A character study of mental illness and change

Posted on May 7, 2012 in Health Debates

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NationalPost.com –
May 6, 2012.    Joseph Brean

Settling in by the window of a French bistro along the strip of Harbord Street that caters to Toronto’s academic gentry, the psychiatrist David Goldbloom refuses a glass of wine without a second thought. Frankly, he looks appalled at the suggestion, as he will soon be seeing patients at the Centre for Addiction and Mental Health, where the lingering odour of even the most delicate grape could cause untold problems.

And yet, given the daunting task before him as the new chair of the Mental Health Commission of Canada, whose national strategy launches on Tuesday, one imagines the man could use a drink.

For the casual observer, the parade of news stories about mental illness at the extremes can inspire despair. In Halifax, a gay activist is killed by a man on a one-hour leave from a secure forensic psychiatric unit. In Toronto, a schizophrenic man kills his father at home, and then himself in jail. An Ontario appeals court rules that a man who killed his wife may collect on her life insurance, over their son’s objection, because he was insane when he did it.

And the Ontario legislature vows to review police procedure to reduce the number of mentally ill people hurt or killed in confrontation with police.

With headlines like these, it is tempting to see serious mental illness as the incorrigible problem child of Canadian health, social and justice policy, epitomized by Ashley Smith, the mentally ill New Brunswick teenager whose cross-country tour of Canada’s penal system illustrated its myriad failings and ended with her suicide being videotaped by guards.

But as he prepares to launch Canada’s long-awaited national strategy on mental health, complete with a budget-style media lock-up on in Ottawa, Dr. Goldbloom is much more optimistic, and his perspective is wider than the terrible extremes.

“We do have a problem with perceptions of dangerousness among people with mental illnesses,” he said. But it is only that — a perception problem — and things are changing.

“We know that prisons, jails, are the last great asylums of North America for people with mental illness,” he said over a lunch of steak frites and tap water. “The biggest asylum in the United States is the Los Angeles County Jail. There’s about 20,000 inmates and about 2000 of them are severely mentally ill. We know that people with mental illness are really vulnerable to being victimized in a prison system, and that care in a prison system for people with mental illness is nowhere near where it needs to be.”

At the same time, he said a shift in public attitudes to mental health has opened vast new possibilities for progress all across the spectrum of mental health — from problems that are not illnesses, through the various forms of depression, anxiety and behavioural symptoms, to serious and persistent illnesses like schizophrenia and bipolar disorder. Big philanthropy has followed suit, such as the $10-million donation last week by Margaret McCain, widow of food magnate Wallace, for youth programs at Toronto’s Centre for Addiction and Mental Health, where Dr. Goldbloom is senior medical advisor.

Once an aspiring actor, he also chairs the Stratford Shakespeare Festival, and comes from a family of prominent doctors. Energetic and funny, he joked that he recently emailed some Jewish friends about the Stratford Festival’s recent Broadway smash hit production of Jesus Christ Superstar, and included a “spoiler alert” in case they did not know the lead character dies in the end.

“I’ve never seen anything quite like it,” Dr. Goldbloom said about the spike in public and government interest in mental health programs, and the newfound ease with which these topics come up in public discourse — even in death notices that explicitly mention suicide, where once it was taboo. By taking lessons from grassroots advocacy for breast cancer and HIV, Dr. Goldbloom said he hopes to harness and promote this trend, but problems keep coming fast and furious, and he has taken over the commission at a decisive moment in its history

Formed in 2007 with $130-million in arms-length funding from Health Canada, and set to close in 2017, the Commission has always had a dual purpose, first articulated by inaugural chair and retired senator Michael Kirby, whose family experience with mental illness inspired his 2006 report Out of the Shadows At Last.

On the one hand, the MHCC combats stigma, a goal it has pursued, for example, by commissioning research on media archives to show journalism students how frequently news stories that mention “schizophrenia” are negative in tone, and how infrequently they are positive.

On the other hand, the MHCC was also mandated to prepare a national strategy on mental health from its uniquely independent position outside the federally-funded provincially-administered health system.

It is that duality in the commission’s purpose — between its optimistic orientation against stigma toward empowerment and recovery, and the worryingly frequent system failures on serious mental illness that call out for a comprehensive strategy — that has caused it the greatest grief and put it on the defensive, never more than last year, after the leak of a draft strategy that was long on platitudes, but short on substance.

