Tag Archives: involuntary treatment

Political Correctness and Medicine

By Marvin Ross

I always thought that the only area of medicine that applied absurd political correctness concepts to the detriment of those needing help was in the treatment of those with serious mental health illnesses. I was wrong. And note that I am not being politically correct when I say mental health illnesses rather than mental health issues and problems.

Readers of this blog probably need no introduction to one of the main deterrents to treatment for people who are ill and do not know they are ill. In most jurisdictions in North America, it is hard to hospitalize someone against their will when they are very ill because we bend over backwards to defend their rights to not be hospitalized. Better to let them live on the street or be in jail than to force them into a medical institution.

Sadly, Ontario goes even further by allowing someone who is hospitalized involuntarily because they pose a danger to themselves or others to then refuse the treatment that will enable them  to get well. Consequently, there are people in hospitals for years left sick and untreated because we respect their right to not take medication.

It turns out that we apply the same stupid rules to those with Alzheimer’s. In Ontario, at least. A number of years ago, I arranged for my mother to go into a nursing home because she had dementia. She had been assessed at a geriatric facility in Toronto described as “a global leader in geriatric residential living, healthcare, research, innovation and education, with a special focus on brain health and aging”. She did not have Alzheimer’s but dementia which was visible on MRI studies of her brain.

As a result, I had no difficulty finding a suitable nursing home for her. She was not happy going into it but she did become a long term resident for probably well over 20 years, enjoyed her stay and was well cared for. It was probably the mid 1980s when she went there.

Fast forward to today and I am the power of attorney for someone with Alzheimer’s as his family is spread around the globe with no one locally to look after his needs. The disease has robbed him of his ability to have any insight into his diagnosis much like anasognosia for those with serious mental illness. His Alzheimer’s was diagnosed by a leading Toronto hospital affiliated with the Faculty of Medicine at the University of Toronto. He has been assessed countless times with the standard mini mental status exam and it is obvious talking to him that he has dementia.

But here is the thing. He is not capable and while he lived alone, he had to have substantial support at home and he was going to a day program for those with dementia. When a spot opened for him at a very good home for dementia patients, we arranged for him to be admitted. He refused, of course, and as his power of attorney, I was worried about moving him and selling his condo. I spoke to the social worker at the geriatric unit who told me that his test scores were bad and that if I listened to him and did not have him placed, I would be remiss in my duties.

Two members of his family flew to Toronto and had him placed there. He got used to it and is happy and safe.

The problem for the future is that the home is not capable of providing intensive nursing care so their residents will eventually need to be moved to a nursing home. With the aging population, there is a shortage of these beds and a long waiting list. Beds in acute care hospitals and dementia homes are held by people who need nursing home but are occupying beds until a place opens up in a more appropriate setting, As this individual is starting to deteriorate, I tried to fill out an application for a nursing home to prepare for his future needs.

Turns out that is now complicated. Ontario has a bureaucracy called the Community Care Access Centres which co-ordinates home care and placements. It is a huge bureaucracy which no longer exists by name as it was merged with another large bureaucracy but the functions are there. My charge has a case worker who authorized some minimal home care for him and did periodic assessments. I called her to get an application and left a voice mail.

Next day, I received a call that they cannot send me an application because his file is inactive and I have to start intake all over again. It will only take a few minutes and I was transferred to someone else who took down the information they already have. I was told I would get a call to arrange a new assessment. Another one.

I then got a call from someone who I could not understand on my my voice mail but I did get the phone number and extension. I fully expected the person who called to answer but no, I got someone else. She had no idea who called me or why but found the name of the case manager who would call me. When I did get to talk to the case manager, I was told that she must do an assessment because his last assessment was a year ago and his status might have changed.

Of course it has, I told her. He has Alzheimer’s which does not go away and is progressive. In the past year, he has gone to living alone with support to needing a home. He now has a small GPS device in case he gets separated from his caregiver while out which did happen. And he will continue to deteriorate and will eventually need a nursing home. I wanted to put in the application because it can take 2-3 years to find a good one. Regardless, she said, I have to test his competence and tell him we are applying for a nursing home.

But if you tell him about a nursing home, it will set him off and he may not recover from that. He denies he has the disease and he thinks he is employed at the day program he goes to. His competency can be assessed without the need to tell him. I have to tell him she said. It is only fair and I cannot hide it from him.

As a result, I told her no. I will wait until he deteriorates to the point where his placement is an emergency and he will remain in a bed that someone else could use until the system finds him a place that is more appropriate. This is a problem that is happening throughout Ontario. Patients blocking beds in acute care hospitals they do not need because they need a nursing home and can’t find one. And the blame for all this goes to the bureaucrats.

