Let’s Not Dis Personhood

“A personality disorder is anyone I don’t like”

This was a comment made by one of my first teachers when I started psychiatric training. He was in his mid-70s at the time and knew the writings of Kohut and Kernberg. He meant the statement facetiously, cautioning me, a first year resident, to use such a diagnosis with awareness.

After 30 years being a psychiatrist I still bristle at having the words ‘person’ and ‘disorder’ so close together.  Words have power and are an important tool for psychiatrists.  Over my career I’ve met individuals who’ve been told “You have ________ (insert DSM personality label – usually Borderline or Narcissistic) Personality Disorder”.  For a few this was helpful and made them feel they weren’t alone with the problem. For others being given such a label triggered a sense of hurt and even shame that lasted for years.

I do not object to the construct of personality disorders (PD).  I accept that there are individuals who are emotionally more or less sensitive than optimal, that have difficulty putting themselves in others’ shoes, who find themselves caught in longstanding patterns of behaviour that don’t serve them or those around them well.

It’s not the diagnosis, it’s the language.  We’re taught to first, do no harm.  Language matters and words can hurt.  It’s time to find better language.

Psychiatry has a long history of using terms that later become so stigma-laden that we leave them behind – think of the terms used for persons with intellectual challenges in the 18th century which included idiot, imbecile and moron.  These were diagnoses, not insults, at the time.

Diagnoses are a means of shorthand.  They distill complex ideas into a few words and allows for more efficient communication.  But it has a downside; it allows us to condense many concepts, feelings and biases into just a few words.

When I hear clinicians using the term ‘personality disorder’ it’s usually laden with judgement and judgement of something very deep, of the essence of the human being.  Patients aren’t just being overly sensitive in feeling hurt and shame when told the label; they know they’re being judged as people. Often clinicians are talking about them critically, even mockingly, behind their backs.

Some might point out that denying patients ‘honest’ information around diagnosis deprives them of information they need to effect change.  Do we want to be like physicians of the past who would avoid using the word cancer due to stigma?  Yet cancer and personality disorder are different in how closely they reflect on one’s personhood.

All too often clinicians talk of personality disordered patients with derision and disdain. My sense is that such talk is frequently a reflection of the clinician’s frustration with trying to work with the individual and expressing a sense of powerlessness that the patient/client will ever change.  Yet I cannot imagine oncologists sitting at rounds and talking derisively of patients with cancer for whom they do not yet have effective treatments.

It’s hard to cultivate compassion for persons who seem responsible for their own pain.  Clinicians’ feelings of frustration are inevitable for any but the most sainted among us.  At the same time I’ve never met someone with severe personality pathology who enjoys the intense emotions, the roller-coaster feelings and troubled relationships.  Their suffering is real!

Hopefully my frustration will not come out in the form of hurtful words.  It should however drive me to strive to overcome my still many limitations as a clinician.

Shalom Coodin

All We Are Is Story

“All that we are is story. From the moment we are born to the time we continue on our Richard_Wagamesespirit journey, we are involved in the creation of the story of our time here. It is what we arrive with. It is all we leave behind. We are not the things we accumulate. We are not the things we deem important. We are story. All of us. What comes to matter then is the creation of the best possible story we can while we’re here; you, me, us, together. When we can do that and we take the time to share those stories with each other, we get bigger inside, we see each other, we recognize our kinship – we change the world, one story at a time…”

                                                             Richard Wagamese


“There is no greater agonyAngelou_at_Clinton_inauguration_(cropped_2) than bearing an untold story inside you.”

                                                          Maya Angelou



Over the past few years I’ve had the privilege to work with individuals with Posttraumatic Stress Disorder; soldiers and military veterans, first responders, RCMP (yes, those who sometimes wear the iconic Canadian red surge uniforms), as well as those who have had to endure physical, sexual, emotional abuse of any kind.  All come with stories; painful, precious stories of what they have witnessed and experienced. Stories that at times haunt and torment while awake and asleep.

I know there are a number of well-studied treatments for PTSD however I always seem to come back to what some call ‘exposure therapy’ but which I think of as simply listening.  Listening, actively listening requires being present and helping the person tell their story, a story that often has never been put into words.

