Popular TV and Mental Illness Misrepresentation

By Dr David Laing Dawson

Currently two serial TV shows of the thriller/spy genre feature major characters who suffer from bipolar illness. Both usually take their medication and acknowledge that it keeps them stable. So far so good. They are successful likable characters and thus could be seen as antidotes to stigma, to the usual poor representation of mental illness by film and television. But in both story lines the characters go off their medication in order to decipher a complex conspiracy. They become manic, paper the walls of their rooms with clippings, photos, lists, time lines, arrows, connecting lines, question marks.

Voila. The unlikely pattern becomes clear to them. And once again the myth of madness and genius being one and the same is exploited for entertainment.

Our brains are organizing machines. They are always looking for patterns, recognizable and logical patterns. In a state of mania and hypomania, aroused, alert and scanning for such patterns, the brain does indeed find them more readily, that is, the brain invents them. The manic person sees connections and patterns where none exist, and to make this connection the manic brain often invents forces, and powers and conspiracies that are pure fictions. This might result in an interesting piece of art, a fascinating stream of consciousness, or even an entertaining performance, but it is a dysfunctional state and it does not result in valuable insight. The usual result is loss of employment, loss of community, loss of reputation, and eventually loss of freedom.

To portray mania as a form of genius does great disservice to those who actually suffer from this illness.

Of course mental illness does not discriminate so we are as likely to find that it strikes a brilliant mind as often as that of an oaf. And that is not a pattern either. Just statistical probability.

Stigma, The Brain And Brain Illnesses

By Dr David Laing Dawson

Every day the news contains at least one item describing our struggle to understand a difficult or troublesome or tragic human behaviour. As I write this there is an ongoing trial of a man accused of killing, dismembering, and then burning a Calgary man and woman and their grandson who happened to be on a sleep over with his grandparents. It is reported that the accused held a grudge against this grandfather because of a failed business arrangement years ago. The grudge “grew in his mind” until….

Then I read of a woman who committed suicide two months after the birth of a child. The grieving husband wants to shed light on post-partum depression but the emphasis in the article was about trying to alleviate the shame some women feel because they cannot breast feed.

This is the article that stuck in my mind because it emphasized the problem of stigma, the need for awareness, and the “let’s talk about it” approach to “mental health”. All well and good. But it continued the trend of trying to understand these tragic behaviours as the consequence of some kind of rational, all-be-it extreme, thought processes.

I understand this. When confronted by any odd human behaviour we try to “understand” it by applying two mechanisms: a logical sequence of cause and effect and empathy (how would I behave in similar circumstances?).

We live our lives believing in the supremacy of mind; we organize socially and act independently within an assumption of “mind”, of “free will”, of “choice” and consequences and personal responsibility. We are very reluctant to accept the fact that the brain can hijack this process, that the brain is the primary organ dictating human behaviour, that the brain, this biological computer system of cells and neurohomones and fragile connections, can go wrong. This reluctance has extreme advocates such as Bonnie Burstow who thinks…. or who’s brain leads her to think…

Actually I have no idea what she really thinks and why she thinks  it.

But phrases like “mental health issues”, euphemisms for mental illness, and much anti-stigma publicity continue to support the primacy of mind and downplay the role of brain. They continue to support the notion that all troubles, with a little support, acceptance and understanding, can get better, be overcome.

This does a tremendous disservice to those who suffer from true, serious mental illness.

From her culture, her family, and perhaps from all the current pop cultural emphasis on breast feeding, the new mother in question probably felt some degree of disappointment that she could not breast feed. But this was not an experience that propelled her, through a logical sequence of thought processes, to suicide.

No. Serious postpartum depression, and postpartum psychosis is as clearly as any serious mental illness, a brain problem. The brain has hijacked the thinking process. It is no longer rational. This is a brain illness.

Prevention of the tragic consequences of this illness requires knowing which women who have given birth are at risk, screening for and identifying this illness, recognizing it as a brain illness, and treating it vigorously as one would treat any serious and life-threatening illness.

Sure, let’s talk about it and de-stigmatize it, but we also need to recognize that it is an illness, a brain illness, and offer, make available, medical/psychiatric treatment, and occasionally protect by holding the sufferer in a safe environment while waiting for treatment to take effect.

