treatment outcomes for their patients with severe mental illnesses.
• Family caregivers must be included in the Circle of Care. Clinicians and community service providers must make efforts to receive important clinical information regarding the individual with the illness from the family caregiver.
• Government, and Health Care Administrators have the moral duty to acquire more education about the severity of mental illnesses, their prevalence and the symptoms such as anosognosia or lack of awareness before making decisions regarding legislation. Their decisions regarding funding must be guided by the needs of the most severely mentally ill.
• Clinicians and community service providers have the moral duty to acquire more education about the severity of mental illness, the positive, negative and cognitive symptoms and the prevalence of severe mental illnesses. Symptoms such as anosognosia, and other negative symptoms affect communication and interfere with treatment and service compliance.
• More knowledge of severe mental illnesses could result in more realistic expectations of the individual’s behaviour which might elicit more empathy. With improved knowledge about severe mental illnesses, communication between clinicians, service providers and family caregivers would improve as would the quality of services.
• The consumer survivor movement does not represent those families whose loved one suffers from a severe mental illness. This movement proclaims that “people do and can recover”,  While it is important to always have hope, 25% of people with schizophrenia need a strong network to get by. Fifteen percent do not do well and 10% die from suicide.  Governments will continue to underfund programs for those with serious mental illnesses with this continual exposure to false messaging. For more information about schizophrenia, click on the following link:  https://www.merckmanuals.com/en-ca/professional/psychiatric-disorders/schizophrenia-and-related-disorders/schizophrenia

Additional Resources

Lefley, Harriet Family Caregiving in Mental Illness. Sage Publications; 1st edition (Jan. 19 1996)

MacCourt P., Family Caregivers Advisory Committee, Mental Health Commission of Canada. (2013). National Guidelines for a Comprehensive Service System to Support Family Caregivers of Adults with Mental Health Problems and Illnesses. Calgary, AB: Mental Health Commission of Canada. Retrieved from: http://www.mentalhealthcommission.ca © 2013 Mental Health Commission of Canada

Hatta Santoso Ong, Paula Ann Fernandez, Hui Khim Lim. Family engagement as part of managing patients with mental illness in primary care. Singapore Med J. 2021 May; 62(5): 213–219. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8801858/

O’Reilly RL, Gray JE, Jung J. Sharing information with families that carry burden of care for relatives with severe mental illness. Journal of Ethics in Mental Health, 2015

Stigma and the Mental Health Commission of Canada Keep Turning Up Like a Bad Penny

By Marvin Ross

Warning to readers – some sarcasm and mild profanity.

In 2018, a report commissioned by Health Canada recommended that the Mental Health Commission of Canada (MHCC) be disbanded. The authors of that report, Dr. Pierre-Gerlier Forest and Dr. Danielle Martin, looked at the effectiveness of all the so called pan-Canadian health organizations. There was a long list of criteria they had for assessing these groups outlined in Chapter Seven of their report. After lauding the commission for its work on destigmatizing mental health, they concluded that:

“What Canada needs today is the complete and seamless integration of mental health into the continuum of public health care. What Canadians want is public coverage of proven mental health services and treatments, beyond physicians and hospitals. To be successful, those services must be integrated with primary care and supports for physical health, rather than isolated from them. We came to the conclusion that MHCC, in its present form and with its current orientation, is not the best instrument to achieve the objective of integrating mental health into Medicare.”

I gave a silent cheer when I read that because I had been critical of their work in many of my Huffington Post columns. They did some good work such as their report on family involvement which was excellent but ignored. Other than that most of what they did was irrelevant.

I cheered too soon because the commission is still here and they’ve just put out a 100 page report on how to destigmatize mental health care. Called Dismantling Structural Stigma in Health Care, they partially define stigma as:

• lack of treatment or their symptoms are undertreated or ignored
• excessive wait times compared to physical health issues
• insufficient staff/resource allocation to MHSU-related care
• physical space for MHSU patients that is of lower quality or standard than the spaces offered in other care areas

The solution to those problems has nothing to do with stigma but to the lack of resources Canada assigns to these serious illnesses. The Fraser Institute recently reported on the inadequate resources we have for serious mental illness – too few medical staff, insufficient psychiatric beds, too few community resources and little supportive housing. Compared to other developed, wealthy and progressive countries, Canada is at the bottom. Unless changes are made, we will be down with third world countries.

