Tag Archives: Psychiatry

Anti-Psychiatry Bold and Profane

By Dr David Laing Dawson

Let me make a simple bold and somewhat profane statement about anti-psychiatry. Which I take to mean, really, anti-medical-pharmaceutical-psychiatry.

When I entered medical school and later psychiatry, I would have been content to believe that all these psychiatric illnesses were entirely “psychological” in origin and form. It was the 1960’s so I was even quite ready to believe that all this insanity was really a sane response to an insane world.

Insanity is fascinating. I have spent hours talking with, listening to people who believe the CIA is watching them, their phones are bugged, the television sends them messages, they are emissaries of God, the voices tell them they must kill someone, they are controlled by radar, Xrays, Radio waves, microchips, which in turn are controlled by the police, shadowy evil figures, particular races, the CIA, the Mafia, Martians and Venusians. The devil has figured in many of these conversations. God in many others.

I have talked with people who fear to leave the house, who keep the blinds down lest the watchers watch them, people who can’t cross an open patch of land, people who must count the ceiling tiles, who must pray every time they think a bad thought, people who must have every sequence of action and thought end in an even number.

I have talked with people too depressed to talk, to move, to shit, to piss. I have talked with people too agitated, too distraught, too full of dread to sit. I have talked to people who assumed I came from either God or The Devil or both or either. I have talked to people who could not complete a single sentence without it wandering elsewhere. I have written questions on paper for people who feared to talk at all. I have talked with people who keep their eyes on the door, or on the ground.

I write fiction and plays. Dreaming up historic, family, life event, and even intrauterine causes for mental illness is fascinating. I have entered a patient’s delusions. I have explained to a woman who thought her self to be Queen that I was the Prime Minister and therefore, in our parliamentary democracy, someone she could listen to. I have talked to “the illegitimate son of Adolf Hitler”, to a man who could “whistle up the wind”, and to women who set themselves on fire. I have talked with a man who killed two children and then their mother.

I would actually be content (but for the suffering from depression of my own mother) to have these people in humane mental hospitals, fed and clothed and active and cared for and available for me to talk with, explore, dialogue with, interpret, help to find a psychological cause, a trauma, a series of adverse childhood experiences that might explain their perceptions of reality. In fact I have done all of these. I have sat next to a manic with arm on her chair to comfort without touching, on a mattress on the floor with a man wanting to kill somebody, in parking lots and back porches. I have talked with a “King of Kings.”

It is fascinating. It is human. It is dramatic. It is sometimes comedic. It can provide me with wonderful fodder for my fiction, my plays.

But I am also a doctor. And as much as I romantically like the idea of being an Alienist, living in the manor house of the large Asylum and dining with the “lunatics”, or setting them free to roam a Grecian Isle, I must try my best to relieve their suffering. And, it seems, that from the mid 1960’s, just when I entered this field of psychiatry, we began to develop pharmaceutical agents that actually work, that relieve suffering, that restore functioning, that control these terrible illnesses.

My patients want their suffering relieved. They want their function restored. They want their illnesses controlled.

So, my anti-psychiatry friends, I must continue to prescribe drugs, relieve suffering, help restore functioning, and forgo the psychoanalytic pleasures, the philosophical, poetic explorations, the mad interpretations, just as I must insist on vaccinations for all children, and forgo all the wonderful and fanciful spiritual and moral interpretations of spots, and fevers, and delirium of the early 19th century.

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Some Personal Thoughts on the Locked Doors of Psychiatric Wards.

By Dr David Laing Dawson

In the late 1960’s through the 1970’s I was one of many who worked to unlock the doors of psychiatric wards. We were, after all, highly influenced by the idealism of those years. And to a large degree we succeeded. At least here and there. At least until this century when they began to be locked again.