And, contrary to what Bonnie Burstow and the anti-psychiatry people say, we now have effective treatment for depression and psychosis.

We are Now in Big Trouble

by Dr David Laing Dawson

The other evening Mr. Tapper of CNN came out directly and asked the following question: Does Mr. Trump know the difference between the truth and a lie? Does he say these things as strategic gambits, all the while knowing they are falsehoods, in some cases outrageous falsehoods, or is he incapable of knowing the difference? This dichotomy suggests either he lies nastily and without regard for any semblance of truth as a political strategy, a gimmick, a distraction, or he is incapacitated.

Neither answer is very reassuring. And if this is an incapacity what is the nature of it?

There is a simple and consistent answer to this question. Pathological narcissism.

Trump’s lies are responses to that which his inflated ego cannot accept. All information, evidence, facts that suggest Trump is not supreme, the best, the most popular is unacceptable to him and therefore must be denied or rebuffed with “alternative facts”. Any successes or glory he does achieve must be revisited, replayed, exaggerated over and over again.

The fact Donald Trump’s narcissism is extreme enough to require this level of denial of reality (the size of the crowds, the “3 – 5 million illegal votes”, murder rate, wire taps) means it is incapacitating. He is incapacitated.

His lies, his tweets, are not even bounded by plausibility. They will continue, grow more outrageous, and dissolve in a wild lashing out.

Unfortunately Kim Jong Un and the excited commentary on American television may be providing Mr. Trump a way to lash out and destroy. And then, which I am sure aligns with an image in his head, he can stand akimbo in his great black coat upon the scorched battlefield like a Vulcan God.

Follow Up – Education More Important Than Ever

By Marvin Ross

I’ve been contemplating a personal follow up to David’s blog on the importance of public education but I’ve been procrastinating. I decided to write it after having lunch with someone who was complaining that a grandchild was being sent to a private school at a cost of $25,000. His argument was that the local school the child goes to is quite good and he will have to be driven to the new school where he will lose contact with all his friends in the area.

The ability to play with other kids on the block, walk to and from school with them, and to hang out is an invaluable educational tool. I grew up in a Toronto that was just starting to break free of the grip of the Loyal Orange Order – a Protestant fraternal group that celebrated the defeat of the Catholics at the Battle of the Boyne in 1690. Most important jobs were reserved for Orangemen who proudly marched on Yonge St every July 12 behind someone outfitted on a white steed playing King Billy to celebrate the victory of William of Orange over Catholics.

Toronto was just beginning to see an influx of immigrants from all over the world at that time. Up to then, the main immigrants were Jews and Italians. The elementary schools were becoming mix of ethnicities and we all mingled and played together (with the occasional fights that were settled easily). As English Protestants ruled, classes began with the Lord’s Prayer and the singing of God Save the Queen. Once a week, some kindly minister conducted a class on religion.

Jews could be excused but I stayed as did most of the others as I recall. This invariably led to our existence being recognized by the holy man who talked about religion in general rather than his own denomination. We learned about and from each other. Groups of kids from different backgrounds would share experiences outside of class. I can still remember our comparing what we ate for Christmas dinner (which I didn’t have) and being intrigued because my best friend was Japanese and they ate octopus.

As I progressed through the years, more diverse people began showing up in class. At this time, most Blacks were descendants of those who came via the underground railroad but we were soon joined by people from the Caribbean. In elementary school, I went to a drop in centre across the street from our house run by the African Episcopal Methodist Church. One year, I was one of the three wise men in their Christmas pageant. Of new arrivals at that time, the most exotic was a new Algebra teacher called Mr Gupta. No one had ever seen a South Asian before but what was most remarkable was that his two sons were in his class. They were math whizzes much to our disgust.

I don’t want to give the impression that there was no racism as there was but it was slowly beginning to break down thanks to the children from large groups of people from diverse places. We mingled together in school, played and fought together on the playgrounds in the neighborhood and began to develop understandings of each other. In her book on growing up in Toronto as a child of Holocaust survivors (When Their Memories Became Mine: Moving Beyond My Parents’ Past), Pearl Goodman describes how playing with the neighbourhood kids and dealing with them in the local school, helped her contend with the views and trauma her parents had from their experiences.   The outliers were Jewish kids in the area who were sent to Jewish parochial schools rather than the public schools. They were quite different from us and even talked differently with the sing song accents so familiar to those whose first language was Yiddish.

