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


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

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




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

Thank you John Oliver!

If you haven’t yet watched the Last Week Tonight segment on mental health and ACT stop reading now and click below to open the clip on YouTube.

John Oliver

John Oliver presents so much so quickly and makes me laugh and cry and shake my head at the absurdity of so many situations. Anyone working in ACT knows the absurd discrepancy between the needs of persons with SPMI (and their families) and the lack of services in so many places.

It’s wonderful that John Oliver, his writers, producers and HBO did this.

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.

No to cats? Not yet!

ACT clinicians should know some of the theories around psychotic illnesses.  For this reason it’s worth reading Andre Picard’s article in today’s Globe and Mail  The family cat is not Typhoid Tabby.

Picard Cats Globe

The possible connection between cats and schizophrenia– it’s not the cat, it’s the toxoplasmosis, a tiny parasite that many cats carry – has been posited for decades.  Dr. E. Fuller Torrey, a very respected American psychiatrist, has written on this for years citing research dating back as far as 1953.  Recent re-analyses have ignited new discussion.

Picard is a respected Canadian public health journalist.  Read his article if only to be able to reassure families that they didn’t cause their child to get schizophrenia because they had a cat.

If you have time consider reading or watching Picard’s convocation talk (available on the Globe site) to the graduating med school class at U of Manitoba, delivered May 14th this year.  A short excerpt:

picard talk vid

“One of the greatest privileges in our society is to have the letters MD after your name. Those two letters confer great power. And with that power comes great responsibility, to quote Voltaire – or Spider-Man, depending on your literary predilections.

Shortly, you will be taking the Hippocratic oath. You’ve probably all heard that it says: “First do no harm.” It doesn’t actually – that’s just bad media reporting.

But it does say a lot of important things. I think the line that matters most in the oath is this: “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.”

Sadly, too many physicians fail to honour that part of the pledge.

We have built a sickness care system rather than a health system. We have designed that system for the convenience of practitioners, not patients.”

Read the whole thing – it’s worth it.

Shalom Coodin

PS: My friend  – and team leader – Roman Baranowski is going to be doing not 1 but 2 presentations at the Third European Congress on Assertive Outreach – in Oslo, Norway being held June 24-26.  If you’re there say hello and tell him I sent you – he’d love to meet you and to talk ACT.

Hallucinations, Violence and a Closed-Ended Question

Last week was delusions. This week hallucinations.

The authors of the MacArthur Study of Mental Disorder and Violence write:

“The presumption of a link between hallucinations and violence is, if anything, even stronger than the supposition of a relationship between delusions and violence. Clinicians are taught uniformly during their training that patients experiencing command hallucinations, in particular voices commanding them to commit violent acts, are usually dangerous and in need of immediate hospitalization.”

So what did they find?

They conclude: “Our findings regarding the connection between command hallucinations and violence are somewhat more in keeping with conventional wisdom than were the results on delusions and violence. Although command hallucinations per se did not elevate violence risk, if the voices commanded violent acts, the likelihood of their occurrence over the subsequent year was significantly increased. These results should reinforce the tendency toward caution that clinicians have always had when dealing with patients who report voices commanding them to be violent.”

There you have it.

In the next section in Rethinking Risk Assessment (worth reading, as noted previously) they address “Violent Thoughts” and note:Rethinking Risk Assessment cover

“Have you recently been having thoughts of harming other people?” For as long as anyone can recall, this has been a standard question of clinicians’ mental status examinations for patients at admission and discharge from psychiatric facilities. Clinicians in training are taught routinely to make this inquiry. Indeed failure to ask the question could be considered negligent if the patient harmed someone soon after the examination and the victim claimed the injury could have been avoided with proper clinical inquiry about the patient’s thoughts of harming others.”

This question – “Have you recently been having thoughts of harming other people?” – isn’t one I would use or teach. It’s a closed-ended question that requires only a single word response. Does ‘yes’ or ‘no’ really provide the clinician the information they need?

While I’m not a forensic specialist, I’ve met many individuals struggling with paranoia. They have told me of feeling threatened, feeling unsafe, even fearing for their lives.  Their goal wasn’t to hurt someone; they wanted to feel safe themselves.  Thoughts of hurting others wasn’t about ‘hurting others’ it was about protecting themselves – it was defensive!

When I meet someone dealing with paranoid thoughts I ask them about their thoughts. I ask what steps they feel would be reasonable to take in order for them to feel safe, to deal with the ‘threat’ they perceive. Some individuals may take a passive stance – “There’s nothing I can do, they’re just too powerful ”, while others might say “I keep a machete under my bed all the time and if they try to come and get me I’ll get them first”.   In my view, this information is much more valuable than a yes/no response. It leads to problem solving.

Remember Shalom’s 3 favorite words “Tell me more.”

Shalom Coodin