Suicide was never the main concern. An actively suicidal inpatient had already come to the hospital (which meant he or she wanted help) or had been brought to the hospital (which meant he or she had let their “intentions” be known to someone, and thus, at least partially, welcomed intervention). Besides, we still had seclusion rooms and one on one staffing to watch over such a person while we waited for the treatment to take effect. And usually it did. In fact, the highest suicide rate of any demographic is during that first year post discharge from a psychiatric ward. And usually (with some autopsy evidence to back up this observation) after they stop taking their medication.

An elopement followed by an act of violence was the real concern with unlocked doors. In theory and practice, we need but recognize that potential for violence in timely fashion and quickly institute treatment for the underlying illness, usually a psychotic illness, usually very treatable.

Still, that was the fear. And that fear encompassed our fear of failing, or making a mistake, of the consequences to a victim and the patient, of the community reaction, and of any legal repercussions. Not to mention the frustration of the police who had just apprehended and brought this man to hospital last week and now were looking for him again.

And there is another day-to-day reality. On a ward of 20 or 30 patients there might be only three or four of concern. One might be demented, confused, and likely to wander, perhaps over to the pediatric ward. Another might be actively psychotic and still talking of revenge. And another might be planning a break to acquire drugs. Another, a teen or youth, might simply want to go partying with his friends and be bridling at any restrictions.

So each day the ward staff would have to decide to keep the door locked or not, or place a nurse or security person on the door through the day and lock it at night. Or put each of these three or four at-risk patients on one-to-one staffing. And each of these solutions, save the permanently locked door, is expensive. And sometimes that number of worrisome patients might exceed 50% of the total with insufficient staff to assign one-on-one.

Statistically an elopement from a psychiatric facility, locked or not, followed by an act of violence is very rare, but always news worthy. Far more often the act of violence is committed by someone who should be in a psychiatric facility receiving treatment but is not. (Vince Li)

Elopements from psychiatric facilities, whether locked or not, are usually followed by inconvenience, folly, worry, drama and comedy. The whole human condition. Here are just a few of my experiences:

One evening the ward calls me at home to say William has eloped, and then he has phoned the hospital from a pub to say he is suicidal. I drive 30 miles in a rainstorm, find him in the pub, buy him and his newfound friends a drink, and drive him back to the hospital.

She has been divorced 20 years, but is now a little manic. She elopes. I am called by an irate ex-husband who tells me he arrived home to find her naked in his bed with a bottle of champagne. I cannot help but chuckle at the image; he tells me it is not a laughing matter.

The young man has been gone a few days. We worry about him. He has some unhealthy attitudes about the police. He is also manic. The police bring him back to the hospital. They found him making a loud and rambling speech from the roof of the police station.

She elopes. She is gone a few days, and not returned to her home. We receive a call from a psychiatric facility 400 miles away. Traveling on a Grey Hound Bus she had threatened suicide and been dropped off at their hospital. At our expense they would send her back.

He eloped from the open door facility, having refused treatment for his bipolar illness. He went straight to the Vancouver Aquarium, jumped in and swam with the Orcas, which attracted much attention, and then gave a press conference for some Vancouver reporters.

On the other hand, another woman suffered from depression but appeared much better now. Her husband said he wanted to take her home for the weekend. This seemed to be a reasonable step in her recovery. But on that weekend-leave from the hospital he took her to visit Niagara Falls. She jumped to her death.

Doors locked or unlocked or partially locked or locked at the discretion of the staff. It has, I suppose, very strong symbolic meaning.

But a psychiatric facility is a world of illness, despair, insanity, confusion, risk, drama, worry, folly, comedy and tragedy. A world of decisions being made about people’s complex lives with limited tools to do so, sometimes with limited information, often with limited staffing. A world in which we now have effective treatments but a myriad set of rules restricting their use. A world in which the staff are asked to keep everybody safe, but with the least possible restrictive methods. A world in which questions of civil liberties, freedom from illness, the right to refuse treatment, the right to be insane if not harmful, the right to unrestricted movement, the right to die – it is a world where all those profound issues are debated every day, and not merely as theory.

