Should Mentally Ill Women Have Babies?

There was a time when mentally ill women were sterilized.  People forget history.  If you forget history you’re doomed to repeat it.

Identification with the Agressor is the coping strategy whereby a person claims to say or be something another wants out of fear. A mentally ill woman saying she doesn’t want children may well be identifying with the aggressor, the aggressor being society today.  It’s called ‘internalization’.  

I’m not invested in women having children or not having children.  It’s the reason that counts.  Mentally ill women commonly have major self esteem issues.  Many have been commonly abused.  The consequence of emotional, physical and sexual abuse is a sense of inadequacy.  This can well translate to I’m not ‘good enough’ to have a child or « I could never be a mother ».

Récent studies have shown that women’s magazines are one of the principle harms to women’s self esteem.  

Having a child I remind women is an athletic event. If you can run, jump, play basketball, soccer, or do a long hike you’re fit. Ironically the larger the ‘hips’ the more likely a woman is to have an ‘easy’ delivery. We have moved a long way from the Twiggy anorexic to the Kardasian butt proud celebrity images. 

Yet there’s still many myths perpetrated on women by the women’s magazine industry.  The myths and ‘politically correct narratives’ push their various sales pitches, backers and propaganda agendas.  Ask your doctor and he/she will tell you if there’s any ‘physical’ reason to not have children?  

When I delivered babies, like every midwife and obstetrician, I liked seeing ‘hips’.  Traditionally ‘female shape’ equates with easy delivery.   That’s it.  Obviously if a woman has heart disease or  a rare  metabolic disorder there is reason for proper prenatal care.  Few conditions are  a contraindication to pregnancy and mental illness in general is not one of them. 

Mood Disorders, Personality Disorders, Thought disorders, and in fact, almost any mental illness is not a reason to avoid having children.  Mental illnesses in general are genetically receptive and the risk of transmission is so minor as to not be an issue.  Really! Really!  

The ‘genetics’ of mental illness is in its infancy and while certain traits ‘run in familie’s’ like alcoholism, the chance of transmission of the traits is incredibly small.  Even schizophrenia which has a strong genetic contribution must have environmental factors to lead to the expression of the schizophrenic genes.. A person can have the risk of schizophrenia because of certain genes but only if, for example, they smoke marijuana in adolescence will the schizophrenia be expressed.  If one identical twin has alcoholism the other twin has a 50% chance of developing alocholism but only if he or she drinks.  

Mental illness is ‘multi factorial’ and commonly ‘recessive’ as opposed to ‘dominant’ which means least likely to be transmitted generation to generation.  Mental illness is therefore not part of the  standard ‘genetic talk’ given to future parents.  If you have huntingdon’s chorea and want boys you might want to talk to a geneticist.  The risk of transmission of a ‘dominant’ trait is significantly higher 

However alot of women who have mental illness have been told they are bad, different, crazy,  all their lives.  She come to  believes this.  She then is likely to translate this to mean that she would not have a good child. A child of hers will be bad like her. The bad ‘seed’ myth.  Further, she believes she will not make a good mother.  Yet motherhood is on of the principle reasons for women ‘changing their life’ around. So many professional women I know used to drink and party other girls but when they became mothers they put on their big girl panties and did a hell of a good job. So women can change and it does not follow that a woman diagnosed with mental illness young will produce a bad child or be a bad mother. 

Dr. Whitaker the famous child psychiatrist also said , If you want to know about how a woman feels about having children ask her how she feels her mother felt about having her.  Self fulfilling prophecies in families can be undone in counselling and routinely are. 

It’s useful to counteract mis information and disinformation with preventative medicine ‘facts’.

My favourite fact regarding child birth that I love to share, to the chagrin and groans of my female friends, is that having children is beneficial biologically for women increasing their health and longevity and reducing disease. This part is true and sadly not shared as wildly as the abortion industry data with its political baggage.  However, here’s what gets the groans, The Amish studies showed that improved health and longevity for women   held true up to 12 children. Therefore, I tell women ‘don’t have the 13th child’ . The data showed no value with having more than 12 children.