I’m not so naive to believe that simply telling one’s story makes the pain, the intrusive memories, the flashbacks vanish.  Many live with PTSD as a ‘chronic’ condition that medications and therapies cannot fully relieve.

I came across an intriguing TED Talk recently by writer Emily Esfahani Smith titled There’s more to life than being happy.   She addresses what she terms the ‘pillars’ that contribute to happiness, the first three being belonging, purpose and transcendence. She goes on to speak of how the the fourth pillar, that of meaning “tends to Happiness TED Talksurprise people. The fourth pillar is storytelling, the story you tell yourself about yourself. Creating a narrative from the events of your life brings clarity. It helps you understand how you became you. But we don’t always realize that we’re the authors of our stories and can change the way we’re telling them. Your life isn’t just a list of events. You can edit, interpret and retell your story, even as you’re constrained by the facts.”

I believe that helping individuals to articulate their story is also relevant to those who struggle with psychotic illnesses.  Illnesses like schizophrenia and bipolar disorder profoundly shape lives.  The effects of the illness and, at times, the effects of treatment such as involuntary hospitalization, seclusion, restraints – at times necessary – involves traumas often with lasting effects.

It has been a humbling and gratifying role to listen.  To those who have shared their stories with me I want to express how honoured I am to have been given the privilege to hear them.

Shalom Coodin

When Addiction is Terminal!

Are there clients for whom addiction is a terminal condition – individuals who will inevitably die from their alcohol and/or drug use?Alcohol-addiction

The answer is undoubtedly yes, made ever clearer with the death toll from the current opioid crisis.

So what should I, as a mental health professional do with this answer?  Am I able to predict who will make it in the almost always roller coaster journey of recovery?  Should I not ‘waste’ my time with those who have no wish to change their pattern of use? Should I tell their families their loved one will have to “hit bottom” and this may involve death?

What to do when dealing with someone seemingly determined to head, full speed ahead, on a path to self-destruction?  Here are some things I try:

  • I remind myself how poor I am at predicting the future.  I’m no fortune teller. And knowing this allows me to believe change is always possible.
  • I repeat to myself the injunction to “Be kind, for everyone you meet is carrying a great burden”.  Individuals  struggling with addictions are truly fighting a daily battle.
  • If I can, I tag off.  One of the most valuable things with ACT is that you’ve got people around you.  Feeling burned out with a client is a sign you need someone else to take over for a bit.
  • I go back to basics.  I think of what I’ve got in my Motivational Interviewing toolbox. I try listening, really listening to what my patient is saying.  I bite my tongue HARD whenever I hear myself about to point out the obvious value, the life-saving importance of changing.  I explore their life, finding out how they came to be where they are.  I ask about the ‘good’ things that alcohol and drugs provides them before focusing on the ‘not so good’ things.

For some patients the best I can offer is relationship, relationship, relationship.  A limited, professional and non-judgmental relationship. I stop thinking how I can change the person. I focus on learning something about them, and then learn something more, and on and on.

And I keep in mind William White’s words while reflecting on his career working in addictions:

“What we are professionally responsible for is creating a milieu of opportunity, choice and hope.  What happens with the opportunity is up to the addict and his or her god.  We can own neither the addiction nor the recovery, only the clarity of the presented choice, the best clinical technology we can muster, and our faith in the potential for human rebirth.”

If you want to read a bit more consider looking at some of my related blogs such Ultimat-hmms? or What Works? Don’t Know!  or It’s complicated! or Denial Denier.

Even better, do an educational session on basic MI skills and then plan another, and another and another… You got the idea!

Shalom Coodin

Jan 30, 2018

Coaching vs Parenting Or Home Depot and Recovery

While reading an academic paper it made me smile when I came across this line:

“…coaching teams function like the Home Depot motto: “You can do it. We can help.

That is a wonderful reminder of how ACT clinicians ought to see their role in working with clients!