I am no longer as concerned about a locked or unlocked door as I once was. As long as everybody is doing their best to care, to protect, to keep safe, to reduce harm, to comfort, and to treat mental illness. And as long as we have hospitals and staff to do this.

Psychiatry, Eugenics and Mad in America Scare Tactics – Part II

By Dr David Laing Dawson

I am not shocked that we passed through a phase in our evolving civilization when we seriously considered Eugenics. Until we understood a little about genes and inherited traits, every serious abnormality must have been considered an accident or an act of God, perhaps a punishment for some immoral thought or deed. Certainly a stigma and something for a family to hide, if it could. And, at the time, the tribe or village would feel no collective responsibility to look after the impaired child, the disabled adult. This infant and child would be a burden on the family alone until she died, usually very young.

But coinciding with a time our tribes, our villages, our city-states, and then our countries developed a social conscience, a new social contract, and accepted the collective burden to care for these disabled members, we began to learn of their genetic origins. It would be entirely logical to then consider the possibility of prevention.

When medicine discovers a good thing, it always takes it too far, and then pulls back. When men and institutions have power we always, or some of us at least, abuse it, until we put in some safeguards. And there is always at least one psychopathic charismatic leader lurking nearby willing to bend both science and pseudo science to his own purposes.

But we have, here in the western world, passed through those phases (and hope to not repeat them). Now every year we find genetics is more complicated, that there are more factors involved. And every year we pinpoint at least one more detectable genetic arrangement (combinations, additions, deletions, modifiers, absences) that cause specific and serious abnormalities.

But here is where we are now medically and socially in the Western World: We can test the parents’ genetic makeup, we can test the amniotic fluid, if indicated we can test the fetal cells, we can offer parents a choice to abort or not; we can tell them of projected difficulties, available treatment or lack thereof, likely outcome, and possible future improvements in treatment and cure. We have also socially evolved sufficiently (and are rich enough) for the state to assume some, or, if necessary, all of the burden of care.

That is where we are, notwithstanding the difficulties of providing this care, and the antiabortion crowd: Some genetic certainties, some intrauterine tests, some blood tests for carriers, some absolute and some statistical predictions, and parental choice.

Now we come to genetics and mental illness. We have no certainties; we have some statistics; we have no intrauterine tests, no blood tests, and we have parental choice.

For science to not continue to pursue a genetic line of inquiry for serious mental illness would be a travesty.

Nature/Nurture. I think I entered psychiatry at the height of this academic debate. On one hand the psychoanalysts dominated US psychiatry, while biological psychiatry (Kraepelian psychiatry) dominated British psychiatry. (R.D. Laing was an outlier). Meanwhile psychology figured if you could train a dog to salivate at a bell you could train any kid to do anything. At the same time many poets, essayists, and not a few Marxist sociologists were telling us that the insane were not insane. It was the world around them that was insane. From Biological Determinism to parental cause to the Tabula Rasa and back to Social Determinism.

Other psychiatrists worked hard to find a way of including all possible factors: the bio/psycho/social model. (Which I would like to see redefined as the bio/socio/psychological model, for it is clear to me that our behaviors are driven first by our biology, secondly by our social nature, by social imperatives, and thirdly by our actual psychology, our cognitive processes. (Just watch Donald Trump)

How much of our nature is determined genetically, or epigenetically in the womb, and how much by our experiences as infants and children and teens and adults? When it comes to human behavior it is clearly all of the above, to different degrees and proportions.

The studies show that the risk of developing schizophrenia is 50% if your identical twin has schizophrenia, whether raised together or apart. This was often touted to show that 50% of the causative factors for schizophrenia must be environmental. But we now know that identical twins are not really genetically identical. And the interplay of genes, genome, brain development and environment is time sensitive. (Despite her fluent English my wife still stumbles on some English sounds. They were just not the sounds her brain was hearing at age 3.)

On the other hand identical twins reared apart are later found to have developed surprisingly similar traits, speech patterns, skills, and interests. And on every visit with my daughter in Australia she complains about the knees I bequeathed her.

