Category Archives: Trauma and schizophrenia

One Last Comment (for now) on Trauma and Schizophrenia

By Dr David Laing Dawson

I do not understand the term “co-causal”. In the study of disease we look for necessary etiological factors, contributing factors, and protective factors. For TB it is necessary to be exposed to a certain micro-organism. Contributing factors include crowding, poor ventilation, poor immune system, poor nutrition. Protective factors include excellent immune system, robust health, hygiene, fresh air.

“Trauma” is a loaded word. It generally infers a major assault on one’s body, brain, mind. When the word is used it is understood in this way. A diet excessively rich in carbohydrates causing a particular messenger protein to be manufactured and released by mitochondrial DNA and then influencing the genes that are scheduled to turn on or turn off other genes during future developmental phases is not, in usual parlance, a “Trauma.”

And finally, with respect to statistics and scientific journals: There was a time I think when only the scientists and medical professionals read these articles, and generally they knew how limited, usually, each was in establishing an ultimate truth. Each depended on a specific population studied, on particular definitions, particular measures of outcome, experimental bias, reader bias, uncontrolled variables. We also always knew that null studies do not get published.

Now the selective summaries of these studies show up in newpapers and google if they “find something”.

It has been of interest to me as a male Canadian of European descent to learn definitively if it is healthier to partake of no alcohol, red wine only, one, two, three, or four drinks per day. So I confess that I read these studies more often than studies on “schizophrenia and trauma.”

Given the large numbers of people who drink alcohol and the large numbers of people who drink none, it really should be easy to answer my question. Much easier than tracking down “co-causal” intrauterine factors in the development of schizophrenia.

Yet despite the money and interest in the alcohol question, large population studies, and definitive statements in the press, we still know (scientifically) little more than my grandmother who preached “moderation.”

More on Schizophrenia and Trauma

By Dr David Laing Dawson

The studies cited by Bruce Wilson do not demonstrate a causal relationship between childhood trauma (neglect, abuse, deprivation, sexual abuse) and schizophrenia. They do, quite logically, demonstrate a relationship between childhood trauma and severity of the course of schizophrenia. That is, the specific injuries to cognitive developmental processes, focus, attention, arousal systems, and affective pathways in the brain caused by serious childhood neglect and/or abuse, (if this person later develops schizophrenia or bipolar disorder), cause a more refractory and debilitating form of the illness. The trauma experienced may also shape the nature and form of the symptoms.

Abuse and neglect in childhood make schizophrenia worse.

And then we have “Lies, damn lies, and statistics”:

Some studies show, for instance, when adults are hospitalized with a diagnosis of schizophrenia, and asked or surveyed about childhood trauma (specifically physical abuse,  emotional abuse, emotional neglect, physical neglect, sexual abuse) they answer in the affirmative between 7 percent for sexual abuse and 13 percent for emotional neglect and a total of 49 percent overall. Now these figures turn out to very similar to the same percentages we find when we survey the entire population. In fact when the definition of trauma is expanded to include major losses, bullying, witnessing a death, the percent of the general population answering in the affirmative is more than 80% even in countries like the US.

In the general population 15 to 25% of women and 14% of men report being sexually abused as children or teens.

So if I simply take these figures from legitimate studies I could make a case that a smaller percentage of people suffering from schizophrenia report being abused than the general public. (e.g., for sexual abuse, 7% of schizophrenics vs. 15%+ of general population) . At the very least I can certainly say that these studies do not show a causative link between abuse and schizophrenia. In fact I can use these figures to support the opposite conclusion.

But for years it has been known that identical twins raised in the same household are only concordant for schizophrenia 60 to 80% of the time. This does imply that an environmental influence could make a difference for 40 to 20%. (My own small sample of identical twins (2) with schizophrenia over 50 years places concordance at 100%)

But if the twins are raised in the same household they must have had similar environments and experiences through childhood and adolescence. It is rather inconceivable that one identical twin was abused and/or neglected and the other not.

So this presented a puzzle.

But now we know that a.) 99.7 percent of the DNA of every human is identical, b.) that human DNA is 96% percent the same as that of chimpanzees and c.) identical twins do not have exactly the same DNA and d.) expression of any gene can be influenced by many factors (including other genes), many of which are probably intrauterine. For example, identical twins can develop similar but not identical finger prints.