The line is from a paper titled The Work of Recovery on Two Assertive Community Treatment Teams by Salyers et al.  In it they explore how to best measure recovery orientation. Looking at two Indiana ACT teams and using observational measures and interviews over time, they identified “Recovery Critical Ingredients” in four areas: Environment, Team Structure, Staff Attitudes and Process of Working with Consumers (see table below or click to view online).

Recovery Critical Ingredients Table 1

In visiting the teams they found thatDespite teams’ similarities in baseline fidelity to the ACT model, we experienced many differences between the teams during our visits – both teams were meeting similar ACT model standards, but were approaching the work very differently.”

Some recovery measures are more objective, such as rating the environment looking for such features as “Open waiting area, posters about recovery, posted team mission included recovery” versus  “Separate waiting area and bathrooms, several signs with rules posted.”  More challenging to quantify are Staff Attitudes, which included looking at components of Positive view of Consumers, Positive expectations of consumers and Strengths-based Language.

They note that Concepts of risk and trust appeared central to treatment decisions and differentiated two distinct models of recovery work: coaching and parenting. Coaching teams have high trust in consumers’ ability to self-manage and view the risks as low” noting that “ The majority of consumers on coaching teams would manage their own medications and receive more intensive monitoring if repeatedly demonstrating need. This approach seems closely related to staff beliefs that consumers are “like us” in fundamental ways and should be afforded the greatest freedoms possible. As in Davidson’s view, coaching teams function like the Home Depot motto: “You can do it. We can help.”

So, should all teams be striving to become more coaching/recovery-oriented? The answer isn’t as clear as one might think.

“It may be easy to see these programs as though one team is “good” and the other ”bad,” particularly in light of recovery concepts. But both teams expressed feelings of genuine concern and care for the consumers and took pleasure in positive events in consumers’ lives. And, there were some downsides to the coaching approach. The team’s hands-off approach may foster independence quickly, but at least one consumer reported that the process was too fast — the team believed the consumer was more ready than he did. Differences in staff and consumer expectations of need are common, even in teams that are actively trying to be more consumer-directed. Another difficulty was that the team struggled with maintaining fidelity to the ACT model over time. At the time of our follow-up visit, the team was in danger of being de-certified for infrequent consumer contacts. Although the less frequent contacts could reflect staff vacancies, it is also possible that the initial coaching drifted into a mild form of neglect with the team not intervening enough, perhaps in service of the recovery ideal.” 

I’ve touched on this issue in previous blogs – in Tough Gig I expressed my view that Perhaps the most important role of the team leader is to set the underlying direction for the team.  Is our team focused on long term recovery or are we more focused on medication treatment and stabilization?”  In the blog Forcing Treatment and addressing the issue of outpatient commitment I wroteI believe forced treatment is of value. I don’t believe my conviction in any way diminishes my firm belief in recovery principles and client-centeredness. At times it’s the illness, not the individual that’s making the decision to refuse treatment. The goal of forcing treatment is to allow the individual to find their healthy, true voice”.

Consider using Salyer’s paper for a team education session to look at how your team operates.  Maybe put out questions such as

  • Are we maintaining our recovery orientation?
  • Are we too assertive?
  • Does everyone on the team have to be of the same mindset?

I think leadership has to bring a recovery-orientation to the team, not as a mandate but as a guiding principle.  Otherwise teams can fall into the trap of becoming mobile medication clinics.  Medication is unquestionably necessary – if someone is psychotic they can’t really engage in meaningful work – but medication should never be an end in itself. (see my blog Ultimat-hmms?)

As always thank you for your time.  Happy Holidays!

Shalom Coodin MD FRCPC

November 29, 2017



What Works? Don’t Know!

As I’ve gotten older I’ve become more open to using interventions I should’ve used earlier in my psychiatric career.  Especially for persons with addictions I’m more open to trying naltrexone, and even , in appropriate situations, benzodiazepines in a controlled fashion where I see evidence for crippling anxiety/panic symptoms.

This does leave me open to occasionally feeling ‘scammed‘; where a patient leaves me feeling like my openness to trying to help was taken advantage of.  It happens.