This is not stigma! It is discrimination!

In fact, stigma is not a problem as I pointed out in the many blog posts dealing with Marlene Bryenton in PEI and her successful attempt to get her son, Andrew, returned to PEI from life on the streets of Toronto. If there was stigma, she would not have received help from total strangers searching for her son and helping him with food, drinks, and clothes.

What can be stigmatizing are people with untreated psychosis wandering the street listening to their delusions and/or committing violent acts while under the spell of those delusions. The best solution to stigma was put forth by Dr. Julio Arboleda-Florez. In an editorial in the November 2003 issue of the Canadian Journal of Psychiatry, he said: “Helping persons with mental illness to limit the possibilities that they become violent, via proper and timely treatment and management of their symptoms and preventing social situations that might lead to contextual violence, could be the single most important way to combat the stigma that affects all those with mental illness.”

The late Dr Arboleda-Flores was an emeritus professor of psychiatry at Queen’s University in Kingston, Ontario and headed up the anti-stigma Open the Doors program sponsored by the World Psychiatric Association.

Canadian consultant Neasa Martin who consulted with the Mental Health Commission of Canada once wrote that “mental health problems are best framed as part of our shared humanity. These are an understandable response to a unique set of circumstances and not purely as genetically based illnesses or a diseased state of the brain.”

The way to decrease stigma, her paper says, is through direct personal contact with the ill. I first learned this when I presented a paper on stigma by medical professionals towards the mentally ill at a conference where Martin and Chris Summerville, the executive director of the Schizophrenia Society of Canada and a member of the Mental Health Commission of Canada, presented in the same workshop with me. They both chastised me for increasing stigma. I should have been promoting friendship with the ill and not demeaning them by suggesting they have a disease, they told me.

By way of a catty anecdote, they both objected to my presenting at the workshop as they thought they should be the only ones. One of the organizers had to be called to explain to them that a workshop involved a few presenters and I was one of them. They were not happy.

One of the activities employed by the MHCC was to use the Empowerment Council (a group of “consumer survivors” at the Centre for Addiction and Mental Health) to teach first year psychiatry residents at the University of Toronto. This group achieved notoriety when it launched a losing court challenge of community treatment orders (CTOs). They claimed CTOs were unconstitutional but their key witness was a perfect example of how effective they really are. Their witness had a history of numerous hospitalizations interspersed with an attempt to stab her mother and she assaulted a doc in the ER. After being put on a CTO, she had no more hospitalizations and was doing volunteer work. When the judge asked her what’s wrong with CTO’s she said she just did not like them.

You can’t make stuff like this up.

This is what this group set out to do for the psychiatry residents:

“the Department of Psychiatry at the University of Toronto partnered with the Empowerment Council to co-create InSight: a committee of representatives from community organizations with a history of working for and with mental health service users. The committee developed a series of guiding value statements, such as “People with psycho-social disabilities have the right to determine their own priorities” and “Empowering the community is facilitated from an anti-oppression, anti-racist/anti-colonialist, disability-positive framework.””

And

“InSight created the Centering Madness course to teach first-year psychiatry residents about the history of mental health care, the lived experiences of people with mental health problems or illnesses, and the body of knowledge created by service users and mental health advocates over the past 40 years.”

All Woke shite.

First year psychiatry residents have spent six years studying, writing exams and seeing patients in order to have the privilege of being called doctor. Now, they are embarking on an additional five years of study to be called specialists in psychiatry. I don’t dispute the need for users of these services from expressing their opinions but the intent of the above goals is, in my opinion, flaky and it is coloured by their previous attempts to derail the useful tool of CTOs to help people get and stay well.

At the time I’m writing this, the council website is undergoing changes and is not accessible but this is what is said about them. They engage in “systemic advocacy to ensure representation of client perspective, includes education on choices, self advocacy, critical thinking and political awareness; outreach and community development; professional development and research”

I had heard that many of the residents and faculty at the university were not happy with what they were being told and the MHCC admits that in their report. They said:

“The Centering Madness course for first-year psychiatry residents aims to identify how power and privilege play a role in psychiatric practice and explore oppor­tunities for engagement and solidarity work with mental health service users. Designed and delivered by service users, it challenges entrenched psychiatric beliefs in a way that is both emotionally uncomfortable and intellectually challen­ging for many residents. This initially prompted resistance from students and faculty alike, some of whom felt that it was a waste of time to have non-psychiatrists teaching residents.”

