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

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


Remembering Judi

A week before the tragedy of 9/11 I attended the First International Congress on Reducing Stigma and Discrimination because of Schizophrenia held in Leipzig Germany.  At that conference I met Judi Chamberlin (click to read Wikipedia entry), an outspoken advocate of patients’ judi-chamberlinrights and a fierce critic of psychiatric labeling, of forced hospitalization and compulsory treatment.  I got to spend a bit of time with Judi and enjoyed hearing her thoughts.

Judi Chamberlin died in 2010 but her book On Our Own is still available. She didn’t pull her punches. In the introduction she writes:

George Orwell would find the language of the psychiatric system an instructive example of his profound understanding of how words can be used to transform and distort. Just as Big Brother uses benign words to mask totalitarianism, so does psychiatry use words like “help” and “treatment” to disguise coercion. “Help,” in the common sense meaning of the word, must flow from an individual perception of what is needed. There are many things that can be done to a person against his or her will; helping is simply not one of them.

I do not see psychiatry as a tool of social control; I see it as the area of medicine that deals with the most complex part of the body – 100 billion neurons with 100 trillion connections.  I also think it’s worth going back to the ideas Judi Chamberlin articulated; the need for persons with mental health issues to advocate for change, the importance of protecting the rights of individuals who may find themselves disempowered, the need for those granted power – especially psychiatrists – to always be aware of how they exercise iton-our-own. I still remain an advocate for forcing medication treatment(click to view previous blogs on this) in certain situations.

Listening to critics and critiques of what we do is of indisputable value.  Without reminders as to the dangers of labeling people (please consider reading my blog on APA -Best/Worst) , of the inherent trauma in what we must do at times, such as involuntary hospitalization, we lose a valuable perspective.

Mental health clinicians should come back to these periodically.  How about ACT teams have one education session per year to look at Judi Chamberlin’s criticisms of the mental health system?

Shalom Coodin MD FRCPC


Down On The Farm

Recently I was listening to an interview on CBC radio – the Canadian equivalent of NPR – with Kay Parley. (Click image below to view the CBC website). At age 93 Kay recounts her experience of being admitted to a psychiatric hospital as a young woman – the same hospital where her father was a patient and where her grandfather had been treated.  While the webpage plays up the LSD treatment piece,Kay Parley Interview this is really an aside.  The more interesting elements of Kay Parley’s story, for me at least, were around her recovery journey and her discussion of how important certain professionals were.  She talks of how valuable it was to have recreation therapists who engaged her in tasks and of how important working on the hospital farm was for many patients.

I’ve met older psychiatrists who also spoke with real appreciation of the value of the farm work that went on years ago in the large psych hospitals of years ago.

Meaningful work is tremendously important for most of us including persons with severe and persistent mental illness.  At the same time I have very mixed feelings about the history of work in the asylums for which patients were rarely adequately paid.Farm work 1929

In teaching psych history I ask trainees to consider the case scenario below.  It could also be used for an ACT teaching session, maybe facilitated by the vocational specialist on the team.

Consider listening to the Kay Parley interview – it’s really quite interesting.

Shalom Coodin

Case Scenario:  It’s 1930.  Dr. David Young, medical superintendent of the Manitoba Asylum ( or insert name of large hospital in your area) has died and you’ve been asked to take over the role.

One of your first challenges is to make a decision around the Asylum’s farm facility.  For years patients have performed a variety of  tasks and such activity has always been considered therapeutic.

Several labour unions have threatened to protest in front of your office and to launch legal action unless you put a stop to the practice of making patients do unpaid work.  While you point out that patients are never forced to perform work, the union reps are unmoved.  You’ve appealed to the provincial/state government for funds to pay patients and this request has been repeatedly rejected.  (Keep in mind it is the Great Depression with roughly 30% unemployment across the country)

How would you address this?

Some additional questions to ask might include:

  • If rehabilitation is important isn’t it reasonable to press patients to work?
  • If lack of motivation is a symptom of schizophrenia might patients benefit from being encouraged to work?
  • What is the difference between rehabilitation and recovery?



Powdered dog lice and crab eyes

“A typical physician attending the insane in 17th century America administered an assortment of concoctions made from such ingredients as human saliva and perspiration, earthworms, powdered dog lice, or crab eyes. Special importance was attributed to an herb called St. John’s wort which was blessed, wrapped in paper, and inhaled to ward off attacks from the devil. LiceAstrological lore found expression in prescriptions: one physician instructed that bloodletting and blistering be timed with phases of the moon; another called for boiling live toads in March and then pulverizing them into powder, a delicacy credited with preventing and curing all kinds of diseases. From his medical treatises the doctor might prescribe ancient and medieval remedies. Hellebore, an herb used by the ancient Greeks to cure mental disorders, was specified as being “good for mad and furious men.”  A preparation known as “spirit of skull” involved mixing wine with moss taken from the skull of an unburied man who had met a violent death. Hot human blood, as well as pulverized human hearts or brains, presumably helped control “fits.” While these prescriptions represented the best-known “cures,” the nauseating quality of the mixtures suggests that the remedy rather than the illness was the more formidable obstacle to recovery.Crab eyes Vomiting may actually have been helpful, and certainly had powerful psychological effects. In any event, the “cures” reflect the state of medical knowledge in colonial America, a time when physicians and laymen read and use the same medical recipe books. Most doctors remained preoccupied with commonalities and epidemics.”