During that time, there was even a radio program hosted by the Minister of Citizenship, Jack Pickersgill, who gave his audience information about the various immigrant groups (called New Canadians), who were flooding into the country. The Governments attempt to help them gain acceptance

Education was a prime reason that fear and distrust of others began to break down. Aside from the fact that most kids in my high school could swear in Yiddish (as Jews were the largest group), tolerance and understanding was starting to emerge in all areas. A holdover from the War was the fact that high schools in those days all had cadet corps affiliated with various regiments and often our teachers were called by their military rank. My history teacher was a major.

My school was affiliated with the Queen’s Own Rifles, an old and respected regiment that landed at Normandy on D-Day and fought its way north to help in the liberation of Belgium and The Netherlands. We had to go on a Church Parade one Sunday to the regimental church and when we got there, the Sgt had us all lined up. His command was Jews and Catholics, fall out and we did and spent the church service in the basement playing foot hockey while the poor Protestants had to endure a religious service.

Education helped us integrate and learn to understand and tolerate each other and is very crucial today more than ever. And it is this understanding and respect for each other that results in US Muslim Vets offering to stand guard to protect Jewish cemeteries from vandals or Toronto Jews standing guard at Mosques to show solidarity.

It has always been important for us to learn about and accept others as equals and that process flourishes when we all go to school together.

Education – More Important Than Ever

By Dr David Laing Dawson

Truly excellent, really well funded Public Schools are the answer to many of our problems and especially so in the United States. But, despite that, the US Congress has proposed a new bill ( HR 610) that will gut their educational system.

Some years ago a  book of essays by Robert Fulghum was published with the title “All I really need to know  I learned in kindergarten”. Hold hands when you cross the street. Share, be kind to one another, clean up after yourself….  It is cute and fanciful but beneath the smile of recognition there lies a profound truth.

Schools have two jobs. Educating our children may actually be secondary to socializing our children. Originally I suppose, as some sociologists point out, the goal of our newly invented schools was to prepare our children for the  factory jobs generated by the industrial revolution. Show up on time, do as you are told, work all day until the Bell rings.

Many years have passed. Our schools have gone through many evolutions keeping up with the changing needs (and fads) of the times. The curricula have changed, and many of the social rules have changed, each accompanied by much dissent and discord.

But I would argue that as our cultures have become so diverse and complex, as our populations become less and less homogeneous, and as future employment becomes both less certain and more multifarious, the role of socializing our children in good public schools becomes more important. Dramatically more important.

Every kid should be sitting in a classroom, playing in the school yard, singing in the choir with at least 50 percent of the other kids being, well, different. Our children need to work with, and play with kids unlike themselves during those 12 or so formative years. Smart kids, not so smart kids, shy kids, obnoxious kids, athletic kids and handicapped kids, black, brown,yellow, white kids, poor kids and not so poor kids, kids with two parents and kids with one, kids who speak other languages, take different religious holidays, wear some different clothing.

There has of late been a rise in “hate crimes” and racial vandalism.

In a way hate crimes and racism are pernicious extremes of tribalism, and they rise in frequency when tribalism grows and especially when our leaders fan the embers.

I think to combat this we must first accept the fact that tribalism is in our genes. We are programmed to notice if someone is not of our tribe. It would be a very important trait in our prehistoric period. Science tells us that when we encounter a stranger, we first notice his dress, and then we notice his tribal markings (think hair/tatoos/metal piercings), then we pay attention to language and voice, and lastly skin colour (when we primates first developed these perceptual skills, we were likely all the same colour).

Our sense of tribe can expand, and one day might include all who live on our earth. A large swath of the white American tribe recently accepted a black man and elevated him to their highest office. Though clearly there were many who never accepted him as one of them.

Still more recently we have seen how easily tribalism can be provoked and inflamed. Brexit, Marine le Pen, Trump. We can struggle against this, we can do our best to fight this trend, but the long term solution is having every one of our children attend, from JK to 12, a well funded Public School, and a school with the complete mix of kids I mentioned before. I would allow home schooling only if, for health reasons, attendance was not possible.