I hope I’ve made my point so let me go on to addictions as the MHCC is involved with stigma busting of that too. I am less familiar with those issues, I’m afraid, but I do know that there is a huge shortage of good addiction and treatment facilities within our universal health care system. People have to pay thousands to get help when it should be available to all for free.

There is nothing in this paper about substance abuse or substance use disorder based on a search of the document. There were two references to addiction and those pertained to submissions from Addiction Recovery and Community Health (ARCH) in Alberta and Biigajiiskaan: Indigenous Pathways to Mental Wellness – a partnership between an Indigenous agency and St Joseph’s Health in London, ON.

The Alberta agency “tracks structural stigma by providing a patient-centred, trauma-informed, recovery-oriented model of care for people with substance use problems in a hospital setting. It offers services such as peer support, ID procurement, an in-hospital supervised consumption service, withdrawal and pain management, addiction counselling, an outpatient transitional clinic, and treatment and referral services.”

The program in London provides “culturally safe, specialized care for Indigenous people with serious mental illness, addictions, and concurrent disorders by combining traditional healing medicine, care guided by Indigenous Elders, and ceremony with hospital-based health-care practices and psychiatric treatment in a hospital setting.”

Outside of those statements, I can find nothing further on addictions and no editorial comment is required from me.

But, I would like to mention that Canada has a Canadian Centre for Substance Abuse (CCSA) which the 2018 report also recommended be disbanded. The report stated “The required functions and roles related to substance use and addiction can be assumed by a national network focused on discovery, innovation, and implementation, built on the foundation of the Canadian Research Initiative in Substance Misuse (CRISM)”

No surprise that they are still there with a huge staff of “knowledge brokers” whatever that means. As an example of their effectiveness, deaths from opioid overdoses continue to reach new heights.

And, my reader who tipped me of about this report, requested that I ask all of you who are willing to provide feedback to the Mental Health Commission which you can do here as well as to download the entire report. https://mentalhealthcommission.ca/resource/dismantling-structural-stigma-in-health-care-an-implementation-guide/

Sadly, these efforts remind me of Monty Python and the Ministry of Silly Walks. Such a complete waste of resources that does no good for anyone.

Critiquing the Naysayers and Skeptics of Psychiatry

By Dr David Laing Dawson

For every advance in the medical specialty of psychiatry, and every attempt to define, categorize, and improve the treatment of “mental illnesses”, there have been naysayers, pundits ready to proclaim that these aberrations of mental processes and behaviour are not illnesses or diseases at all.

Thomas Szasz would say “mental illness” is a myth, that such behaviours are really understandable reactions to an over-controlling society, even that we’d make more progress thinking schizophrenics are liars. Alan Watts, in a lecture I attended, likened mental illness to being something akin to a bird on a different flight path from the rest of the (overly conforming) flock. R.D. Laing worked overtime finding meaning in psychosis, and linking such behaviours to crazy-making parental behaviour. Then we had the frozen (unloving) mother syndrome, and the double-bind theory, again each of these ideas trying to make the symptoms of psychosis (and autism) look like rational responses to an irrational world, or, at least, to irrational parents.

And then we have L. Ron Hubbard, Scientology, Robert Wittaker, Eckhart Tolle, and then Gabor Mate with his focus on childhood trauma (with a bit of Taoism thrown in) causing everything and anything.

With his scarf draped stylishly around his neck, his voice trance-inducing, Gabor informs us that infants have no capacity for self-regulation (who would have thought?), and then he goes on about the child’s “authentic self”, and not being able to express this authentic self can be, well, traumatic. Eckhart, with his soothingly hesitant voice and kind eyes, tells a woman who suffers from manic depressive illness, rapid cycling bipolar disorder, and who has finally, after six years of chaos and delusion, started taking medication that has brought her peace – he tells her that with meditation she might be able to stop her medication, and perhaps transcendental meditation would be right for her.

Had all these men kept their contrarian views and ideas within academia and professional discourse, they might have simply provided a much needed balance to medical and pharmaceutical overreach.