As I mentioned before, genetics gets more complicated the more we are able to study it. Some DNA sequences seem to predict a mental illness in adolescence or adulthood but not the exact one.

Of course that finding may reflect not so much on environmental influences as on the vagaries of our definitions, our current diagnostic system.

An old colleague once remarked that our criteria for the diagnosis of schizophrenia are at the stage of the diagnosis of Dropsy in about 1880. I think he exaggerated. They are closer today to a diagnosis of Pneumonia in 1940. (Note that we can now distinguish a pneumonia that is bacterial caused, from viral, or autoimmune, or inhalational, and which bacteria, but our antibiotics help only one form of pneumonia, and each of these forms of pneumonia may have one of numerous underlying problems (biological and social) causing the vulnerability to developing pneumonia.)

For mental illness the development of drugs (1960’s on) that actually work much of the time threw a monkey wrench into this ongoing debate and inquiry. It tipped the balance to biological thinking for many of us. But it is a logical fallacy to assume a treatment that works reveals the original cause. The treatment is disrupting the chain of pathogenesis at some point but not necessarily at the origin of the chain.

We will continue to argue nature/nurture, and science will continue to investigate. And doctors will continue to treat with the best tools they have available.

If Dr. Berezin is correct (which he is not) and serious mental illnesses like schizophrenia, manic depressive illness, autism, and debilitating depression, OCD, and anxiety are all caused by “trauma”, much hope is lost and we will not find good treatments and cures for centuries. For today, despite what Donald Trump and Fox News tell us, in our childhoods in Europe and North America we experience far less trauma, strife, deprivation and loss than every generation before us. Yet mental illness persists in surprisingly persistent numbers.

Dr. Berezin is taking a leaf from the Donald J Trump book. He is trying to frighten you with images of violence, abuse, regression, lawlessness for his own purposes. He is waving Eugenics and Hitler at you in much the same way Donald conjures images of rapists, criminals, illegals, and terrorists streaming across the American border.

But lets get real:

Serious mental illness (schizophrenia, manic depressive illness, debilitating anxiety and OCD, true medical, clinical depression) are little helped with non-pharmacological treatments alone. The reason we do not see today, mute and stuporous men and women lying in hospital beds refusing to eat and wasting away is because we have the pharmacological means (and ECT) to treat depression. The reason we do not have four Queen Victorias and six Christs residing in every hospital is because we now have drugs that control Psychotic Illness. The reason we don’t see thin elated starving naked men standing on hills screaming at the moon until they die of exhaustion is because we now  have drugs that control mania. The reason we don’t have as many eccentrics living in squalor collecting their own finger nail clippings and urine is because we now have very effective pharmacology to treat serious OCD.

All of these people also need social help and someone in their corner, but without the actual pharmacological treatment it will get us nowhere.

(Though, I must admit, today, you may be able to see untreated catatonia, untreated stuporous and agitated depression, untreated mania and untreated schizophrenia in some of our correctional facilities).

But lets look at the less serious mental problems as well for a minute. A patient tells me she is afraid of flying, and always avoided it. But her father is dying in another province and she needs to fly there to see him one last time. She is terrified of getting on that plane. She imagines having a panic attack and disrupting the flight.

A fear of flying. A phobia of flying. Those of us who have such a phobia can usually manage by avoiding travel by plane.

But my patient. She needs to make this trip. Now perhaps I should send her to a trauma therapist who might uncover the fact a school friend was lost over Lockerbie and have her grieve about this, and still be afraid of flying; or perhaps to a cognitive behavioural therapist who might try to convince her that her fears are unfounded, pointing out how air travel is safer than car travel; or perhaps a desensitization approach in which the counselor uses relaxation techniques and has her imagine being at the airport, boarding the plane, and perhaps accompanying her to the airport on the day of travel; or perhaps I should find out if the fear is based on sitting so close to 300 strangers for 5 hours, or riding in a 20 ton contraption at the speed of sound two miles in the air; or spending 5 hours locked in a cigar shaped coffin with 300 strangers…..