Further having children under the age of 30 causes women to have reduced risk of  future cancer and early death.  

Similarly since women have their ‘eggs’ for  life, giving birth young, age 20 to 30 is better than age 50.  As giving birth is an athletic event it’s not surprising that 20 year olds have easier less complicated deliveries than 30 year old and definitely 40 year olds.  However having a baby as a ‘teen ager’ is directly associated with poverty and social problems which translate to future health problems. 

 Probably in western culture and society the ideal time for having a baby is 25 to 30 years of age. It is significant  because men have no such ‘biological clock’.  Given the power of female pheromes and fertility coupled with sociobiology,  reproduction as male defence against fear and denial of death,  casual sex is attractive with this age group of women regardless the age of men.  That doesn’t mean the man consciously wishes to ‘father’ the child or children. It does mean that men and women are vastly different, in a society which wishes often to deny this.  Women  benefit from being ‘informed’.  

When I was doing a  specialty in community medicine and public health I learned that the doctor is a powerful source of health information which people tend to follow.  I believe in ‘informed consent’.  I believe women who have mental illness need to hear that there is no ‘general’ reason for them not to have children.  Of course they can simply not want children but this should be for that reason rather than ‘because I’m mentally ill’. 

There are valid reasons for not wanting to have children. A truly valid reason I heard from a brain injured patient for not having children was « I can not manage my own health needs I don’t believe I would be able to give the time and focus to a child. ».  The question then follows , would you want a child if that was not an impediment?

Underlying any discussion with a mentally ill person may be the idea of ‘worthiness’.   The elite commonly have children.  Justin Trudeau and Sophie have children and nannies.  Donald Trump has children.  Obama has children.  In a world where the elite have control they might simply want to reserve resources for their children and deny mentally ill women children not for their benefit but simply to reduce the competition for resources on their own children, whether they’re mentally ill or not. Power corrupts. Absolutes power corrupts. The mother of the prime minister of Canada was mentally ill and no one discouraged her from having children. Yet if she was poor and nobody would that be the case.   In general the discussion for having a child should be the same for the mentally ill and the not yet diagnosed mentally ill. This is a factor because mental illness often appears later in life. Further the sophistication of diagnosis in western countries is hundred fold beyond the diagnosis of mental illness in other parts of the world.  So many Canadian and American women would simply not have a mental illness diagnosis if they were born elsewhere. By contrast this is not true for heart disease or diabetes.

My friend wanted a PHD rather than have a child. Another friend wanted a house. Children cost money and sometimes only the elite are able to make marriages work in these anti family times.  « I don’t like children. ». Now that’s a good reason not have children. Fortunately in Canada we have a social system with a great deal of support for all women having children so that the mentally ill will as likely have social and economic support having children. Certainly in countries where there isn’t a social network mental illness is a greater stigma.

I enjoyed a mentally ill woman who said she wanted to adopt a child using much the same logic as a person uses who chooses a ‘rescue dog or cat’.  Suffering anxiety about a lot of physical symptoms she had fear of pregnancy but saw that her somewhat delineated fear would make that a challenge but she understood she would make a good parents.  She cared for her dog and her neices and everyone trusted her to baby sit. 

I sometimes hear young people in general say they don’t want children because there are too many people on the planet.  The reason that upsets me is that that was the halcyon cry of the Morgenthaller abortion industry in my youth.  Morgethaller, Jewish,   had three children but aborted so many catholic babies.   That was when the elite were having 3 babies and the ‘peasants’ were told not to reproduce.  Yet thirty years later the government is inviting all and sundry to immigrate to here, saying that there are ‘too few people’ in the west.  

Meanwhile,  the greatest means overall of  reduce third world child birth ,where the women don’t have the education or financial resources,  to ensure optimal parenting, is to address infant mortality.  Maternal education is central to reducing the size of the family which economically is associated with reducing overall the growth of population. .  Women historically have lots of children because children are an old age pension plan.  Boys are especially at risk of dying early but are also the ones who contribute most to the family income.  If children are likely to live women are more willing to have less children. 