I suppose I would not oppose a small number of private schools because to do so would limit some important freedoms.

I think we already see in some idealistic young people who have grown up in very diverse and inclusive schools a sense of tribalism expanded to include the whole world.

Americans especially: Do not undermine your public school system. Fund it, grow it, improve it. There in lies the hope for your future.

“Last Night in Sweden”

By Dr David Laing Dawson

Donald Trump’s reference to Sweden at his rally in Florida has been met with much astonishment and satire. He has tried to explain that he meant to reference more of a trend of refugee crime in Sweden than a single recent event. His supporters repeat this. His detractors roll their eyes.

But what he actually said and how he said it and the manner in which he absorbed the source material are, as usual, very telling. They speak to his attention span, how he is influenced, how he formulates thoughts, his limited vocabulary, and the superficiality of his cognitive processes. Here is his statement: “..you look at what’s happening last night in Sweden. Sweden, who would believe this? Sweden. They took in large numbers. They’re having problems like they never thought possible.”

The source of this remark is a Fox News report he watched the night before. Hence the “last night”. His thinking process collapses the time he watched the report and the time of supposed “events.” The television screen that he watched was split screen. On the viewer’s left a talking head reports an immigrant inspired crime wave in Sweden. This information was apparently gleaned from particular face book rants. But on the right half of the screen we watch videos of unidentified violence and crime: fires, vandalism, assault, riots.

The spoken information is not sourced from government data or first hand reporting but from Facebook tirades and a filmmaker with an agenda. The visual information (always more potent than words as we know) is of unknown origin and time frame.

This makes an impression on Donald Trump. He says, “You look at what’s happening…who would believe this?” So he has not taken in words and images and formulated and judged them, thought about them, considered them, reflected on their meaning – no, instead he simply excitedly points to them, “You look…”

“They took in large numbers.” He conjures an image of swarms of refugees rather than any considered look at numbers, programs, origins, and the problems of integration and settling.

And then, using a kind of vague hyperbole, “They’re having problems like they never thought possible.”

Trump frequently falls back on these kinds of qualifiers and exaggerations. They create an emotional impression without any kind of actual description, identification, or assessment. His favorites are: “You wouldn’t believe.” “Unbelievable” “Like they never thought possible.” “Like you never thought possible.”

Of course I may be wrong. Such speech patterns may not reflect the patterns of his thought; they may not indicate he has the cognitive processes of an excited 14 year old. Perhaps it is an act, a ploy, a strategy. Perhaps in private he can think and talk as a responsible adult.

Now that is a really frightening thought.

Time, Gentlemen, Time

By Dr David Laing Dawson

Open letter to all the sane and sensible Republican lawmakers who wish to see their children and grandchildren grow up in a safe world.

It is time to huddle with sane and sensible Democrats and figure out how to remove Donald Trump from office. Perhaps you are doing that already. God speed.

Thursday this past week, for almost 90 minutes, Donald Trump gave us what has been called “vintage Trump.”

And in that almost 90 minutes, once again, Mr. Trump demonstrated that you have elected for your president a man who is:

  • A world-class narcissist
  • A man with a very short attention span (unless he is the subject of praise, and adulation)
  • A careless liar. A very careless liar. “You look at what’s happening last night in Sweden.”
  • A man with a teenager’s vocabulary and the conceptual abilities of a 14 year old.
  • A man for whom everything (and I mean everything) is about his own greatness.
  • A man with very poor impulse control.
  • A man with a level of knowledge of the world equivalent to that of a bright 12 year old from a good public school: “I’ve been briefed…and I can tell you one thing about a briefing that we’re allowed to say …because anybody who ever read the most basic book can say it…nuclear holocaust would be like no other.”
  • A man with no sense of the complexities (and safeguards) of governance in a democratic system. “The FAKE NEWS media (failing , , , , ) is not my enemy, it is the enemy of the American People!”
  • A man who, strikingly, does not notice, does not seem to understand or care about, the meaning and inferences of his own words. “You will never meet a person less anti-Semitic (less racist) than I am.” “I’m not calling it fake news anymore, I’m calling it very fake news.”
  • A man who always blames others, who cannot take responsibility for any failures or mistakes or even oversights. “I was given that information. I don’t know. I was just given it. We had a very, very big margin.”
  • A man still obsessing  about the woman (Hillary) who almost beat him, and the black man more loved than he.
  • A man who lives for adulation, excitement, winning, not working, not actually doing a job. Hence the constant replay of the November election, and the reprise in Florida last Saturday evening.