Or I might simply prescribe for her five dollars worth of Lorazepam and offer a few encouraging words to get her through the trip.

Then lets look at something in between, like ADHD, one of the diagnoses mentioned by Dr. Berezin.

It is not a difficult equation for me. The child can’t sit still in class, he is too easily distracted, lacks focus, can’t concentrate, always being reprimanded by the teacher, socially ostracized because he intrudes, he pokes, he speaks out of turn, he angers too easily.

To become a successful adult he needs to succeed in at least one thing, if not more than one thing, in his childhood. If, with accommodation at school, and some parental strategies, some adaptational strategies, such as being allowed to wear earphones and take an exercise break every 20 minutes, have one-on-one instruction, good diet, better sleep – if these work, then he may not need medication.

If they don’t work it means he will fail socially and academically and maybe at home as well. He will be in trouble all the time. He will become surly, or give up, or become more aggressive, or depressed. In his teens he will self-medicate.

If the difference between a child failing or succeeding socially and academically is a single pill taken with breakfast it would be, to use that word again, a travesty to not prescribe that pill. And that is true whether the ultimate or necessary causative factor is inherited or acquired, or some complex combination of biological vulnerability, epigenetics, infantile and toddler experience, parenting styles, pedagogic methods, diet, and video game addiction.

 

 

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 dictionary.com “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

Why I’ve Been Prescribing Psychiatric Medication For 47+ Years

David Laing Dawson

By Dr David Laing Dawson

In 1968 the police brought a very tall man to the emergency department of a large urban hospital. I quickly learned the man had two PhD’s, one in literature and one in Library Sciences and he was employed as the chief librarian of an important Canadian Library. He was also manic. He could not sit still; he could not stop talking. What spewed from his mouth was a fascinating, pressured, endless run-on sentence of literary quotations, interpretations, criticisms, philosophical observations, and trivia.

The emergency department was designed as an oval, so it was possible to walk the corridor in a continuous circle of approximately 200 feet. This we did. I kept pace as he strode, talked, ranted, and raved, around and around that oval. I carried with me a glass of water and a pocket of tablets in my little white intern’s jacket. Every second or third circuit when he paused briefly to catch his breath I offered him a tablet and a sip of water. He accepted this, swallowed the tablet and continued his journey. I tried to remember some of what he said. I wish I had had a tape recorder handy. His observations roamed over much of English Literature and the history of western thought, in fragments, non sequiturs, creative associations and rhyming couplets.

The tablets in my pocket each contained 100 mg of Chlorpromazine. At four hundred milligrams he slowed at little. By the time I had given him 600 mg he was able to pause. And finally, at perhaps 800 mg and the passage of the better part of an hour, he could sit. The pressure in his speech diminished. He could now absorb his environment. I could now speak a little and he could now hear me.

In 1970 a dishevelled, tall bearded man was brought to a hospital by his family. They had found him, after months of searching, standing outside the Vancouver library in the rain. He had been sleeping rough; he was malnourished; he was not speaking. He was also a lawyer who had disappeared from his office practice, and his family, after announcing he was running for parliament, emptying his bank account, and then being briefly arrested for causing a disturbance. Now he was homeless, depressed, not communicating.

With clean clothes, a soft bed, good food, friendly nurses, and my anti-depressant medication, he was soon talking, more animated. But then he swung into a manic state: over-talking, grandiose, agitated, irritable, demanding. He wouldn’t sit in my office. He stood, paced, demanded I let him leave, ranted invective at my profession, my interpretations of reality, refused my pills. He stood and paced. I sat and listened. He didn’t leave, though the doors were never locked. His family let him know he needed to stay and accept treatment. The law society told him they would not reinstate him without treatment and a doctor’s note. Eventually he sat. Eventually we talked. He accepted my pills, my mood stabilizing medication, lithium. Eventually he was reunited with his family. Eventually he got his licence back. He became an outpatient. He re-established his practice, stayed on his medication, and asked me if I would like to play squash with him.