Further maternal education regardless of religion, culture, country or race results in reduction of childbirth to the magic ‘three children’. This is the number even the ‘elite’ choose.  Replacement plus a spare. 

The trouble is the most barbaric repressive regimes deny women education . For God knows what reason feminists don’t address this issue.  Women’s liberation did. Women’s Libertation which I marched and fought for  considered female education as the means to female emancipation.  

I believe the stigma against the mentally ill is so great that women with mental illness are at risk of not having children because they feel unworthy or have low self esteem. They are at risk of being marginalized, demonized and denied what clearly the elite persist in having.  The old certainly still see the value of family though Marx and Engles were against family when they planned the communist revolution.    

Most mentally ill women have great pregnancies, easy deliveries and make great mothers.  

UBC Psychiatry Department has a specific division of enlightened brilliant compassionate female psychiatrists who specialize in Prenatal, Perinatal, and Post Natal consultations for Mentally Ill women. If any one has serious questions or concerns they can get the best answer there. Not on Google. Not from Hollywood. Not from Housewives on the Moon.    

I want women with mental illness to have the same ‘true choice’ that other women have in this regard.  I believe in education and informed consent. 

RATE YOUR DOCTOR

Every year or two I look at ‘rate your doctor’ and consider retiring. There are such vehemently angry complaints that it’s hard to forget the obvious truisms:
1) You can’t please everyone.  I want to but I don’t need to.  I was actually ‘mr. popularity’ in school. To be ‘popular’ one has to be a ‘people pleaser’  and I can be a very good people pleaser.  However good doctors simply aren’t functioning on the same basis as ‘car salesman’ or ‘government beurocrats’.  Doctors who are no longer clinicians rarely admit to themselves their cowardice and how hard front line work is.  It’s the same with soldiering. Leading from the rear is very popular today. It wasn’t always so. When I was a family physician I was really loved and admired.  As a family physician one is there to ‘serve’ one’s patients and rarely is in conflict with the patient except ,as I found, the ‘psychiatric’ patients or the ‘criminals’.  In ‘physical medicine’ while a ‘diagnosis’ might be unwelcome, like ‘cancer’, it’s not ‘blamed on the doctor’.  By contrast as a psychiatrist I have been spat in the face when I advised a patient of my “diagnosis’ because ‘psychiatric diagnosis’ and especially ‘drug and alcohol abuse’ diagnosis carry stigma and ‘consequence’.
2) You chose psychiatry despite an extensive interview process in which those doctors before you explained that you as a psychiatrist you would be necessarily ‘unliked’ and even ‘vilified’ if you did your job well.  So why I am saddened today when I have such vicious and deceitful attacks on my character and my behaviour 30 years of practices and tens of thousands of patients later?  Probably because I’m increasingly told to treat the patient as a ‘customer’ and give them whatever they want even if it kills them.  Just make sure you ‘record’ what the authorities want to hear and ‘cover your ass’ like they do.
3) The College of Physicians and Surgeons across Canada have had to acknowledge that doctors working in the field of drug and alcohol addiction are the most complained against and those working with criminals are the second most complained against. Indeed there are class action suits against “Rate Your Doctor’ by psychiatrists because our ‘duty’ to society requires us to report people who are dangerous to themselves or others.  I am forever hated by a number of pedophiles I diagnosed in my practice and reported to the authorities or ‘forced’ them to self report.  I am forever despised by a number of people who felt they had the ‘right’ to kill their ex and I reported them to the authorities when they were not open to discussion of alternatives.  I am forever loathed by a number of people who I ‘locked’ up because they were acutely suicidal or extremely psychotic.  They lived and they got sane but they didn’t come back to see me because to them I was part of the ‘bad time’ and they thought I was ‘authoritarian’ and ‘over reacted’ and maybe felt they had the right to say they were going to ‘kill themselves’ and had a gun or planned to jump off a bridge that night.  