Epigenetics and environmental factors certainly play a role in the onset, development and the course of any genetic illness. There also always have been, and continue to be, problems, differences, and great variability in the diagnosis of schizophrenia, making most surveys involving this diagnosis suspect. And the onset of trouble (early symptoms) can be well hidden in a protective, adaptive environment, or explode early in a troubled home.

And it is my experience that the immediate “environmental factors” that precipitate a full blown schizophrenic psychosis in a person genetically vulnerable to schizophrenia are not “traumas”, but (besides drug use) rather common, normal, usual developmental social stresses: Attending high school, leaving home to live on campus, share a student house, first job, first date, first relationship, first child, even the push and expectation to advance developmentally and socially…

And by the time identical twins reach the age of schizophrenia onset there may easily have been a sufficient number of different epigenetic and environmental factors to offer, 20% of the time, protection for one and not the other. (And a more productive line of research might be to figure out what those protective factors are)

As I have been reminded recently, serious trauma in the first few years of life (neglect, deprivation, abuse, sexual abuse) causes enormous damage that is readily apparent in the years of childhood and adolescence long after the child has been rescued. Let us not trivialize this level of trauma by including disappointment, unhappiness, failure at sports, having to change schools, growing up poor, name calling, loss of a friend, or even of a parent, under the rubric of TRAUMA.

Time to do Away with Trauma as a Cause of Schizophrenia.

By Marvin Ross


I just read an excellent article in Psychology Today called Schizophrenia and Trauma: My parents did a great job, I still developed schizophrenia I highly recommend the article and it has spurred me on to refute once again the nonsense of trauma causing serious mental illness. Trauma is actually something that the parents and the families of those who are ill suffer with.

David has touched on this a couple of times and stated that

“People with psychotic illness do not need someone probing the wells of their psychic discomfort; they do not need (no matter how well-intended) a therapist scouring their childhood memories in search of an unhealed wound. They need support, safety, security, grounding,  and satisfying routine before they can get better. And good medical treatment.”

That actually happened to the person who wrote the article I recommended.

I also recommend a second blog that he did when he was criticized for his view that trauma does not cause serious mental illness.

Another recent good article on the topic just appeared in a UK paper by Alastair Kemp and Ruth Hunt called the Traumatic Power Struggle Within Mental Health. They argue that ideological differences are being used to cut services. If the problem is simply trauma and not biological then the sick need to take responsibility for their problems and their failure to get well. If they don’t, why give them government supports?.

Another good paper is by Dr Boris Vatel, a psychiatrist at the Indiana State Hospital in Evansville, IN called Unmasking trauma-informed care which appeared in Current Psychiatry Archives, October 9, 2015. He points out that:

trauma-informed care has no language for dividing pathology from normality and because everyone’s experience and pain are seen as equally “valid,” trauma-informed care actually trivializes severe trauma by placing it on par with experiences that objectively would be classified as merely unpleasant.

Now, if trauma causes serious mental illness, then I should have schizophrenia.

I don’t!

I grew up in Toronto as the child of poor, working class, Jewish immigrants at a time when Toronto was not the tolerant wonderful multi-cultural city it is today. Then, my father died when I was 10 and I had a number of serious medical problems. I remember my uncle taking me to a synagogue, introducing me to the sextant and telling me that he would look after me while I was there. I actually thought I was going to be living in the synagogue with this garlic smelling guy with the numbers tattooed on his arm. That was traumatic.

It turned out that I did not have to live there but no one told me that I would have to go to morning and evening prayers for a year to say the mourners prayer instead of playing with my friends (traumatic). The Rabbi partly saved me by telling me I did not have to come for morning prayers.

Allow me to look at all the people with schizophrenia and/or their families whose books I’ve published.

I am not so naive that I do not believe that prosperous, educated people do not abuse their kids or that their kids cannot suffer trauma but there was no trauma in these cases.

Susan Inman in Vancouver wrote After Her Brain Broke about her experiences with her daughter who developed schizophrenia. Susan was a teacher and her husband a university professor and there are no signs in her book that her daughter suffered any trauma. What was traumatizing for her daughter and for the family was the counselor they hired to help her daughter. The counselor was one of those who believed in the trauma theory, grilled the young lady on potential traumas she may have experienced and even set back the proper treatment by her actions.

