institutional psychiatry

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

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

 

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…

History Shorts

In the next few weeks I’m doing a couple of teaching sessions with psychiatric residents on the History of Psychiatry.

Several years ago Francine Chisholm and I put together a PowerPoint module to try to grab trainees attention for what can be a tough-sell subject.  It’s meant to be a self-driving experience where the user gets to click where they want to go (this was pre-Prezi). I haven’t yet figured how to make the whole thing available online but will keep looking into this.  In the meantime here are three video clips that give a taste.  The third one, a poem by a woman in an asylum, I still find moving.

Benjamin Rush 

Lobotomy

Ode to a Key

My goal isn’t to judge the past (though I do).  The goal is to make residents (and me) aware of our limitations and to leave us humble about how much we still don’t know.  Readers of this blog know I believe clozapine is a valuable medication.  At the same time I sincerely hope it’s obsolete in fifty years; I suspect people will look back and think “what was he thinking using a medication like that?”.

“Those who cannot remember the past are condemned to repeat it.” – George Santayana

As far as learning psychiatric history, that’s a good enough reason for me.

Shalom Coodin

The CMHR and Nazi Psychiatry

The Canadian Museum for Human Rights (CMHR) opened recently in Winnipeg, my hometown.  CMHRIt is powerful in both form and content. The focus is on human rights and the creators wisely didn’t try to replicate the Holocaust Museum in Washington.  The exhibits are engaging and diverse.  The sections on First Nations / Aboriginal peoples are particularly moving.

There is some focus on the treatment of the mentally ill, the experience of the asylums and the unpaid labour done in those institutions.  There are also details on Action T4, the program put in place by the Nazis for identifying and murdering those seen as “useless eaters“, first by starvation and lethal injection and later by poison gas. Before the Jews were put into gas chambers the technology was perfected on those with mental illnesses and disabilities.

Psychiatry during the Nazi era: ethical lessons for the modern professional, available in its entirety online, is well worth reading . In it Rael Strous writes:

“During the Nazi era, for the first time in history, psychiatrists sought to systematically exterminate their patients. It has been acknowledged that the medical profession was profoundly involved in crimes against humanity during this period, with various publications describing this malevolent period of medical history. It is less known, however, that psychiatrists were among the worst transgressors.”

And

“Much of this process took place before the plan to annihilate the Jews, Gypsies and homosexuals of Europe. Hitler never gave the order to kill patients with mental illness. He only permitted it in a letter written in October 1939 and backdated to September 1, 1939. Psychiatrists were therefore never ordered to facilitate the process or carry out the murder of mentally ill…they were empowered to do so.”

ACT clinicians are often working with individuals who have devastating illnesses that are life-changing for them and their families.  It’s important to remember that one’s value as a human being is not contingent on whether one has, or doesn’t have, a major mental illness.

Read Strous’s paper and, in 2015 come visit the CMHR – you’ll be moved by both!

Wishing you and yours – including your clients – a Happy and Healthy New Year.

Sincerely,

Shalom Coodin

Cycling History

The history of psychiatric treatments has, in the words of Leland V. Bell:

remained in a state of flux.  Indeed, 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.”

Pick the treatment – insulin coma, Metrazol, malarial treatment of tertiary neurosyphilis (for which a Nobel Prize was awarded), ECT, lobotomy (for which another Nobel Prize was given) – the cycle has repeated. More recently the same pattern has emerged, to a lesser degree, with SSRIs and second generation antipsychotics. It’s not that these are ineffective treatments – they were and are of benefit! It’s just that when each first arrived they were overvalued and overused. They become another tool, not the only tool.

Why bother studying history? Because it raises our awareness of where we came from, where we are and, hopefully, makes us think where we’re going.

It is all too easy to forget the kind of lives many clients had not so long ago.  With onset of a psychotic illness, usually in early adulthood, they would’ve been admitted to an asylum, might well have lived their entire lives there, died there and been buried in the asylum’s cemetery.

While there’s still a long way to go in finding effective treatment tools our clients are, for the most part, living radically different lives than they would have had they been born 100 years before.

The attached video shows Dr. Heinz Lehman with three men suffering with catatonic schizophrenia. I wrestle with the ethics of posting this as I doubt these men ever gave consent for the use of their images. At the same time this footage has been in the public domain for decades. The images are powerful; keep in mind what Dr. Lehman says in the intro – these men have been in this state for between 5 and 15 years and that their symptoms are less severe than they had been.

 

Heinz Lehman was a distinguished Canadian psychiatrist who is credited with bringing chlorpromazine – Thorazine to Americans, Largactil to Canadians – to clinical practice. He did not invent or discover it but was the first to start using it, in his own admission out of desperation to help patients.

Most of psychiatric history is a history of psychiatrists. There is another history that needs to be told – that of patients. Pat Deegan’s film The Politics of Memory powerfully presents this.

To help clients find their voice, to speak their history, will remain one of the most important tasks for ACT clinicians.

Shalom Coodin

PS: To find a copy of Treating The Mentally Ill; From Colonial Times to the Present by Leland V. Bell,  check on Amazon.