In 1978 parents brought a young man to see me. He was mute. He had stopped talking altogether. I had a white board in my office, and pads and pencils. The young man was willing to sit and respond to questions by writing out his answers. I found he dare not speak because if he did some tragic event would occur in the world. People would die. He knew this because it had happened. He had become angry, and had taken the Lord’s name in vain, and an earthquake had killed hundreds of people in the Middle East. He agreed to return to live with his parents, to eat and shower and sleep, and to swallow before bed each night the small tablet of Perphenazine I prescribed, and come to see me weekly. He came each week, and each week for an hour he wrote his answers on my white board, and when he tired of that, on the pad of paper I gave him. On his ninth visit I handed him the pad of paper. He put it aside and said, “We don’t need that anymore.”

On a lovely Sunday morning in June of 2008 my wife and I went for a walk. On the journey back I pondered ways to spend a leisurely afternoon. But then we found a frantic woman waiting for us in our parking lot. “John is psychotic again,” she said. John is her brother. An hour later I was in their father’s house. John was on the back porch smoking and pacing. I joined him there. He was agitated, mumbling half sentences in a semi-coherent fashion, some to himself, some to me. Changeable moods swept across him. His eyes would light up and he would tell himself and me that he was Jesus, and he had a mission to save the world, and that I would be forgiven, and then his mood would quickly darken, and he was evil, perhaps the devil himself, and that he should be punished, that he should destroy himself, and then just as quickly back to Jesus. I offered him a wafer of Zydis, a rapidly dissolving form of Olanzapine. He ignored this. His moods and thoughts continued to shift from Jesus to the devil, from good to evil, from a mission to save the world, to the need to destroy himself. I offered the wafer again, and this time he took it and let it dissolve in his mouth. A half hour later he was able to come into the house, and sit, and to sit quietly, and sip tea, and then to speak more rationally. Over the next few hours he became more coherent, better able to focus on the reality at hand. He would stay this night at his father’s, take another Zydis before bed, and they would come and see me in the morning.

It is now 2015. I am astonished to learn that there are people today, even some mental health professionals, who do not believe in the existence of mental illness, nor of the efficacy of psychiatric medications. I suspect that the closest brush they have had with insanity and pharmaceuticals is reading Jack Kerouac and William Burroughs in college, and the only knowledge they have of mental illness, and of the fate of the mentally ill before these medications were developed, has come from Hollywood, or the episode of Murdoch Mysteries I watched last night.

On Solutions to Psychiatric Burnout

David Laing DawsonBy Dr David Laing Dawson

The anorexic girl is down to 84 pounds. It is time for her weigh-in. She stands on the scales, dressed as before, and, lo and behold, she now weighs 84.5 pounds. Excellent. You offer praise before you notice the suspicious bulges in the pockets of her sweats. And was that a whiff of ketones you smelled on her breath?

The call comes at 11 pm. Your patient is in emergency, suicidal. How can that be? You just saw her in the afternoon and not only did she say she was doing fine, but that you had been a big help.

He is agitated today, restless; his eyes scan suspiciously. You ask about his medication and he tells you he tossed his pills in the toilet. You ask why. He tells you he doesn’t need them anymore. In fact, he’s never felt better. And now he knows it is true. He does have a mission to spread the word of God. Or maybe he’s evil and should be killed. And then he’s standing, glaring at you, and you glance at the clock and see that your next patient has probably arrived, and you haven’t finished your notes from this morning, and the man in front of you was doing so well last month, and now — do you have time to talk him into going back on his meds? Is it safe to let him leave? What are the odds of the inpatient unit having a bed? What is that new process for admitting someone? And then the receptionist calls to tell you your next two patients are waiting.