Sandra Yuen MacKay (My Schizophrenic Life) developed schizophrenia at a fairly young age despite being in what seems to have been a loving Chinese-Canadian family. Her father was an architect and Sandra has gone on to become a very successful artist. She is the winner of the Courage to Come Back Award in Vancouver, one of the faces of mental illness in Canada, and exhibits her work in the Vancouver area. No signs of trauma.

Erin Hawkes-Emiru (When Quietness Came) came from the Maritimes and became sick while a student at Dalhousie University in Halifax. Her mother is a librarian and her father a university professor with the only signs of trauma being the trauma to Erin of having difficulty finding a medication that worked for her in her adventures with horrible psychosis from Dalhousie University to the University of British Columbia. I lost count of the number of times the police had to wrestle her into ambulances for another trip to the isolation ward.

Erin’s doctors finally found an anti-psychotic that worked; she completed her masters in neuroscience, is a peer counselor in Vancouver and speaks to conferences of families, doctors, nurses and others. She too is a Courage to Come Back winner.

The late Dr Carolyn Dobbins (What A Life Can Be) spent a childhood engaged in sports and was about to qualify for the US Ski Team at Lake Placid when she became ill. Carolyn did manage to get her PhD in psychology from Vanderbilt despite her illness and was a successful counselor for many years. She grew up initially in Colorado but then her family moved to Knoxville where her father was a practicing pediatrician. A childhood friend, Dave Kopel, wrote an extensive review of her book in his blog at the Washington Post

Carolyn mentions no trauma whatsoever in her childhood other than the trauma of her disease that severely impacted her life. Unfortunately, she passed away early but she lives on in her book which is still very popular.

There was also no trauma in the life of Sakeenah Francis (Loves All That Makes Sense) other than being African American in a racist society. Her parents were educated citizens in Cleveland and Sakeenah attended an African American University where she met and married her husband. It was after she married that she developed schizophrenia. She and her mother had differences when she was growing up but so do many people who did not develop an illness. Her family was incredibly supportive as so many families are. She was able to return the favour by helping look after her father when he developed Alzheimer’s.

The one person with schizophrenia whose story I’ve published is Paul Flannery (Shot in the Head) whose story and the history of the family was written by his sister. Paul developed schizophrenia in his mid-teens and never properly recovered for a host of reasons. This very large Irish American family was highly supportive and there is no indication of any severe trauma that might have triggered the disease as the trauma proponents claim. Paul’s twin did not develop the condition even though there is a high likelihood that twins will.

My own personal experiences also disprove the trauma theory but I have to comment on one of the stupid suggestions we got from a social worker and psychologist before the proper diagnoses. Seems my son was suffering from being in a family where there was too much love. We were stunned by that comment and still are today. And my son has told me how happy his childhood was. The day we were told the too much love story, my son admitted in the session that he had been using a lot of marijuana. As David pointed out in his blog “Involve Parents”, this is not unusual. Our son told us that we were pretty stupid not to have noticed and pointed out how he always cleared out the fridge when he got home from being out with friends.

Earlier this week, I met with the Alzheimer’s patient I am power of attorney for and with his new doctor. No one ever mentions trauma as a cause of Alzheimer’s which, like schizophrenia, is a disorder of the brain but with no therapeutic options unlike schizophrenia. As with schizophrenia, signs of paranoia are creeping into his symptoms.

The vast majority of parents stand by and support their kids and endure tremendous stress and often cost while doing so. As an example, when I was involved with the local chapter of the Schizophrenia Society of Ontario, we had an annual golf day put on for us by the National Hockey League Old Timers. They were an incredible bunch of generous characters. One of our members, a fairly elderly woman, would stand at the 1st tee all day to lecture each foursome on schizophrenia and the importance of supporting us. It was a very hot day and she did not move to so much as get a drink or to pee for fear of missing a foursome.

Isn’t it about time we put this stupid theory into the garbage where it belongs.

