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

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





“We have consensus in the U.S. about what alcoholism is and what it is not, a consensus so nearly complete that to question its basic assumptions is to be either rejected as a dangerous heretic or pitied as misguided and misinformed.”

William R Miller

In his paper Haunted by the Zeitgeist Miller goes on to question those basic assumptions.  And yet I don’t think anyone would label Bill Miller – of MI fame – a dangerous heretic, misguided or misinformed. HauntedZeitgeist

Haunted by the Zeitgeist is a great piece for ACT team teaching!  Though published in 1986 it remains just as relevant today.

Miller touches on six assumptions on alcoholism that are still firmly held on this side of the Atlantic. He asks:

So what is alcoholism, really? If you ask most any informed American you are likely to have it explained to you that alcoholism is an irreversible disease that causes a person to lose control over drinking. Broken down into its component assumptions, the elements of this traditional American conception of alcoholism are as follows:

  1. Alcoholism is a disease. It is recognizable as a unitary syndrome with certain symptoms and a predictable progression.
  2. Alcoholism is a disease. Although the etiology is not completely known at present, it probably has a physical cause as well as psychological and spiritual elements.
  3. Loss of control is the central symptom. An alcoholic loses the ability to control his or her drinking. “One drink, one drunk.”
  4. Alcoholism is irreversible. One can never become a recovered alcoholic, only a recovering alcoholic. Return to drinking causes resumed deterioration. “Once an alcoholic, always an alcoholic.”
  5. The only possible hope for an alcoholic is total and permanent abstinence from alcohol.
  6. Far and away the most effective means for achieving this is through the fellowship of Alcoholics Anonymous (AA)…

The origin of these assumptions is not scientific data… The pervasiveness of this view in the US is difficult to explain to those living in other nations, where wholly different assumptions may be held…

He goes on to address each of these assumptions, presenting evidence to support or challenge them. For example on the idea that Alcoholism is Irreversible he writes “…to any reasonable reader of the scientific research on alcoholism treatment outcome, this assertion must be regarded as soundly refuted…Suffice it to say that there is no scientific basis for maintaining the possibility of nonproblem drinking outcomes, and that there is substantial evidence to the contrary.”Alcohol and Culture

He concludes with “Perhaps our best guiding principle through all of this is to remain close to the data. The current American conception of alcoholism and the treatment system that has been perpetuated by it exemplify how far it is possible to stray when a particular theory becomes more important than evidence itself… It is premature to claim to have the answers when we are still searching for the right questions.”

The ideas Miller presents are still very true and this article provides food for thought and discussion.  It’s worth taking small pieces of it and using it for a team education session. Get someone on the team to distil it down and present some of the ideas – perfect role for the team psychiatrist!  (Don’t make everyone read through the whole paper.)  After such a session your team members should have more questions, not less.  And isn’t that the goal?- to have better questions, not simplistic answers.

Sorry I can’t post a pdf of the whole article- I did ask the NY Academy of Sciences and was politely told that it is accessible online for a fee (as little as $6 – click here to view).  Or you can still buy a used copy of this publication (click to view via Amazon) for about the cost of a venti pumpkin spice Starbucks.

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.

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 


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

ACT Curriculum, Part II

” In the ongoing battle against mental illness, some of our most valiant warriors are on the front lines ITDD Coverworking with dually diagnosed, seriously ill individuals – that is, individuals who present not only with chronic and severe mental illness such as schizophrenia or bipolar disorder, but also with substance abuse. These patients confound the best efforts of public mental health systems and networks of treatment programs for addiction. As the authors of this book point out, the traditional approach has been to choose one diagnosis and focus treatment efforts on that before moving on to treat the second diagnosis. Typically and tragically, these efforts have most often been futile. Now Kim Mueser and his coauthors describe in this ground-breaking work a treatment for these difficult patients that provides a “Seamless integration of psychiatric and substance abuse interventions in order to form a more cohesive unitary system of care.”

                                                                                                                Dr. D. Barlow, from the Editor’s Note

If your team doesn’t have a copy of Integrated Treatment for Dual Disorders you must, must, must get a copy. This compilation covers a slew of stuff, from the basics, to assessment, group interventions to working with families and more. It really is a necessary resource that every ACT team should have on the bookshelf.

“…persons with severe psychiatric illness are at much greater risk for developing a substance use disorder than people in the general population. What accounts for the very high rate of comorbidity of the psychiatric and substance use disorders? Understanding the factors that contribute to the high rate of comorbidity may provide clues useful in the treatment of dual disorder.”