One psychiatrist observed that the draft version did not even mention “psychiatry,” nor “schizophrenia” or “bipolar,” but “recovery” was mentioned 67 times and “support” 127 times. Advocates for schizophrenia treatment have similarly warned of the influence of anti-psychiatric academics, even anti-medicine conspiracy theorists, on the commission’s many advisory boards.

The draft was so widely criticized that the Commission’s CEO, Louise Bradley, vowed in a letter to Canadians to “correct” its failures of emphasis, because it “does not sufficiently reflect the essential role neuroscience, treatment and psychiatry have to play.”

This is one of the many problems Dr. Goldbloom, a long-time MHCC board member, was promoted to solve. As a front-line expert on the nastiest of mental disorders, he is ideally qualified to quell suspicions of anti-psychiatry from without, while also confronting expressions of it from within. But he is touchy about what went wrong.

“What got released was a draft. The draft was nowhere near a level of reaching board approval. It was a work in progress,” he said. “It’s a better document now. The language has been refined over the course of the last year to try to better communicate the beliefs of the commission and the beliefs of the people who serve on it.”

He said the next few years will be devoted to the critical “translational aspect” of the strategy, in which a national vision is adapted for local application, from provinces, most of which already have strategies, down to the level of municipalities.

Dr. Goldbloom said the board focused closely on the strategy’s terminology, deciding on the term “severe and persistent mental illness” to capture the worst, while also taking the position that not all mental health problems are illnesses. He said “presenteeism,” for example, or being incapable of working while at work, is of major social and economic concern, though not an illness in itself.

“That is not talking about mental health ‘issues,’” he cautions. “I hate ‘issues.’ Nobody with cancer says ‘I have neoplastic issues,’ ‘I have cell proliferation issues.’ They say they have cancer.”

It is a refreshing bluntness. More than any other health problem, mental illness is vulnerable to fuzzy, clichéd thinking. Psychiatry itself has a mixed history in this regard, Dr. Goldbloom said, of being misled by its own metaphors, and forgetting what is proven and what is fanciful theory. Freudian psychoanalysis is the big example, but the same can be seen in theories, false but once widely held, about the origins of mental illness in faulty parenting.

With the rise in understanding of genetics, Dr. Goldbloom said we have shifted to “a much more profoundly biological paradigm” in how we understand mental disorders, but full insight remains elusive.

“We don’t know what causes schizophrenia, but it’s not bad parenting,” Dr. Goldbloom said, pointing out that if you have an identical twin with schizophrenia, your odds of getting it are 50%.

“The point is it’s not 100%. If it was cystic fibrosis, you would get cystic fibrosis,” he said. So there is more going on than just genes, some of which you might be able to control, such as exposure to stress, for example, or marijuana, which in susceptible young people can trigger psychoses. Similarly, if everyone in your family had a heart attack at 40, you would probably take measures to prevent your own,” Dr. Goldbloom said.

“This is about managing risk. You can’t control genes, you can’t pick your parents. But genes are not absolute destiny,” he said. “The extent to which stigma, illiteracy or shame stops people from checking things out is a tragedy.”

At the extremes, the contrasts between normal and pathological are stunning and clear, but Dr. Goldbloom doubts he will ever be able to pin mental illness to the wall, in the way that viruses explain the common cold, or tobacco smoking explains lung cancer.

“What people don’t appreciate is that we draw arbitrary lines in medicine, between health and disease, all the time. There’s been intense focus on this line drawing in psychiatry, in the context of all of the controversy around DSM-V [psychiatry’s diagnostic manual],” he said. “We are inexorably attracted to certainty. We love dichotomous variables. We love lines that we can draw. Unfortunately, the simple conclusions are often the most alluring and the most incorrect.”

He cited the panic over suicide and drug abuse among NHL enforcers as an example of jumping to glib conclusions, but he acknowledges that the impulse to grasp at even a wisp of understanding is unavoidably human.

“How do the parents of any child who has any kind of disorder not wonder about their own genetic contributions to their kid’s illness?” he said. “Every caring parent scrutinizes themselves, their behaviour, their biology, when they see a child of theirs suffer. I think it’s inevitable. We don’t have evidence they could have done something difference when it comes to schizophrenia or autism, so I think one of the comforts we can provide to families is alleviating that sense of blame, castigation, but also not simply blame, but sometimes shame. Those are not the same. And one of the things that magnifies shame is stigma. Because if your child has liver failure or diabetes, the response of the community around you is support. They’re all over you like a dirty shirt… But [in the case of mental illness], for some families the response is social distance. People back away.”

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