Dr. Francis rightly points out that we should not diagnose from a distance, and that a criterion for the diagnosis of narcissistic personality disorder is that the patient be suffering, not merely wreaking havoc on others.

On the other hand, Typhoid Mary was healthy, yet few would disagree with removing her from the kitchen.

And we have lately seen glimmers of the rage within, the rage that will be unleashed when he is cornered, trapped, and finally undone.

Please read my manual for undermining democracy and note the progress to date.

More on Vince Li and Absolute Discharge

By Dr David Laing Dawson

Let me give a little background to my previous blog on Vince Li.

I have had many patients over the years (50 years now, actually) who have done well with treatment, who recover, who have insight, who promise to stay on their medication. They are good people. I like them. We become friends. With some it can involve an ongoing dialogue about needing or not needing to stay on medication.

But at some point most of them stop their medication, at least once. Their lives have changed. They have been well for 20 years. They meet a family doc who doesn’t understand why they are still taking Olanzapine. They fall in love. They move. They get ill in some other way. The pharmacy changes hands. Their doctor moves. They come under the influence of one of any number of cults, including Scientology. They read the bullshit of the anti-psychiatry crowd, or the homeopaths. Someone offers them cocaine.

So at some point most of them stop their medication at least once.

With psychotic illness the illness returns, and it always returns in the same way. With some my relationship is good enough that I can cajole them into going back on their medication. With some I have had to spend hours offering it while my patient tries to decide if I am a friend or the devil. With others it means a complete relapse and re-hospitalization.

And in most cases, the only ones hurt by this relapse are my patient and his or her family. That is no small thing though. The social, emotional, vocational, educational, and sense- of-self cost is huge. Often a year or more of progress is lost.

Lack of insight may be a good predictor of human behaviour, but insight itself is not. An equally poor predictor of future behaviour is remorse, or a display of remorse. “Good behaviour, model patient or prisoner” has also little to do with what will happen in a different context five years from now. I will agree, however, that a good support system is a good predictor, but we need that support system in place for 40 years.

We clinicians are further hampered by our natural empathy, our natural sympathy that flows toward anyone nearby. It is not special; it is just human. At least twice a week during commercials I see on the television screen an emaciated fly-covered child. I get up and refill my glass. But should that child and his mother be in the room with me, my response would be quite different. Hence, as I have seen many times with CCRB cases over the years, the staff actually caring for and treating the patient are very poor at predicting future behaviour.

Now, I have not examined Mr. Li. It is possible he had a psychotic episode that will never reoccur. In my 50 years experience I know this to be only possible if the initial psychosis was caused by a brain injury, a stroke, toxic substances, or withdrawal from toxic substances, or very severe acute trauma within the time-frame of the psychosis. But from what I have read Mr. Li developed a schizophrenic illness with hallucinations and the specific delusion that resulted in a very specific horrendous crime.

So, from my 50 years of experience, I would say the people who know Mr. Li, who have spent time with him, are the last people who should be making predictions of future behaviour. Secondly, insight, remorse, promises, even absolute statements of conviction are not good predictors of distant future behaviour.

We know this man, when well, is a very nice man, and could be a good citizen of any community. We also know when ill he is capable of committing a horrendous crime.

Would it not be reasonable to use the tools we have to keep him well for the next 40 plus years? To protect Mr. Li and any future community in which he resides? They are not overly constrictive or intrusive considering the possible consequences of a relapse.

By allowing even a remote chance of a repeated homicide by Mr. Li you are doing everyone else diagnosed with a psychotic illness a great disservice.