I console myself by going back to other’s wisdom such as William L. White’s chapter Some Closing Reflections on the Lessons of History in Slaying the Dragon: The History of Addiction Treatment and Recovery in America.

An example on “What works? “:

“Addicts make numerous attempts at aborting active addiction, and success and failure are all too often measured by a single intervention rather than combined or cumulative interventions. It is always the last attempt that is judged to be successful when, in fact, what may have proved the crucial factor was time, experience, maturity, the sudden opening of some developmental window-of-opportunity for change, or the cumulative effect of numerous interventions. What history tells us is that the early reports of such breakthroughs in the understanding and treatment of addiction are notoriously unreliable and should be treated with great caution and skepticism.”

I know that I’m going to get taken advantage again at some point by a patient who has addiction issues, but it’s still worth it. Trying to help individuals who are locked in powerful struggles is tricky and there’s much we still don’t know.  Persons with addictions are wrestling, torn between what they know and what their brain tells them they “need“.  As always it comes back to the issue of ambivalence:

“The history of addiction as experienced by America’s addicts is a history of SlayingTheDragonBookCoverambivalence. Addicts simultaneously want – more than anything – both to maintain an uninterrupted relationship with their drug of choice and to break free of the drug” …
“…one of the constant rediscoveries in this history is that espoused motivation to be drug free at the time of admission to treatment is not a predictor of positive treatment outcome. …  There has been a growing recognition that motivation is best viewed, not as a precondition of treatment, but as something that emerges out of an effective treatment process. Motivation is increasingly being viewed, not as something inside the client, but as something that emerges out of the interaction of the client’s intimate social network, the therapist and the broader treatment milieu.”

The work is more marathon than sprint.  Change takes time, lots of time.  Don’t get cynical and start thinking “people never change“.  Don’t you believe it!  Personality stays reasonably intact over longer periods of time but life happens, everyone experiences losses, joys, changes and traumas.  People do change, it’s just that we’re not good at predicting when.

In the meantime clinicians and agencies should stay focused on building dual disorder capacity. The goal should be what Dr. Ken Minkof wrote several years ago: “universal competency, including attitudes and values, as well as knowledge and skill”.   Please consider having a look at my post RUCCISC? from 3 years ago.  Dual disorders is such an important issue for ACT clinicians there should be an education session devoted toward one of the many aspects of it every 4-6 months.

Have a look at my two pages of excerpts from White’s book (click to view pdf) Slaying The Dragon Excerpts .  Even better, buy the book itself, which is available on Amazon.

Shalom Coodin MD FRCPC


Shalom CoodinS

August 16, 2017

“When something important is going on, silence is a lie.”  

 “The only thing necessary for the triumph of evil is that good men should do nothing.”
This is meant to be a blog about mental health issues, not politics.  Yet there are moments when everything becomes political. For my family, friends and colleagues in the United States of America this is one of those moments. My heart goes out to you as you go through this painful time.
I am Canadian and with a name like Shalom Zalman Coodin, clearly Jewish.  In this small corner of the Internet I want to record how I feel today.
In a hundred years we will still study and speak the words of Dr Martin Luther King Jr.  We will still quote Nelson Mandela. But the words of the current president of the United States will be seen for what they are – those of a bully and a moral coward.
“Speak truth to power”
And if you’re a psychiatric resident consider learning a bit about one of our profession’s darker periods – see my blog on the CMHR and Nazi Psychiatry.
Shalom Coodin
August 16,2017

Change The Topic

By July 2018 Canada will have legalized marijuana. Will this result in  northern reefer madness? I think not.  I do hope the discussion shifts to more pressing issues than that of marijuana.  However the next topic – that of medicalizing drugs of abuse  – is likely to be even more polarizing for the psychiatric community.

The opiate crisis needs to be addressed.  A New York Times article reports NYT OpiateDeathsthere were an estimated 59,000 drug overdose deaths in 2016 in the U.S.  Drug overdose is now the leading cause of death for Americans under 50.

