mental illness

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

 

SG’s Landmark Report

In November the Surgeon General came out with a comprehensive report titled facing-addiction-in-americaFacing Addiction in America.  Much of the content won’t come as a surprise to ACT clinicians.  For example in the executive summary it notes that:

“Our health care system has not given the same level of attention to substance use disorders as it has to other health concerns that affect similar numbers of people. Substance use disorder treatment in the United States remains largely segregated from the rest of health care and serves only a fraction of those in need of treatment. Only about 10 percent of people with a substance use disorder receive any type of specialty treatment. Further, over 40 percent of people with a substance use disorder also have a mental health condition, yet fewer than half (48.0 percent) receive treatment for either disorder.”

It’s a definite step forward when the Surgeon General, Dr. Vivek Murthy is making the rounds of various media outlets  trying to get the message out on the need for change.  Watch his interview on PBS Newshour (click to view)

surgeon-general-pbs

When I was a young psychiatrist I had a simple solution for patients who had substance use problems – “you have to go to AA (or CA or NA or GA or …)”.  I did my patients no good.

Two years ago I wrote a blog titled RUCCIS (click to view) pointing out how Ken Minkoff has, for years, been calling on mental health programs to provide Comprehensive, Continuous, Integrated System of Care (CCISC). He writes how

In a CCISC processevery program and every person delivering clinical care engages … to become welcoming, recovery- or resiliency-oriented, and co-occurring capable.  Further, every aspect of clinical service delivery is organized on the assumption that the next person or family entering service will have multiple co-occurring conditions, and will need to be welcomed for care, inspired with hope, and engaged in a partnership to address each and every one of those conditions in order to achieve the vision and hope of recovery.”

In that blog I commented how “on Minkoff’s webpage, the word ‘chronic’ appears only once! That word has a pernicious, disempowering effect on clients and care providers. It should be expunged from our vocabularies. Long lasting, long term, long-standing – I’m okay with all of these, but chronic – NO!”.  The Surgeon General’s report does use the ‘C’ word and I appreciate that the authors have their reasons for this.  I do think we need to see these problems realistically but we also have to leave room for that mysterious element of recovery.  Tony Bennett just celebrated his 90th birthday and I just recently learned that he went through years of addiction and nearly died of a cocaine overdose.  Meeting him at that time in his life could anyone have seen where he would be 35 years later, what with having a ‘chronic’ condition?

There are no simple answers.  ACT teams should, as always, focus on delivering the best services possible.

With the holiday season upon us, Roman, Kevin and I want to wish you and yours all the best of the season and a happy and healthy New Year!

Shalom Coodin

Ultimat-hmms?

When do you “draw the line” in working with a client?  Is there a time when ACT clinicians have to put out a “you must – or else!” statement?

I think there are rare occasions where an ultimatum is understandable.  Mostly in my experience it’s been related to concerns of violence towards the team or others.

In a 1990 paper  titled The Use of Ultimatums in Psychiatric Care (Click to view) Dr Schwartz looks at this thorny issue.  While not directly addressing ACT I think the issues are very pertinent.

I believe in the use of contingencies but as Schwartz points out:

“The threat to end treatment is not just another contingency in the context of ongoing treatment.  When we make that threat, we invoke the final contingency available when all the usual contingencies we employ have failed.  At that moment we issue an ultimatum: “Either you do as I say [enter an alcohol treatment program, take this medicine, come to sessions regularly] or I will not work with you”.  Only the language of ultimatums captures the unique power of this moment…”

He goes on:

“An ultimatum can be very powerful indeed, but the particular nature of its power must be appreciated.  Often it represents an abuse of power or a disregard of responsibility.  Yet it may be the only way out of meaningless or harmful treatment.”

Schwartz then lays out 7 principles for consideration.  The first is, beyond ethical issues a reminder as to practicality.

“An ultimatum controls the psychiatrist’s future behavior and limits the range of responses to the patient”. ultimatum-cartoon

Ain’t that the truth – the ultimatum restricts the one putting it out there leaving them little choice as to what path to take next.  And using an ultimatum doesn’t exactly invite a collective problem solving approach now does it?

Another point:

“Do not neglect the potential gain in therapeutic alliance that comes from trusting the patient unless the trust is proven to be misplaced.”

I especially admire Schwartz’s sixth point:

“Be wary of institutional pressures to trust conventional wisdom over the patient’s understanding of his own needs”. 

Read the whole article.  Even better – present it to the team to read it together as part of an educational session.  Open it up for discussion. And let me know what you think.

Thanks again for stopping by.

Shalom Coodin

Horror, guns, mental illness.

I have no special knowledge about what happened in Orlando this past weekend in which 50 innocent people were murdered and a greater number wounded.  It is unimaginably horrific.  There are no words.

I do not in any way mean to suggest that the Orlando killer was mentally ill.  This may have been just an act of evil.