But the one common theme for all of these gurus has been, of course, fame, fortune, and salesmanship. And so their ideas reached the general public, families, sufferers, and perhaps worse, politicians and policy makers, and they have done great harm.

And each of their ideas is very human, for it is very human to blame. Blaming takes away mystery, confusion, uncertainty. It also gives us false hope, hope that these illnesses can be completely vanquished by:

• a change in our behaviour,
• by better parenting,
• more love,
• creating a much less toxic and
• more tolerant society.
• meditation and the right attitude

And make no mistake: All of these ideas are based in blame: blaming, in turn,

• Western Medicine itself,
• mothers,
• abrogation of personal responsibility,
• loss of “family values”,
• parenting practices,
• capitalism,
• toxic cultures,
• our schools,
• conformity,
• big pharma,
• Western Civilization,
• materialism,
• urban living….

And each of their ideas is the equivalent of a placebo: If swallowed whole, accompanied by belief and hope, they can make you feel better for a little while.

For politicians and policy makers they also provide a means of saving money. For certainly, if mental illness is a myth, why spend any money on it? And if childhood “trauma” is the root cause of everything, then lets just set up a three digit help line for abused kids. And instead of costly professional care lets just provide emotional support.

Experimenting with Alternatives

When I entered Riverview Hospital as a first year Resident in 1968 I was no fan of mental hospitals, insane asylums. It was the sixties after all, and we all suspected that our institutions needed an overhaul, that they were part of the problem.

The University Department of Psychiatry took over a ward in Crease Clinic and we unlocked the door and started a “Therapeutic Community”. This really meant that each day would start with all patients and all staff sitting in a very large circle in the day room, discussing whatever the patients wanted to discuss, and sometimes making decisions collectively. It was a humane if often chaotic approach to health care. It gave our patients a greater sense of autonomy and control. For myself it was a wonderful laboratory to observe human behaviour: A paranoid man would stand and shout and dominate and accuse. A manic woman would get up from her chair, dance over to the man and sweep him away in circles and sit him back in his chair. A patient would ask for a weekend leave. Another would say, “Don’t let Albert home. He was talking about killing himself just yesterday.” And another, annoyed by the word salad spewing from someone’s mouth, would say, “Joan, for God’s sake, go back on your meds. You’re talking crazy.”

A tolerance for chaos was required of staff, for uncertainty, and sometimes for threat and danger, but it did seem a humane step forward, though certainly not a treatment for what became increasingly obvious, are illnesses, aberrations, diseases of the mind/brain. Medication was the treatment. Talking in a group, being allowed more agency, counseling, walking on the grounds, exercise, safety, quiet time, music, working on crafts – these were means of fostering well-being and recovery, of taking back one’s life.

During those years we attended that lecture by Watts, talked through Irving Goffman’s ideas about spoiled identity, read R. D. Laing, Hannah Green, Foucault and Thomas Szasz, along with Freud, Yung, Frankl, Erikson, Piaget, discussed in group the double-bind theory, attended a workshop by Fritz Perls, tried out a little gestalt therapy, drama therapy, marathon encounter group therapy, even a little hypnosis.

And in those latter experiments I certainly learned how fragile our perceptions are, and how one person, a leader, a guru, can accrue so much power over his students’/followers’/patients’ thoughts and lives. And how tantalizing that power can be.

On Being a Doctor

I gave up the intense and dramatic group therapies when I realized I was no longer sure if my motive was helping my patients or gratifying my own ego. I went back to being just a doctor.

Yes, there’s more to human beings than the illnesses from which we suffer. And achieving a state of wellness, of stability, of bonhomie and equanimity, requires more than treating illness with pharmacology.

But listen to those gurus carefully. Ignore the soothing tones, the mystical ambience, and parse their phrases carefully. You will find mostly empty nonsense or grandmothers’ platitudes. Gabor Mates “authentic self” is a bit of both. A nice enough platitude, but think about it. Do you really want to attend a party, Thanksgiving dinner, a board meeting, a crowded shopping mall where everybody is “expressing their authentic selves”? Please leave most of that authentic self with the cartoons and comedians.

“Doctor, I would like a second opinion.”

“Okay. You have a sprained ankle and you are a bit of an asshole.”