At least half of ACT clients will struggle with co-occurring substance use problems at some point.  This, in combination with psychotic illnesses, poverty and the multiple other challenges ACT clients face, may make them even more at risk than the general population.  (I haven’t found any publications on how the opiate crisis is affecting ACT clients. If you  know of any please let me know.)

I blogged about this issue previously – if you have time read Relativity Risk (click to view).  Note where cannabis falls on the graphs!Drug Harm Graph

Dr. Nutt, an expert in the field wrote how:

“We saw no clear distinction between socially acceptable and illicit substances. The fact that the two most widely used legal drugs lie in the upper half of the ranking of harm is surely important information that should be taken into account in public debate on illegal drug use. Discussions based on a formal assessment of harm rather than on prejudice and assumptions might help society to engage in a more rational debate about the relative risks and harms of drugs.”

Some European countries have moved to medicalizing drugs of abuse.  In a 2014 legal journal article titled Uses and Abuses of Drug Decriminalization in Portugal (click to view pdf) the author says  that “The dire predictions of critics—“from rampant increases in drug usage among the young to the transformation of Lisbon into a haven for ‘drug tourists’ ”—did not come to pass.” She points out that “Portugal’s 2001 decriminalization law did not legalize drugs as is often loosely suggested. The law did not alter the criminal penalty prohibiting the production, distribution, and sale of drugs, nor did it permit and regulate use. Rather, Portugal decriminalized drug use…”

So what has been the effect? While still debated, the author concludes that “The removal of criminal penalties for drug use was intended to de-stigmatize addicted users and encourage treatment. According to Portuguese drug policy officials, the new system has effectively done just that.”

The fentanyl-related deaths that have hit communities such as Vancouver  – but also smaller centers, including my home of Winnipeg – have prompted the Canadian government to take steps, even ordering prescription-grade heroin.HealthCanadaHeroin

I know some will shudder at the thought of physicians ‘prescribing’  heroin.  I do!  However the issue isn’t whether we, as physicians and mental health professionals, ‘support’ drug abuse.  I think using drugs is BAD!  However the choice is not between good and bad options – it’s between bad and worse. Nearly 60,000 Americans and 2,500 Canadians died of opiates in 2016!

ACT clinicians, like other front-line staff may be equipped with naloxone kits, but naloxone is a fleeting intervention for what is almost always a long-term problem.  ACT clinicians should always be listening for opportunities to help clients work towards abstinence but the reality of the work is going to remain focused on harm-reduction.  There are not enough treatment options out there to begin with. For ACT clients who, for multiple reasons, can’t tap into or benefit from conventional treatment settings, there are even fewer.

BTW if your team doesn’t have a copy of Muesser et al’s Integrated ITDD CoverTreatment of Dual Disorders, buy one now! (click to view my previous post on this)  

I don’t  presume to have the answers but I do think we need to have discussions.

Thank you for listening.

Shalom Coodin



ChronicThe word has never sat well with me.  Telling someone they have “a chronic illness” seems to do little but relay a sense of hopelessness.

Language changes over time.  Moron, idiot and imbecile were used as diagnostic and legal terms centuries ago but certainly would never be used as such now.  Chronic, while not as overtly insulting, seems to suck hope out of a conversation. Long-lasting, longer-term, those seem better ways of conveying the concept.  Am I being politically correct? Maybe, but I’m okay with that.

Patricia Deegan’s Recovery: The Lived Experience of Rehabilitation (click to view) was published nearly 30 years ago.  It is a timeless, important read and every professional who works with persons with severe and persistent mental illness should know it.  ACT teams should read it together at an education session at least every couple of years, not as a mantra (though I would not object) but to truly discuss what she presents.

Some excerpts:

“It is important to understand that persons with a disability do not “get rehabilitated” in the sense that cars “get tuned up” or televisions “get repaired.” Disabled persons are not passive recipients of rehabilitation services. Rather, they experience themselves as recovering a new sense of self and of purpose within and beyond the limits of the disability. This distinction between rehabilitation and recovery is important. Rehabilitation refers to the services and technologies that are made available to disabled persons so that they might learn to adapt to their world. Recovery refers to the lived or real life experience of persons as they accept and overcome the challenge of a disability.”