Coming in January: Mind You The Realities of Mental Illness A Compilation of Articles from the Blog Mind You

We have decided to publish a book on the best of our mental illness blogs over the past 4 and a bit years. The book will be available in print and e-book formats everywhere in early 2019.

Below is the introduction:

We began this blog in October 2014 in order to provide commentary on the state of mental illness and its treatment for the lay public. What we provide is a viewpoint from that of a psychiatrist with many years of experience (David Laing Dawson) and a family member of someone who does have schizophrenia (Marvin Ross). Aside from his personal experience (or lived experience as it is commonly referred to), he is also a medical writer, advocate and publisher of books that take a unique look at mental illness.

To date, we have had close to 75,000 views and have been read in 151 different countries since 2014.

We also write on other topics but these are the ones on mental illness covering topics like recovery, treatments, suicide, addictions, and alternative treatments (or pseudo science).

When we began, we had this to say of our purpose:

 Welcome to the launch of Mind You. While we intend to post on mental illness,mental health and life, we decided on the name Mind You to reflect that not everything is black and white. There are ideas and opinions but then mind you, on the other hand, one can say…….

And that is what we would like to reflect. Ideas about mental illness,health and life that can be debated and discussed so that we can come to a higher understanding of the issues. And, we have separated out mental illness from mental health because, despite their often interchangeability, they are distinct.

The National Alliance on Mental Illness defines mental illness as a medical condition that disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a  diminished capacity for coping with the ordinary demands of life. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder.

On the other hand, the World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. That is quite different from mental illness.

Unfortunately there is a tendency to confuse these and organizations like the Mental Health Commission of Canada have a tendency to talk about mental health issues and problems which are not the same as mental illnesses.

 Both Dr David Laing Dawson and I (Marvin Ross) will be posting on a regular basis on a variety of topics.

The posts we have selected for this volume are the most widely read over the past 4 years.

Mind You, ISBN 978-1-927637-31-9, 193 pages distributed by Ingram


More on Trauma in Youth and Schizophrenia

By David Laing Dawson

This blog is in response to a comment made on an earlier blog called As For Trauma Causing Schizophrenia: No! No! No! 

The comment was how do you account for this study? And how can you claim that trauma cannot be causative of schizophrenia?

This is the answer:

There is no doubt severe trauma in childhood can have long lasting effects. But can trauma be a specifically causative element in the development of the full illness schizophrenia? And is it either a necessary causative element or a contributing factor?

Data mining and surveys come up with many associations, some weak, some strong. Fair enough. But we have to examine the definitions of each and every term and understand that association is not necessarily causative. And in this situation we must be very careful what we publicize because any association between trauma and schizophrenia provides support for parent blaming.

I am back to eating butter after something like 20 years of favouring margarine. This because for many years data mining found associations with butter and other animal fats and cardiovascular disease, and only recently further data mining and studies have shown that, au contraire, we need fat, and margarine may be worse than butter. Now I slather butter on my corn and biscuits without guilt. As someone else has pointed out, there is a very strong association between major road accidents and the presence of ambulances.

The word paranoia is used in many of those studies. I don’t know how they define it or determine it. Adolescents suffering from anxiety often experience what they call ‘paranoia’ but we refer to as ‘ideas of reference’. They feel their peers are always talking about them, judging them. Some avoid school because of this. Sometimes this feeling becomes a conviction and then it may be prodromal of a psychotic illness.

Bullying is interesting. I have 30 years of experience dealing with families in which a child is reported as being bullied by his peers. There are some distinct subcategories in this: In one subset, when the details are elicited, it turns out the boy in question is as much a perpetrator as a recipient. They taunt one another. But this particular boy tells his mother that Jason called him a “…..” in order to get a reaction from his mother, or to avoid something, or simply to get in front of the call that is going to come from Jason’s mother or the school.

A second subset is the Asperger/ASD child. They are common targets for bullying, precisely because of the way they react to unfairness, teasing, slights, and taunts. It is not kind and it is not good but they have become targets for bullying precisely because of the social deficits they already exhibit. My own survey reported on this site indicates that at least a third to a half of people diagnosed with schizophrenia have had autistic symptoms since infancy. So I would definitely expect a higher proportion of bullied children to develop a psychotic illness. The bullying is not causative, but the prodromal symptoms of the illness “invite” bullying.