Since this encounter, the Canadian government announced a $50 million dementia strategy that includes prevention and anti-stigma. Sound familiar to the mental illness advocates? How does one prevent Alzheimer’s and other forms of dementia when the causes are not known? What does stigma have to do with anything. As an aside, I wrote a book on Alzheimer’s in the late 1980’s and nothing has changed from then. Same with our treatment of schizophrenia. My 10 year old book on Schizophrenia is pretty much as relevant today as it was in 2008 when it came out.

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Psychiatric Refugees? Give me a Break!

By Marvin Ross

For years, we’ve had a small group of very vocal people who call themselves psychiatric survivors — people who have had psychiatric treatment, do not agree with it and consider that they have survived it. Now, thanks to CBC radio, we have someone dubbed a psychiatric refugee — a woman who fled British Columbia for Ontario to escape her involuntary status in a B.C. hospital. And, it was said, she is not the only so-called refugee.

Comparing yourself to people who survived a genocide like the Holocaust or saying that you are comparable to Syrians and others fleeing in leaky, dangerous boats from war is absurd. But what is also absurd is the story that this anonymous person called Sarah by the CBC told. It is just not logical but it is being used to justify the Charter challenge to the B.C. Mental Health Act that I suggested was misguided.

People deserve to know and to understand what the Mental Health Act is about. They deserve to know the processes that are in place to commit someone against their will and to treat them. And they need to know the safeguards that are in place to prevent excesses and protect the rights of the individual. These are never explained.

First, I encourage you to listen to the interview. To begin with, Sarah said that she went to the emergency at a hospital with her mother because of troubling life events and she wanted help. She was admitted, she said, voluntarily but then her status was changed to involuntary.

Now, for her to have been declared involuntary, she would have had to have satisfied all four of these criteria (page 18 of the guide):

  • Is suffering from a mental disorder that seriously impairs her ability to react appropriately to her environment or to associate with others;
  • Requires psychiatric treatment in or through a designated facility;
  • Requires care, supervision and control in or through a designated facility to prevent her substantial mental or physical deterioration or for her own protection or the protection of others; and
  • Is not suitable as a voluntary patient.

If she was involuntary, a licensed physician must have assessed her and certified that she met the criteria. Then, another independent physician conducted an examination with the same criteria to extend the stay beyond 48 hours.

( See form 4 where the reasons for the involuntary decision must be listed.)

At the end of one month, she would be examined again to determine if she still met the involuntary admission criteria and the proper form would be filled out to extend her stay a further month (page 20 of the guide). If she no longer needed to be involuntary during this period, the doctor can cancel it and she can always appeal her status to a review board at any time.

Once a patient has been deemed involuntary, they are given a form 5 (consent to treatment) (page 173), which explains to them what treatment is being given. Note that Sarah told the CBC that no one ever discussed treatment with her. They had to.

In addition, Sarah’s rights would have been explained to her and she would be given a form 13 to sign (page 182). She did say she had to sign something but she was not sure what it was. The person having her sign would have told her that she had a right to a lawyer, that she would be regularly examined by a doctor to ensure she was being held appropriately, informed that she could apply to a review board to assess her capacity, go to court to challenge the doctor’s decision and/or request a second opinion from a different doctor.

Next, she would be given a form 15 (page 186) to fill out so that she could nominate a near relative to be informed of her status. She did say that her mother went to the emergency with her so I have to ask where her mother was in all this. Surely she would have been liaising with the hospital staff over diagnoses and treatments. While her mother would have no authority under the act, most doctors do encourage family participation. During the CBC interview, Sarah said that she wished her mother could be involved in her treatment and there is nothing in the act that says she can’t be.

Sarah told the CBC that she absconded during a smoke break and that a form 21 (page 193) had been filled out. That form obligates a peace officer to return her to hospital. Sarah said she went to police in Calgary and told them, and that they called her psychiatrist but they did not hold her for return. The form 21 is only valid within British Columbia, but if 60 days had expired, it would not be valid and she would be deemed discharged.

There are so many holes in what she told the CBC that cast doubt on all she said. It is important for people to understand, particularly in light of the court challenge, what protections there are for an individual who is involuntary. This is not something that anyone takes lightly and is done for the best interest of the patient and for society.

The infamous Vince Li, who beheaded Tim McLean on a Greyhound bus, was initially picked up by Toronto Police in 2004 and taken to hospital. He left hospital against medical advice as there was no mechanism with which to keep him.

Imagine what would have happened if he had been treated initially? Tim McLean would be alive, his family would not have suffered the pain and anguish they did, and the first Mountie on scene might not have developed severe PTSD and eventually taken his own life.