“All of us who have experienced catastrophic illness and disability know this experience of anguish and despair. It is living in darkness without hope, without a past or future. It is self-pity. It is hatred of everything that is good and life giving. It is rage turned inward. It is a wound with no mouth, a wound that is so deep that no cry can emanate from it. Anguish is a death from which there appears to be no resurrection. It is inertia which paralyses the will to do and to accomplish because there is no hope.”


“It is important to understand that for most of us recovery is not a sudden conversion experience. Hope does not come to us as a sudden bolt of lightning that jolts us into a whole new way of being. Hope is the turning point that must quickly be followed by the willingness to act.”

ACT and mental health clinicians don’t rehabilitate people, they help create opportunities for change. Getting clients into situations that may lead to better housing, that may lead to an educational opportunity, that provides a chance to feel heard and empowered, that is the goal.  Such opportunities may never come up without the clinicians’ Deegan Paperpersistence and hard work.  Creating such opportunities does not necessarily create change but it can sure help!

In the 4000 words of Pat Deegan’s essay the word ‘chronic’ does not appear once.

If you haven’t read this please, please, please take the time to read it in its entirety.  If you’ve already read it, make time to read it again.

Shalom Coodin

Train ’em and Pay ’em

Can mental health consumers act as teachers for mental health professionals? Should they? If so do they have the pedagogical skills to be educators?

In a 2014 paper titled Consumer involvement in the tertiary-level education of mental health professionals: A systematic review the authors look at the research on this. Interestingly the first citation is of a Judy Chamberlain paper – (see my recent post).

While it’s important to research how to best involve consumers in teaching perhaps it’s time to, as a certain footwear company recommends, just do it!

First we have to recognise the value of lived experiences. On the issue of what we call patients (yes, I am a physician and I still use this term to remind me of my role) I’m increasingly comfortable with the title of Expert By Experience (see my blog I Got A Name on this)   Consumer, client and patient all have validity.  But when a patient asks what I think they should do – whether it’s to use or not use a medication for example, or to try returning to work – usually, before me answering, I’ll point out that my patient is truly the expert. They’ve lived with depression, PTSD, anxiety, psychosis, addiction or all of the above.

It’s well past time for psychiatry residency programs to have included consumers as instructors.  I suggest a plan on how to do this.  Step 1 – Pay Them!  I don’t work pro bono, why would we ask consumers to do so? Step 2 – Train Them!  One of the fallacies in Medicine is that by virtue of going through medical school and then a residency that you automatically acquire teaching skills along the way.  That ain’t necessarily so.  I don’t really know if I’m any good as a teacher – I certainly would have valued learning more about how to be a better teacher.  Medical schools have increasingly recognized this, offering teaching faculty training in how to be better educators.Apple

Just being a mental health consumer or expert by experience doesn’t necessarily make one a good teacher. There are individuals who are better able to articulate and communicate than others.   We need to invite, entice and did I mention PAY those consumers and involve them in ongoing training, not one-off seminars.

I have no doubt that there are such individuals out there because I’ve met them.  We psychiatrists may not like all of what they have to say but that can make for more interesting conversations.

Can those with the most severe, disabling illnesses – ACT clients – be part of this? Yes, I think there are some.  And ACT clinicians, who know their clients so well, would be a great resource for identifying individuals who might take on the role of becoming educators.

It’s way past time.  As I near the end of my career I’m saddened to see so little having been achieved in my community on this.  Maybe the next generation.

Shalom Coodin MD FRCPC

Lobotomy Retro

In the April 16, 2017  New York Times online (free access) is an 11 minute video and article titled The Quest for a Psychiatric Cure, looking at the use of lobotomy.  Lobotomy FreemanWhile many of us know of the history its always jarring; what psychiatrists thought of as an effective treatment in retrospect turns out to be unthinkable!Lobotomy 1

It’s easy to focus on Walter Freeman and his freewheeling lobotomy road tours.  But in order to understand the history one needs to remember the context of the times.