The Absolute Discharge for Vince Li was wrong

By Dr David Laing Dawson

Vince Li has been treated now, for his schizophrenia, for 8 years. He has been living in the community and attending classes. The Review Board has given him an “absolute discharge”. He is, we are told, recovered, insightful, remorseful, and willing to take his medication regularly. Thus he is not a threat and qualified for absolute discharge.

He may well remain healthy and compliant with his medication for the rest of his life.

Perhaps the odds are slight that he will stop his medication and become ill again.

But, here are two realities about psychotic illnesses, schizophrenia in particular:It is hard to catch a relapse.

  1. When a patient stops his medication he will feel fine for a while. And when the relapse begins the first thing to become impaired is insight. One can monitor mood, but not one’s own cognitive processes. So very few people with schizophrenia who stop medication and feel good for a while, are then able to detect, on their own, the early signs of cognitive changes. As the illness worsens the prospect of insight lessens. It is the nature of schizophrenia. It affects thinking.
  2. When relapses of psychotic illnesses occur, the original delusion returns, if not exactly word for word, almost word for word. Thus if the original delusion was relatively harmless, in a relapse the patient’s returning delusion will be relatively harmless. “They are listening to my thoughts from the TV so I don’t ever turn it on.” “It is happening again.” But if the original delusion was dangerous: “I must kill to rid the world of the devil”, then when the relapse occurs the person in question will once again become dangerous.

Thus, even if the possibility of a relapse of illness for Mr. Li is small, such a relapse would be far more dangerous than for most people with this illness.

And if this occurs, if Mr. Li relapses and hurts or kills someone else, the cost will be much wider than Mr. Li and his victim. “Let’s talk about it” will certainly not be enough to reduce stigma then.

Such an occurrence will undermine the compassion and civility of the “not criminally responsible” finding.

The average citizen has trouble buying this defense now, for various reasons, especially when the crime is horrifying. If Mr. Li relapses and commits a crime, the community outcry will be very strong. A relapse and repeat by Mr. Li could thus do great harm to all mentally ill in Canada.

This could have been remedied simply: a discharge (though not absolute) that continued a lifetime of monitoring compliance with treatment. Not overly intrusive or restrictive. Simply making sure that Mr. Li continues his treatment, that he continue to take his pills every day or his injections every two weeks.

If Mr. Li stops taking his anti-psychotic medication, one year or ten years from now, the illness will relapse. And the delusions of this illness always return in the same form.

Trump’s grandiosity.

by Dr. David Laing Dawson

I have been watching too much CNN. I must control this new addiction. It is bad enough to find oneself compelled to watch a train wreck or a car accident, to have to slow down and gawk, but now I’m following the ambulances into the ER and waiting to hear the pronouncements of the doctors and nurses and next of kin.

Each evening several panels comprised of both political persuasions dissect the president’s tweets and statements, seeking substance, direction, and meaning, seeking precedent for his personal attacks, sometimes deftly skipping past his actual words to re-frame and reword the proclamation in question. They are often concerned about the political advantage or disadvantage his words might have. As George Orwell and Mark Twain and others have told us, when the outrageous lie becomes commonplace it loses its ability to outrage us. It becomes “strong opinion”. It may even become “alternative fact”.

But none of these panelists seem to pay attention to a part of Donald Trump’s speech that I think they should. Perhaps they need a linguist on one of their panels. Like a child
Trump calls the judge a “so-called judge”; like an envious teenager he revels in the low ratings of Arnold Schwartzenegger; he demonstrates every day he has no boundaries, personal, professional, or ethical.

But this is the kind of sentence I find most frightening:

“I comprehend very well, better than I think almost anybody.”

Without irony or a wink he begins to tell us that he comprehends better than anybody, that he is smarter than everybody else. Then as he is forming the words he catches a glimpse of how this will sound to others, and he squeezes in the phrase, “I think almost”.

He did the same when he said, “I am very smart.” He squeezed in the word “like” to soften the statement a tad, even if it ended up sounding adolescent.

I can analyze this as a grandiosity that is really an over-compensation for insecurity, but it is, nonetheless, grandiosity: A belief in his own powers, in this case his intellectual powers, that far exceeds reality.

As President Kirkman said last season: “There is nothing more dangerous than a pawn that thinks it’s a queen.”

It is this grandiosity that will bring down the house, or some day implode in rage.