Rather than expecting clinicians to read it cover to cover use the chapters as jumping off points for education session discussions. Has your team ever tried offering persuasion groups (see Chapter 9)? How is a persuasion group different from an active treatment group? What are the problems associated with traditional twelve-step groups for clients with dual disorders (see page 187)?

Norway1 And if you’re going to be in Norway this June consider attending the EAOF’s 3rd European Congress on Assertive Outreach and hear Dr. Robert Drake, one of the authors addressing Assertive outreach for people with co-occurring disorders. (btw sunrise in Oslo on June 24th is 3:55 AM, sunset 10:44 PM!)

Shalom Coodin

“Whatcha Using?”

That’s not usually the way I open a dialogue with a client around substance use.  Rather, I’ll say “Everyone’s exposed to alcohol growing up and there’s lots of marijuana, coke, E, meth and other stuff.  What’s been your experience?”  Better to normalize things and then begin with an open-ended question.  It beats So, do you abuse alcohol and street drugs?”

In my opinion ACT teams don’t need substance use screening tools like the CAGE, the AUDIT or the DAST as much as they need tracking tools.  Most individuals have had lots of contact with services before getting to ACT.  And screening tools are a pretty ‘blunt instrument’,  so to speak.

DrugAlcPicThere are lengthy survey tools that have been used, including those detailed in Allness and Knoedler’s PACT manual.  My team came up with a modification of those.   Clinicians print off the Drug&AlcoholUseTemplate (click to view) – and either go through it with the client or, simply have the client fill it out.  The format is straight-forward, if the answer to the first question, for example:  Have you ever used an amphetamine or crystal meth, what some people call an ‘upper’ or ‘speed’ on your own, either without a doctor’s prescription or in greater amounts or more often than prescribed? is a No, you just flip to the next page.

The results are put in the PACTwise database (yes, a flagrant product placement/plug) and out comes a one page Drug and Alcohol Review (click to view).  This single page report provides an overview – age of first use for each drug, last use, use in theDrugAlcoholReview past 12 months – that gives clinicians an understanding of the client’s pattern of use over time.

This is certainly not the only way to track this kind of info. What do you use? How is it? What do you think would be the ideal tool?

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.”


“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.


Shalom Coodin

Family Matters

It often takes years before a client is connected with an ACT team. This can mean years of crises, hospitalizations and incarcerations. Family members have similarly been dragged along, experiencing the vicarious trauma of witnessing, and being directly affected by, a loved one having severe and persistent mental illness.

Beyond the day to day contact our team maintained with families, Roman and I would periodically facilitate a family group. We did not do this often enough but their effect felt lasting. If your team hasn’t been operating a family group consider giving it a try. Here are a few suggestions for how to arrange it:

  • Offer it in an evening, starting at 7 or 7:30 and allow for around 90 minutes.
  • Serve cookies or pastry, coffee and tea.
  • Hold it in your normal workspace where the team does morning meeting. Throw a drape over the chart rack (if you still have such a thing) to block names.
  • Don’t worry if you’re in the middle of the work area and evening staff are coming and going – it’s good for family members to see how the team operates.
  • Have the team leader facilitate and see if you can get the psychiatrist to come in even if it’s just for 15 or 20 minutes. Other clinicians are usually more than willing to help with this kind of group.
  • Have 30 to 45 minutes worth of material to present. Early in a team’s life the focus should be on the basics of how the team operates, how ACT services are delivered and the like. Don’t present too much – you want to leave ample time for those attending to talk and share. More on what to present below.
  • Invite twice as many people as you expect to attend and aim to have between 10-20 attendees (14-16 is ideal).
  • Welcome all; invite parents and siblings but don’t restrict.  Sometimes there’s an aunt, uncle or grandparent who has been very involved – they should attend.
  • Occasionally you may have a family member who is hurting and monopolizes the discussion. This can be challenging but allow them to talk and try not to cut them off. Family members need time to share the narrative of their experience, which has often been incredibly painful. Let people talk, let others share, don’t feel you have to over-control the process.
  • Don’t feel you have to be an apologist for the mental health system.  Don’t get defensive – listen actively and solicit others’ thoughts and experiences.

A Family Resource Guide cover

Several years ago our team had two excellent nursing practicum students, Lindsay and Uzoma  (see my previous blog on From Treating Team to Training Team), who did a wonderful job of putting together A Family Resource Guide.  It deserves to be shared and used. Consider taking a part of it and using it as the basis for a family session. (Note that on our team we used the term ‘participant’ rather than ‘client’ and you’ll find this term used throughout the document).  Chapter 1, an overview of PACT, is perfect for a first session.

I suggest trying to do a family group twice a year – spring and fall.  Bringing families together to learn from their experiences can be a most gratifying part of our work.

Shalom Coodin