Dr. Heinz Lehman, a Canadian psychiatrist, is remembered for having brought chlorpromazine (Thorazine in the US, Largactil in Canada) to clinical use.  In 1985 he gave a talk on The Introduction of Chlorpromazine to North America (which is well worth reading and maybe using for an ACT education session)

A somewhat long excerpt:

“I should perhaps give some sort of a feel of what things were like in the 1950s, just immediately preceding and immediately following the discovery and introduction of the psychotropic drugs. I was working at the Douglas Hospital in Montreal. It was a small hospital – not small in the number of patients, we had some 1500 or 1600 – but we had very few physicians and very few nurses, one registered nurse for 600 or 700 male patients; the others were all untrained personnel.

It was pretty horrible to work under those conditions: I felt the only way to keep morale up in the 1940s with the few doctors we had then – most had gone to war – was to do some sort of research. So I did all kinds of things, always convinced that psychotic conditions and the major affective disorders differed in principle from neurotic and personality disorders, and they, I was convinced had some sort of a biological substrate. So I kept experimenting with all kinds of drugs, for instance, large doses, very large doses of caffeine, I remember, in one or two stuporous catatonic schizophrenics – of course, with no results…  We experimented with an extract of the pituitary gland, which we thought might have some effect on psychiatric conditions. So I gave it to some of my schizophrenic patients. We kept good records of our patients then – actually daily progress notes – and there was suddenly, on October 16, you see a very long note, describing a miraculous, very dramatic improvement, almost overnight, from one day to the next: the patient was lucid, cooperative, rational, he had a different posture – it was dramatic…  So we had great hopes for this “extract 47,” until we found out, within a week or so, what had really happened: this extract had a high alcohol content! It just shows you that even with the best efforts and looking at all kinds of different criteria, whether they are rating scales or other criteria, one has to be very skeptical, before one accepts even dramatic results as being promising or novel treatments.

We did all kinds of other things. I injected sulphur in oil which was painful and caused a fever; I injected typhoid antitoxin intravenously which produced pyrexia in schizophrenic patients. Nothing helped; I even injected turpentine into the abdominal muscles which produced – and was supposed to produce – a huge sterile abscess and marked leucocytosis. Of course, that abscess had to be opened in the operating room under sterile conditions. None of this had any effects, but all of this had been proposed in, mostly, European work as being of help in schizophrenia. The best results I could obtain were with prolonged sleep, which Klaesi had introduced in the 1920s, but that was quite a dangerous procedure, because it often led to pneumonia and we did not have penicillin in those days. All this led to a lot of frustration but no discouragement. I kept on looking for something.”

I’ve read this article a number of times over the years and always end up humbled.  How, as a committed, caring mental health professional do you go to work every day in a hospital where there’s “one registered nurse for 600 or 700 male patients”.  How unimaginable to be one of the 700 patients suffering in such a place. Many ACT clients would have been in such settings.

Psychiatrists want to help and we are all too often faced with problems for which we do not have effective treatments.  This leaves us vulnerable to forgetting that critically important insight made by historian Leland Bell and which I blogged about 3 years ago in Cycling History.  Bell wrote how

” … institutional psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability.  A new therapy is introduced with great excitement and enthusiasm.  Sophisticated, detailed reports verify its effectiveness and show remarkable cure and improvement ratios.  This excitement and interest soon fade.  Follow-up studies and additional research challenge the initial reports and reveal that the therapy has limited applications, that it should be given only a modest place in psychiatry’s armamentarium.   Even the most dramatic therapeutics have followed this cycle of hope and disillusionment.”

These days there seems to be a lot of buzz around ketamine, an anesthetic used in veterinary medicine which may have benefit in treating refractory depression.  Authors of a recent JAMA review note that “Even these data are limited by the fact that most of those studies evaluated efficacy only during the first week following a single infusion of ketamine,” the authors caution.

It’s not that I doubt that ketamine, or deep brain stimulation or other ‘cutting edge’ treatments are of benefit.  I just think we should approach new treatments with a certain mindfulness (mindfulness is big these days), always keeping Bell’s words in the back of our minds.

Thanks for taking the time to read my musings.

Shalom Coodin