Auditory hallucinations are not, in and of themselves, schizophrenia. People, girls, who have suffered prolonged sexual abuse report a higher incidence of auditory hallucinations. This certainly could be understood as persistent trauma of a particularly disorienting kind causing impairment in the brain’s otherwise quite miraculous ability to (usually) locate the locus of a thought or feeling, as well as causing all the other symptoms of PTSD as well.

On the other hand preteen and teen girls with ASD or prodromal symptoms of schizophrenia are vulnerable to predators within a family and neighborhood.

In sum, there are weak associations, though all suffer from our poor definitions and lack of clarity of diagnosis. None are strong enough to be considered causative. And if this were an association between salt intake and hypertension, to publish early causes little harm. (although even here we now have the problem of some people having too little salt in their diet, and other studies showing high salt intake may have nothing to do with hypertension).

But because this overall weak association with all its definition and cause/effect problems could support the existing serious prejudice of parent blaming for schizophrenia, I have to stick with my simple, “No. Neither psychological trauma nor poor parenting cause the serious illness we call schizophrenia.”

Though, of course, either could make it worse.

Psychiatry, Eugenics and Mad In America Scare Tactics – Part I

By Marvin Ross

Much of what I read on the Robert Whitaker website, Mad in America, stretches logic but this newest blog has to be one of the biggest stretches I’ve seen. Dr Robert Berezin, a US psychiatrist, warns that psychiatry is moving closer and closer to eugenics.

As defined by “eugenics is a word that made everyone at the event uncomfortable. … The very subject evokes dark visions of forced sterilization and the eugenics horrors of the early 20th century. … The study of hereditary improvement of the human race by controlled selective breeding.”

The most famous proponent of eugenics was Adolph Hitler who wanted a pure Aryan race but the subject has been advocated by many in recent history in an attempt to eradicate debilitating diseases. In fact, one could say that the reason for amniocentesis is to do just that. Sampling of the amniotic fluid of pregnant women can predict such things as Down’s Syndrome. And some parents will opt for abortion if Down’s is found but many do not.

Amniocentesis can also predict such genetic conditions as Tay Sachs Disease where the infant usually only lasts to about age 4. But, nowhere in the article by Dr Berezin does he actually show that modern psychiatry is planning to eliminate anyone who suffers from schizophrenia or any other psychiatric disorder.

What he talks about is the fact that genetics is being employed to try to understand these conditions better. He states that:

The accepted (and dangerous) belief is that psychiatry deals with brain diseases – inherited brain diseases. We are back to absolute genetic determinism. Today’s extremely bad science is employed to validate not only the idea that schizophrenia and manic-depression are genetic brain diseases, but that depression, anxiety, phobias, psychopathy, and alcoholism are caused by bad genes

I have no idea why he considers the genetic research to be bad science other than he does not agree with it. So what if he doesn’t. He does state that “The temperamental digestion of trauma into our personalities is the source of psychiatric conditions.” But, as Dr David Laing Dawson has written on this blog:

Childhood deprivation and childhood trauma, severe and real trauma, can lead to a lifetime of struggle, failure, depression, dysthymia, emotional pain, addictions, alcoholism, fear, emotional dysregulation, failed relationships, an increase in suicide risk, and sometimes a purpose, a mission in life to help others. But not a persistent psychotic illness. On the other hand teenagers developing schizophrenia apart from a protective family are vulnerable, vulnerable to predators and bullies. So we often find a small association between schizophrenia and trauma, but not a causative relationship.

Dr Berezin’s concern does not come from anything that anyone has said about aborting fetuses that genetic testing proves will be born with schizophrenia or bipolar disorder or any serious psychiatric condition. And the reason for that is that genetics and the understanding of the causes of these diseases is nowhere near a point that this can be demonstrated with 100% accuracy. Science is a long way from getting to that point if it ever is able to.

Suggesting that these research avenues will lead to abortion, eugenics or something similar is absurd and nothing but scare tactics perpetrated by someone who does not agree with the causation theories being investigated. If these avenues lead nowhere and it is discovered that science has been on the wrong path, then science will self correct. Attempting to generate unfounded fear is counterproductive.