He is depressed. There is no doubt he suffers from depression. Your pills, the combination he is on now, keep him functioning marginally. But he wants more Lorazepam to get through the day, and he’s already taking too many. He is overweight. You’ve talked about diet and exercise but the chances of him following a healthy diet and exercising daily are nil. He just wants to feel better. And you would love to be able to make him feel better but… And now he’s telling you he can’t make it through the day without more Lorazepam and you just finished reading how this drug shortens life expectancy….

He has chronic pain. It is real, and so are his traumas. But you know there is little you can do for him but listen to his complaints about all the doctors he’s seen, the insurance company, the Workers Comp, all their stupid decisions, and now because he has a tenant in his house paying rent they want to reduce his pension….So you listen, and you hope he doesn’t come back to see you, but you know he will because you listen, and he survives another month, and he is a hard man to like, but ….

Ah, the weight and burden of responsibility. People talk of Compassion burnout. Listening to all those difficult lives and tragic stories day after day, and trying not to take them home with you. But the faster route to burnout that I see among mental health workers is an assumption of responsibility for events over which they have no control, leading to a sense of failure, and then cynicism, anger and blame.

In other branches of medicine and nursing, responsibilities are usually clearer, not always, but usually.  Yours and your patient’s responsibilities.

Perhaps you advised against flying in the third trimester, after that little bleed. But your patient ignored this advice and flew to an American city and went into premature labour. You gave her the correct advice; she is responsible for her decision to fly.

You put a cast on and advise no weight bearing for two weeks. You are fully confident your advice will be followed.

You prescribe antibiotics for bronchitis. You know she will take them as directed on the bottle. She, your patient, may even know a little about the history of antibiotics, and how they work, and accept though the drug might have side effects, the benefits outweigh the risks, and she knows as you know that when it comes to bacterial infections, Amoxicillin will work better than megavitamins and positive thinking.

He has chest pain. You ask him to take his shirt off. He complies. He lets you take his blood pressure, listen to his heart. He will wait for the ambulance, let you take a blood sample. He will let you perform an ECG, send him down for an X-ray or CT scan. When you tell him what you think his diagnosis is, he won’t argue. You offer nitroglycerine and morphine. You admit him to hospital and discuss a bypass operation. He doesn’t tell you he disagrees with western medicine and would rather have an incantation, a healing ceremony, or take those little brown Chinese Medicine pills.

Burn out. The problem stems from the burden of responsibility without power or control. A mental health worker who repeatedly assumes (emotionally) responsibility for that which is either not within his or her control, or only marginally so, will become stressed, cranky, dispassionate, and begin to blame the patients.

In this work, dealing with, as examples, that first grouping of anecdotes, the mental health worker must constantly monitor his or her own assumptions of responsibility, know when to act, what he can change and what he can’t, when and how to assume responsibility, and when to sit back, offer compassion and understanding, but allow the universe to unfold, allow people to lead their own lives in their own way. It is a very difficult balance to maintain throughout every day of any mental health professional’s life.

That first girl. She’s cheating by putting rocks in her pockets, isn’t she? She’s making you look stupid. And you are doing your best. And it makes no sense. She is killing herself and you just can’t get through to her.

If that chest pain patient in the last medical anecdote dies of cardiac arrest you will know that you did everything you could to prevent that outcome. But the suicidal patient in the emergency room? What should you do? How much can you do? Is it even feasible to try to assume some responsibility for her actions, her behaviour? Did you miss something she didn’t tell you during that last visit? This is the third time she’s been taken to the Emergency in as many months. You know your colleagues in that department are now blaming you. They are also wondering how come you let your psychotic patients go off their medication?

To prevent burn-out, to prevent the development of cynical attitudes, mental health workers need a supervisory support structure that understands this perennial problem, this complex burden of responsibilities, and which provides mechanisms that help deal with it, help with it. Counseling, workshops, direct help, sharing, consultation, debriefings.

And all too often that administrative and supervisory structure does the opposite. It directly or tacitly blames the mental health worker for events he or she never did have the power to control.