This excerpt is from Treating the Mentally Ill: From Colonial Times to the Present, a great book with a boring cover that I suspect you’d have a difficult time finding (if you indeed wanted to hunt down a copy).

In a hundred years what treatments that we use now to treat major mental illness might end up in such a list?  Will clozapine, with all its side effects, be seen as having been a misguided remedy? (and I think clozapine is the best! click to read more).

I teach a bit of history next month to psych residents.  I’ll get the residents to read another quote from this same book by Leland V. Bell where he writes of how “psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability” (Read and watch more at Cycling History)

My goal is not to make trainees cynical about psychiatric treatment but to make them humble. Physicians should always be a bit skeptical.  One needs to find the balance point between therapeutic optimism  and humility.  We understand so much more about the brain than a century ago; and yet there’s still a huge amount to learn.  I think we’re doing better than powdered dog lice, or crab eyes but let’s wait a hundred years just to make sure.

Shalom Coodin

Still Caged

In Shakles“There is nothing so shocking as madness in the cabin of the Irish peasant…when a strong man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin, not high enough for the person to stand up in, with a crib over it to prevent his getting up. This hole is about five feet deep, and they give this wretched being his food there and there he generally dies”

 Report of an Irish member of parliament c 1800

A couple of months ago my office neighbor Dr. Vivienne Rowan pointed out an article in the New York Times  titled The Chains of Mental Illness in West Africa (click to view).  It is very powerful and well worth reading.  NYT Chains of Mental Illness

At a point in life when many of us are taking up bridge and golf Vivienne, a psychologist,  is volunteering with Doctors Without Borders/Médecins Sans Frontières (MSF).  She shared with me the  picture below, which she’d taken while in Aceh province Indonesia on a MSF assignment.  The man had a psychotic illness. Family had previously been able to pay for psychiatric treatment but had run out of resources.  With no other option the family caged him. While there Vivienne helped arrange for the man to get an injectable antipsychotic and he could then be unchained.Man In Cage pixellated

ACT clinicians should remember what many of our client’s lives would have been like in the not too distant past.  Even with all the challenges posed by severe and persistent mental illness, addictions, poverty and the myriad of other problems clients face, it’s a big step up from what conditions were, and still are for some.

Shalom Coodin

Building – Human – Services

One of the core ideas of the ACT model is getting clinicians out of buildings. Community mental health should be done in the community.

In my community an impressive building went up several years ago meant to be the centralized mental health crisis service. It cost more than 12 million dollars to build and will need millions more to maintain.

Lovely buildings are nice. I like a new office with a big window. But such structures come not only at a financial cost but can divert services away from being continuous, comprehensive and integrated (please see my previous blog  R U CCISC?).

For much of the 19th century the focus of psychiatry was on building standalone psychiatric centers, AKA asylums.  For much of the 20th century the focus was on building psychiatric units as part of general hospitals. For the 21st century hopefully there won’t be much to show architecturally.

In building human services the emphasis should be on the human and services and deemphasize the building. What we (potentially) save on bricks and mortar let’s put into the most valuable part of the equation.

If you haven’t seen David Eggers’ TED talk titled My wish: Once Upon a School, take 25 minutes and watch it.  While he’s not talking about SPMI he is addressing issues like stigma.  At one point, in talking about the Brooklyn Superhero Supply Company he comments “… same principle – one on one attention, complete devotion to the students work, a boundless sort of optimism and the possibility of creativity and ideas…”.

Eggers TED talk

ACT is an evidence-based model and should be practiced true to basic ideas.  It should also allow for creativity and innovation, if not in architecture than in facilitating recovery for individuals with life-changing illnesses.

And if David Eggers’ talk doesn’t make you smile at least twice I will gladly refund your time.

Shalom Coodin

btw thanks to those who took the time to register their opinion on the issue of hospital days and ACT.  More than 90% (of an admittedly small sample) voted that teams should look beyond just the number of hospital days.

Worth Watching

Teaching psychiatric history often focuses on the history of psychiatrists.  And yet there really is not one history of psychiatry – there are many.

PoliticsOfMemoryPatricia Deegan made The Politics of Memory, a film for consumer survivors.  It`s history from the other side; from the perspective of those we treat, often against their will.

Some may find it difficult to watch and some psychiatrists in particular, might find it challenging.  I don’t think Pat Deegan was looking to slam psychiatry but rather calling it as she sees it.  She presents a side of history that is rarely given voice.

While well worth purchasing the film through www.patdeegan.com it’s also available on YouTube in 5 sections.

I have only  two 1-hour sessions with psychiatric residents to talk history, not enough time to show the whole film and discuss.  Two PoliticsOfMemory Quiltsections I do show are in part 1 at the 10:00 mark, with the embroidered quilt and at the beginning of part 2 with the stories of Elizabeth Packard and Ebenezer Haskell.

As well every ACT clinician should know about eugenics, Nazi psychiatry and Aktion T4 in part 3 of the film.

Some might feel this film is ‘anti-psychiatry’.  I don’t.  I think it’s a valuable tool to help mental health clinicians maintain collective self-reflection.

Shalom Coodin

PS: This blog started a year ago.  Since then it’s been viewed 4800 times from 10 different countries. Thank you for taking the time to visit – it means a lot.  Special thanks to Lorna.

To be continued…