Next Part II by Dr David Laing Dawson

On the Sad State of Mental Illness Knowledge in Britain

by Marvin Ross

What is it with the Brits, or maybe just some of them, that they promote strange theories of mental illness and, in particular, schizophrenia? First we had the very controversial British Psychological Society report Called Understanding Psychosis and Schizophrenia that generated a great deal of controversy. See the summary of it by James Coyne. Now we have a course being offered by King’s College London for caregivers of people with schizophrenia.

This sounds like a very worthwhile course given by a university that claims to be one of the world’s leading research and teaching universities based in the heart of London”. I was encouraged to sign up for it and did so much to my chagrin. After the introductory explanations of what schizophrenia is, they tell us that trauma is an important cause of this ailment and that this concept is gaining greater interest. The traumatic event they mention first is the loss of a parent either through death or separation. They then suggest that trauma may be associated with the hearing of voices and that the symptoms of schizophrenia may actually be Post Traumatic Stress Disorder (PTSD).

I looked for references but could find none. As a medical writer I’ve been involved in producing learning materials for doctors and other health care providers and the first rule is that whatever you write has to be evidence based and the evidence must be cited. I recall once being told to find references to prove a statement in a document I was writing on blood pressure that exercise is beneficial.

I left a comment in the King’s College course asking for references but received no reply.

So, lets look at some of the evidence. According to Dr Cheryl Corcoran, a psychiatrist at Columbia University Medical School, chronic stress may lead to psychotic symptoms (hallucinations, delusions) in the context of PTSD or depression. However, she points out that schizophrenia is more than just those symptoms. Schizophrenia, she says “also includes problems in thinking (concentration, planning, memory, etc.) as well as what are called “negative” symptoms (low motivation, difficulty enjoying things, lack of strong feelings, little emotional expression). Schizophrenia can also include odd and disorganized thinking and behavior. She concludes that there doesn’t seem to be any evidence that stress leads to these other symptoms of schizophrenia.

The National Health Service in the UK also disagrees. They say “some people may be prone to schizophrenia, and a stressful or emotional life event might trigger a psychotic episode. However, it’s not known why some people develop symptoms while others don’t.” They point to a variety of possible causes including genetics, brain development, neurotransmitters, pregnancy and birth complications.

According to the Australians Any evidence that childhood trauma directly causes psychosis or schizophrenia is controversial. Psychotic disorders may be secondary to co-morbid affective ilness, substance use, personality, or post-traumatic stress disorders, all of which have been linked to early trauma and all of which are common in those with a psychotic mental illness. Another difficulty for reporting childhood trauma in adulthood is accurately recalling events, and for some people memory is affected by the psychotic disorder. In other areas of research, such as depression, instruments have been developed which employ strategies to overcome recall problems such as the use of multiple sources of information. To date, these strategies have not been employed in most studies of schizophrenia.”

The number one cause of trauma that the King’s College Course cites is coming from a one parent family. Well, as I’m sure that most people know, this is a growing phenomenon. According to the Child Trend’s Database in the US, the proportion of children living with both parents has been in decline since 1970 and reached 64% in 2014. That means that in the US, 36% of children are in one parent families. This is a trend that is universal in the developed world and yet there is no increase in the number of people who develop schizophrenia. One study conducted in England over the period of 1960 to 2009 concluded that “We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported.”

This course also suggests treatment modalities such as Cognitive Behavioural Training for Trauma and Eye Movement Desensitization and Reprocessing (EMDR). Both are tried as treatments for PTSD and may or may not be effective but they are not a first line for schizophrenia. The other risk factor that is talked about is marijuana use but I suggest taking the course and deciding for yourself how relevant it is.

One psychiatrist to whom I mentioned the emphasis on trauma as a cause of schizophrenia commented that this is both insulting to the families and potentially dangerous. But, let me end by quoting my blogging colleague, Dr David Laing Dawson from his blog called As For Trauma Causing Schizophrenia: No! No! No!

People with psychotic illness do not need someone probing the wells of their psychic discomfort; they do not need (no matter how well-intended) a therapist scouring their childhood memories in search of an unhealed wound. They need support, safety, security, grounding,  and satisfying routine before they can get better. And good medical treatment.”