As for Vince Li, he has done so well on treatment that he is now living in a halfway house. I can only guess at the pain he must feel knowing what he did while psychotic and that he would not likely have done if he had been properly treated at the outset.

Vancouver resident Erin Hawkes has written extensively on how the so-called forced treatment had saved her life. She has written in the National Post, numerous times in the Huffington Post and in the Tyee.

The CBC should interview her as well on the court challenge and they should do better fact-checking. If the plaintiffs in this Charter challenge call Sarah as a witness, we will see how well her story holds up to cross-examination.

Note: this first appeared in the Huffington Post on September 26. One person criticized me for attacking mothers which is not what I intended. I pointed out that Sarah’s mother has gone to the ER with her and I likely had input. When I asked where she was, it was a comment directed towards Sarah who said that she wished her mother could have been involved and I suspect she was. I realize that not all doctors and mental health staff are open to families but enough are. My own experience as a family member is that I have always been involved.

One Step Forward, Two Steps Back – Mental Illness Treatment Over the Past 150+ Years – Part IV

David Laing DawsonBy Dr David Laing Dawson

It is difficult, if not impossible, to fully understand the forces altering, changing, insidiously impacting our attitudes, laws, institutions, and behaviour in our own time. It takes distance and serious historians to dissect these things, and even then we are probably viewing them from a clouded contemporary prism. But something happened between 1990 and 2015 I would not have expected in 1970. Many of our mentally ill fellow citizens today are worse off than they would have been had they been born 50 years earlier. There are parts of the United States where one could make the case that they are worse off than they would have been had they been born in 1850. How could this have happened during a period of increasing knowledge, advanced medical tools, relative peace and prosperity?

This is one part of the puzzle:

The mental health laws were tightened, restricted during those years (1970 to 1990), and safeguards put in place, all toward the righteous goal of preventing anyone, ever, from being unnecessarily stripped of freedom and independence without “due process”. On paper it looks fine. Now one could not be held for a psychiatric assessment unless he or she was judged to present an imminent threat of harm to self or others. Within 72 hours if a psychiatrist came to the same conclusion about imminent threat to self or others, that person could be kept for another two weeks. Further safeguards were put in place – appeal processes, Review Board Hearings, lawyers made available, patient advocates. The wording, the processes are all a little different in each North American jurisdiction, but with similar intent and outcome.

And then the act of treating was separated from the act of detaining. A second process is required for involuntary treatment: a determination of not being competent to consent to treatment, and then the treatment authority would be conferred on a nearest relative, or, failing that, a public official. And this determination could also be appealed, taken to a Review Board, and ultimately to court.

This distinction between the right to detain and the right to treat has led to some paradoxical situations in which everybody loses. A person can be deemed too imminently dangerous to self or others to set free, to be allowed to leave, yet competent to refuse treatment. The patient suffers physically, mentally, left in a state of psychosis for a long period of time; families watch this suffering; unhappy doctors and nurses watch someone deteriorate to a state of chronic psychosis, to a state of true madness and unpredictability not seen in our mental hospitals since the introduction of effective medication.

Apart from this paradox all the new rules sounded commendable, and guaranteed to reduce or eliminate type I errors. Type I errors being the unnecessary detention of someone eccentric, a nuisance, but not dangerous, and the forced treatment of someone who should (within our current view of individual rights) be allowed to decide for himself. They prevent the abuse of a Nurse Rached, or a Dr. Donald Cameron. And these new rules were informed, to some extent I am sure, by our increasing awareness of the use of Psychiatry in the Soviet Union to deal with people deemed to be enemies of the state.

We need strong safe guards in all our systems and institutions, for humans in positions of power are always capable of abusing or misusing that power, of convincing themselves on some philosophical basis or other, that they are doing the right thing.

But when we completely eradicate the possibility of type I errors we open the door for type II errors. In this case not detaining someone who, in hindsight, should have been detained, not protecting and treating people who need treatment and protection. The most dramatic form of Type II error brings about the headline that we have read with horror and disbelief about twice per year the past twenty years. A patient is released from hospital, gets on a Greyhound bus, and decapitates a fellow passenger. A young man stops taking his pills and butchers his mother;  another shoots a journalist with a crossbow; yet another shoots an Arizona politician in the head.

But a less dramatic and more insidious type II error has been the increasing numbers of mentally ill (not deemed imminently dangerous to self or others) left to fend for themselves on the street, in shelters, and in jails and prisons. For a significant number of mentally ill people (and their families) we have, over the past 30 years, reversed the reforms provoked by Dorothea Dix in 1843.