The subject of severe mental illness and violence is a perennial one.  ACT clinicians know some of the issues, which are complex.  Consider reading  Metzl and MacLeish’s  Mental Illness, Mass Shootings, and the Politics of American Firearms in the American Journal of Public Health (2015 February).  The authors review the literature and

“critically addressed 4 central assumptions that frequently arise in the aftermath of mass shootings:

(1) Mental illness causes gun violence,

(2) Psychiatric diagnosis can predict gun crime before it happens,

(3) US mass shootings teach us to fear mentally ill loners, and

(4) Because of the complex psychiatric histories of mass shooters, gun control “won’t prevent” another Tucson, Aurora, or Newtown.”

The authors note that “… in the real world, these persons [persons with mental illness] are far more likely to be assaulted by others or shot by the police than to commit violent crime themselves. In this sense, persons with mental illness might well have more to fear from “us” than we do from “them.” And blaming persons with mental disorders for gun crime overlooks the threats posed to society by a much larger population—the sane.”

As a Canadian, where handgun ownership is rare, I’ve felt a certain distance from what goes on south of the border.  Yet the issue is one Canadians must confront as well.  Last month Justice Eric Macklin concluded that 23 y/o Matthew de Grood who in April 2013 went to a house party in Calgary and stabbed to death five young people – “was experiencing a psychotic episode at the time of the slayings.” And “that at the time he caused their deaths, was suffering from a mental disorder that rendered him incapable of appreciating or knowing that his actions were wrong” and concluded that “… Matthew de Grood committed the acts that resulted in the deaths of these five individuals, but he is not criminally responsible for those deaths on account of mental disorder.”

Does mental illness cause violence? Yes, but there’s far more to it. And is ease of access to guns the determining factor? It’s a factor but there’s far more to it!

Metzl and MacLeish conclude that:

… gun violence in all its forms has a social context, and that context is not something that “mental illness” can describe nor that mental health practitioners can be expected to address in isolation.

My heart goes out to all those affected by violence.

Shalom Coodin

June 12, 2016

 

 

 

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

Choosing Death

Should an individual get to choose to end their life, with a physician’s assistance, when suffering becomes too great?

Until a year ago, as The Supreme Court of Canada noted “It is a crime in Canada to assist another person in ending her own life.The Court goes on to write that ” As a result, people who are grievously and irremediably ill cannot seek a physician’s assistance in dying and may be condemned to a life of severe and intolerable suffering. A person … has two options: she can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.”

The Court mandated that physician assisted suicide be legalized across Canada within a year. Now provincial medical governing bodies are trying to formulate guidelines around how this should be done.Death

What about individuals with mental illness? The Court didn’t explicitly exclude mental illness.

I know a woman who developed schizophrenia in early adulthood.  She and her family went through years of torment.  She was hospitalized for years.  She hasn’t been hospitalized for more than 20 years,  lives independently, has friends and looks after her dog.  She is sweet and warm and funny.  Yet when I ask her about her lived experience of recovery she commented that she would choose death over having to go through it again.

Am I to question her assessment of her life?

And yet…  I’ve met so many individuals who have suffered so much and still have built lives of meaning and worth.  Can mental illness be ‘grievous’?  Yes, without question.  Is is ‘irremediable’? I don’t think it is.

The Death TreatmentSome countries have allowed physician assisted suicide for individuals with mental illness.  (See The Death Treatment in the June 2015 New Yorker article on this issue and how’s it been dealt with in Belgium or, even more timely – just out today (and shorter) Margret Wente Right to Die and Mentally Ill on how we need to deal with it.Wente Right to Die

What do you think?

 

Shalom Coodin

 

 

 

“I Got A Name”

Like the pine trees lining the winding road

Croce

I got a name, I got a name

Like the singing bird and the croaking toad

I got a name, I got a name

And I carry it with me like my daddy did…

Jim Croce

What should we call people?  As a physician I don’t have a problem with the term ‘patient’ but recognize its limitations.  It doesn’t really empower individuals.  With my PACT team we used the term ‘participant’ which I came to like.  There are other options including ‘client’, ‘consumer’, ‘service user’  or one I’d not come across before – ‘Expert by Experience’.

In addressing the issue for social workers C. McDonald writes:

The words we use to describe those who use our services are, at one level, metaphors that indicate how we conceive them. At another level such labels operate discursively, constructing both the relationship and attendant identities of people participating in the relationships, inducing very practical and material outcomes (McDonald, 2006, p. 115).

 I think there are merits to each of the various options – for a thoughtful consideration have a look at this article in the (click to view) British Journal of Social Work: What’s in a Name: ‘Client’, ‘Patient’, ‘Customer’, ‘Consumer’, ‘Expert by Experience’, ‘Service User’—What’s Next? British Journal of Social Work: What’s in a Name: ‘Client’, ‘Patient’, ‘Customer’, ‘Consumer’, ‘Expert by Experience’, ‘Service User’—What’s Next?

I do have a preference in terms of recording – I think clinicians should write using the patient/participant/consumer’s name.  For reasons I haven’t yet figured out many clinicians feel they must write using ‘client’ rather than the individual’s name.  I end up reading many, many notes that have the word ‘client’ many, many times.