I am forever hated by the men who I have told the RCMP I believed should not have the ‘right to own a gun’.  One has actually come to my office after learning this and threatened me.  I believe I made the right decision but I saw a very ‘reasonable sounding ‘ Rate Your Doctor ‘complaint’ the next day. I looked because he did say he would hurt me as I hurt him.  Some of the patients I consulted on  told me they were going to kill themselves then ran out of the office leaving me ‘with their bombshell’ and I phoned the police rather than having to live with the consequence if they had killed themselves.  Never as a family physician did I face any of this ‘level ‘ of responsibility or decision making.  As a general psychiatrist and psychotherapist I didn’t either.  But as a consultant psychiatrist working with patients with drug and alcohol problems and specializing in trauma and head injury (with their particularly interesting forms of psychosis and dissociation) I have had immense levels of difficulty that I can’t imagine how I would have handled years past when I only had 12 years of education and experience but a psychiatry specialist degree fresh on the wall.  I liked when I worked in the hospital or university or mental health team because we never had as much work as I do today and always got to sit in committees or consult each other and think about cases and work as ‘team’ so I was never so alone making a decision.
4) Forensic Psychiatry - I’ve worked with a whole lot of criminals, murderers , pedophiles, drug addicts, thieves, institutionalized criminals and not a few ‘jailhouse lawyers’.  Most of my colleagues simply never encounter these folk or avoid them out right. Naturally ‘anti social’ people account for the majority of complaints but rarely tell the truth about what happened including  a key component in their complaint  like ‘dr hay refused to give me valium’ or ‘dr hay refused to give me opiates or oxycontin’ or “dr hay refused to diagnose me add and give me speed," or ‘doctor hay refused to give me medical marijuana (he prescribed it to another guy I know)” or “doctor hay refused to say I was ‘disabled’ for life so I can collect disability for life.”  or ‘dr hay wouldn’t say I couldn’t work ever again because of my depression’ or ‘dr hay refused to take out of his report the part about my doing crack cocaine and heroin’ daily’, or ‘dr hay’s report told my insurance company that I was working two jobs and they cut me off my disability insurance because he fucked me over’ or ‘dr hay said I needed to join some group but he doesn’t understand that I have social phobia or agoraphobia’, “dr hay said I need to join a group if I have drug and alcohol problems and all I wanted to do was see him and talk about how everyone else puts me down’.  “Dr. Hay disagreed with my diagnosis that I read on Google that fits me.”  “Dr. Hay won’t order me an MRI because my lawyer says that would help my case.”  “Dr. Hay told my lawyer I had three previous brain injuries and I didn’t want my lawyer to know that.”  “Dr. Hay told my family physician that I had a half dozen complaints against doctors to human rights and the college and now my family physician won’t see me anymore’.  “Dr. Hay told my family physician that I’d never been in the military and that I hadn’t been wounded and that I was lying to get medications. I was getting oxycontin from this guy for a year but can’t now  because Dr. Hay fucked me over.”
5) Cherry picking - this is the way most doctors run a lucrative and successful practice.  If you avoid a) personality disorders especially ‘cluster b’ or ‘borderline”  b) impoverished c) divorcing people d) people with drug and alcohol history e) ptsd and anger issues f) people with pain disorder and major medical disabilities g) ethnic and aboriginal people with the increased complexity of problems h) LGBT patients with their long histories of discriminations and consequent sensitivities…etc…you can indeed have a very lucrative and successful psychiatric practice. Another way is to see the same people indefinitely at weekly intervals and mother them.  Never say anything that is ‘disagreeable’.  Indeed most ‘counsellors’ and most ‘psychologists’ dependent on the patient as ‘customer’ are very adept at this approach.  However as a psychiatrist I am by contrast ‘consulting to a family physician’ as opposed to just seeing the patient directly. Therefore every patient has another person in the room with them. Further I am held to the highest standard of ‘diagnostic’ and ‘treatment’ protocols which have must have a high association of reducing morbidity and mortality. I can’t do all the shit the homeopathic doctors do for the ‘worried well ‘ and ‘rich’ and ‘get away with it”.  