That bird on a different flight path from the flock? Really? You know it’s going to miss the breeding grounds and perish in the coming storm.

It was clear to all of us right from the beginning that Gregory Bateson’s “double-bind” was a ubiquitous form of family communication and not the cause of severe illness. It too should be left to the cartoons:

Standing at the foot of the stairs, and knowing there was no safe answer to his wife’s question, “Do these slacks make me look fat?”, George froze and entered a catatonic state.

It was 1969 when a mother and father brought their teenage son into my office. The boy was withdrawn, anxious, and when he did talk he demonstrated some thought disorder, perhaps delusional thinking. In that first visit to my office the mother sat in a chair to my right, the boy in a chair straight ahead, and the father remained standing by the door, always with an angry demeanour. In fact, he refused to sit. And I quickly learned that neither the mother nor the father were willing to talk directly to one another. Instead, in my office as well as at home, each would turn to their son and say, “Tell your father…” or “Tell your mother….”. And the boy, of course, became increasingly agitated, sometimes going mute and staring at the floor.

I admitted the boy to hospital and then, well, experimented. For surely, if it were possible for parents to drive a child into a schizophrenic illness, simply through their communication patterns, this would be the one. So I would see the boy alone for a half hour or so, then bring in the parents, then alone again, and then with the parents. Without the parents in the room the boy was no longer as agitated. He would talk to me, make eye contact, engage. But he still exhibited the symptoms of schizophrenia. When his parents were in the room his agitation increased, as did his moments of refusal and muteness.

I treated the boy’s schizophrenia with one of the anti-psychotic medications we had at the time, and I counseled the parents. I did my best, but I’m afraid I do not have a long term follow up.

As later observational research did show, young people developing a psychotic illness do not do well within a household of high expressed emotion and conflict. Their recovery is poor and they relapse more often. But it doesn’t cause schizophrenia.

Harry Stack Sullivan said, “Schizophrenics are not schizophrenic with me.” And yes, a patient, empathic, sensitive, calm, thoughtful doctor or mental health worker, can develop a level of rapport and trust and have a calm conversation with someone who is paranoid and delusional. And at the end of that conversation this person may be more willing to take the medication the doctor is offering. Or not. And that half or full hour in which the doctor found a way of avoiding conflict or confrontation, found a way of helping his or her patient communicate and share his anxieties and fears without lapsing into an angry diatribe of evidence supporting his delusion – that hour was sweet and satisfying, but it did not change the course of the illness.

Many of the observations by these gurus are accurate descriptions or interpretations of human behaviour and the human condition, though not the cause of the illness.

Freud posited that repressed homosexuality was the cause of paranoia. And it was true in the sixties and seventies (and probably Freud’s time as well) that when teen age boys developed schizophrenia with ideas of reference and hallucinations, they often heard their classmates say (and think), “He’s queer, what a fagot”. But then, in my experience, that stopped happening sometime in the 90’s. The ideas of reference (they are looking at me and thinking or talking this about me) and hallucinations (accusative voices) were more along the line of, “You’re a loser.” And it became pretty clear to me that the experience of someone developing schizophrenia was really of imagining and hallucinating that others are thinking and saying the worst possible things about me. Pre-1985 or so, the worst (for a teen boy) would be “queer” or “fagot”. Times changed. Being gay was now not so bad. Now the worst you could be was “pervert” and “loser”.

And yes, medicine tends to overreach, and science is always finessing its conclusions when new data comes to light. And money does drive the pharmaceutical industry. But then, we are all human, and it turns out that money, i.e. capitalism, is the only system that spurs innovation and invention. So we do need capitalism, with much oversight and scientific study.

But it needn’t be dichotomous or conspiratorial. It is very reasonable and enlightened to look at any human misery and ask the question, “If we apply the modern concept of disease to this problem, will it help? Will scientifically applying the disease concept and methodologies to this particular human misery help us understand it, help us find and scientifically prove the efficacy of remedies, maybe even help us understand the causes and be able to formulate a means of prevention?”

There are many human miseries greatly alleviated by applying the disease model, even eradicating some of them. There is also no question that applying the disease model to severe mental illnesses, to psychotic illnesses, and the resulting pharmaceutical treatments for these, has helped, has alleviated suffering, has allowed millions of people to live full lives.