Rogers CarlIf you’ve been reading my blog for a bit you know I love Motivational Interviewing.  MI grew out of the work of Dr. Carl Rogers, who introduced the idea of using the word client.  I support the non-judgemental acceptance Rogers advocated.  However I don’t think calling people ‘client’ rather than using their name does anything in helping operationalize Roger’s ideas.

Years ago I asked the director of medical records at the large teaching hospital where I worked whether there was some medical-legal requirement to use the term ‘client’ or some prohibition on using names.  She knew of none.  I think some believe that using ‘client’ in notes somehow is indicative of good professional boundaries.  I’m all for good professional boundaries but don’t believe using someones name in my notes in any way diminishes my commitment to maintaining such boundaries.

I like narratives.  People’s lives are stories they share with us.  When we document, why not make note of it as a story?

When you’re doing your notes this week try using the person’s name rather than the ‘c’ word.  If you’re an ACT team leader consider using an educational session to raise this with your team and allow people to express their thoughts.

And thank you, Dear Reader, for your time.

Shalom Coodin, MD FRCPC

Found it! Well, maybe not!

In the January 2016 American Journal of Psychiatry is an article titled Finding the Elusive Psychiatric “Lesion” With 21st-Century Neuroanatomy: A Note of Caution.  The first author is Dr. Daniel Weinberger, a big, big name in psychiatry for many, many years. (to learn more about Dr. Weinberger click here).

It makes it that much more noteworthy when someone of Weinberger’s stature writes “It has become research lore that structural changes in the brain are characteristic of many psychiatric disorders and are likely clues to primary neurobiology.” and then goes on to sound a cautionary warning that “the evidence that findings are neurobiologically meaningful is inconclusive and may represent artifacts or epiphenomena of uncertain value.” 

In other words what was found on scans may not be a real change in the brain but rather may be due to head movement (or other possible factors) during the scan. As they point outIs it so far-fetched to imagine that some patients have a harder time remaining motionless during the 10-20 minutes of the typical scan procedure compared to control subjects, many of whom are paid volunteers who often have considerable prior exposure to the constrained and noisy MRI environment?”MRI

Even more admirable is how the authors preface their technical critique (my bold):

Before offering our comments (with full acknowledgment that we ourselves have contributed in the past to the very literature that we are now raising questions about), we first advise the reader about the scope of this commentary:”.  Wow!!!

If you are a psychiatrist or psych resident I highly recommend reading the whole article (sorry but ya gotta pay to read the AJP).  If you’re an interested clinician who just wants the short overview click here to read the abstract.

I know someone who’s skeptical of medical science, pointing out that what’s recommended this year gets turned on its head the next.  This is actually what I love about it – the constant questioning of what is known and what we think we know.  I don’t think Weinberger undermines his credibility by pointing out that he is cautioning about work that he “contributed in the past to the very literature that we are now raising questions about”; it enhances his street cred.

MRI MAchine

Weinberger and co-author Radulescu conclude: “… we opine that current studies are plagued by so many possible systematic confounders that one can only wonder whether, like Wolfgang Pauli, “These results are not only not right, they are not even wrong!” We would caution that researchers and clinicians pause and rethink carefully the conclusions that can be drawn from these various MRI findings in psychiatric research.”

The human brain is the most complex thing in the universe (that we know of so far).  It doesn’t yield its secrets easily.  And as far as our understanding the complexity of it, well, as The Carpenters sang, we’ve only just begun.

It’s not that all the previous research on structural changes associated with psychiatric illness is bunk.  It’s just that we have to proceed carefully,  to realize how much we know, especially compared to not long ago and even more importantly, to know the limits of what we know.

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

Esso Leete

“More than by any other one thing, my life has been changed by schizophrenia. For the past 20 years I have lived with it and in spite of it—struggling to come to terms with it without giving in to it. Although I have fought a daily battle, it is only now that I have some sense of confidence that I will survive my ordeal. Taking responsibility for my life and developing coping mechanisms has been crucial to my recovery. I would like to share some of these with the reader now.”

                                                                                                                                     Esso Leete

Leete Article

How I Perceive and Manage My Illness by Esso Leete is a very personal description of coping with schizophrenia which was published in Schizophrenia Bulletin in 1989.  It remains a valuable tool for both clients and clinicians.  That doesn’t necessarily mean printing it off and giving it to clients though for some individuals that might be helpful.  For others it might work best to read it with them, asking what they think.

 In sharing how she’s dealt with the challenges Leete writes, 

Please understand that these are the kinds of obstacles that confront individuals with a psychiatric disorder every day. Yet we are perceived as weak. On the contrary, I believe we are among the most courageous. We struggle constantly with our raging fears and the brutality of our thoughts, and then we are subjected as well to the misunderstanding, distrust, and ongoing stigma we experience from the community. Believe me, there is nothing more devastating, discrediting, and disabling to an individual recovering from mental illness than stigma.

It’s worth reading the whole of this short, powerful piece and sharing it with clients; many will be able to recognize some of their own experiences and challenges in what she writes. 

Thank you Esso Leete.

Shalom Coodin