By contrast ‘holistic healers’ are play acting in the real world of medicine without ‘accountability’ and yet have much of the benefits that have been long fought for by physicians.  No wonder we have ‘rug doctors’.  I am accountable to ‘science’ and ‘scientific evidence’ and can lose my license as well as my business as well as be sued and yes I can have complaints against me, if I don't. These complaints, not on ‘rate your doctor’ ,but in other forums routinely cost me $10,000 a piece in time and cost and loss of income. I would gladly avoid them but believe if I did that I would increasingly not be practicing medicine or psychiatry but rather practicing law, bureaucracy or some easier more lucrative thing like say, being a “ drug pusher for the multinationals’ .   If I’m in the ‘business’ of medicine I avoid these hazards routinely by ‘cherry picking’.  I ‘specialized in seeing ‘borderline personality disorders’ for many years as a psychotherapist and moved on to ptsd and then drug and alcohol addictions.  It’s common for me to see a person with a half dozen diagnosis and multiple failed treatments or to be seeing a patient with at least a half dozen other caregivers and often a lawyer or two involved in their care.  Summed up I have concluded that I have chosen over the years to work in the areas of ‘greatest need’.  When I worked as a fly in doctor in the north, the Northern Medicine Unit had advertised for the position I took for 2 years and I went to many Indian reserves that hadn’t seen a doctors in years.
6) Cherry picking - Psychoanalytically trained we all learned that the ‘best’ (safest and most grateful and most responsive) was a YAFFIE.  Young, Attractive, Anxious Financially well off, Fun, Intelligent and insightful and Expressive was the best patient. The psychologists and counsellors have like in every other field of endeavour taken this ‘cream’ of mental health work away from the doctors. It’s the same with obstetricians and midwives. The midwives do the ‘easy’ work and the obstetricians are left doing the tough work.  As doctors we are all now doing the heavy lifting and being paid less than those who are specifically living the life  of O’ Reilly because the minute anything becomes ‘tough’ they ‘refer it’ to the doctor or ‘worse’ , the ‘specialist’.  Being a ‘specialist’ is financially fucked today.  When I began I had a practice of loveable ’neurotics’  (they get under their skin”) and 20 years later I found my practice was mostly ‘personality disorders’ (they get under your skin).  Meanwhile my pay scale had decreased, my job satisfaction had reduced, my psychology colleagues were by contrast richer and everyone enjoyed referring their failures and difficult patients to me because psychiatrists and other specialists are the ‘last resort’.  We are lifes’ ‘garbage dump whereas the lucrative and really happy happy easy work and well paid work has been taken over by the ‘alternative health care’ and “allied health care professionals”.  They system is fucked and doctors are striking in England and working to rule in Ontario. And most of my colleagues at my age with my experience and training are trying find ways to avoid seeing difficult case rather than embracing them as they would if the system wasn’t fucked by the incredibly incompetent, inexperience, overpaid, lazy, entitled unaccountable administration.  
6) A week doesn’t go by that a referring gp asks me to see someone and confesses that as many as 50 other psychiatrists have refused to the see the patient. I turn down 10 consults a week.  Apparently I’ve got the lowest standards.  I routinely hear “ I’m sorry to ask you to see another one of my tough cases. I tried referring this to someone else but I called up 20 psychiatrists and they’ve all refused and I know you would but I feel it’s not fair to ask you again.’  I try to keep a few spots for ‘less complicated’ cases. I’m getting phone calls through the night and weekends and even when I’m out of the country, mostly because. “no one else will listen to me’.
7) I used to have two thirds of my patients as what I called the ‘ferraris  did ‘tune ups’ on while  a third of my practice could be described as ferrraris needing complete overhauls.  Somehow that became flipped and now I’m lucky if I’ve got a tenth of my practice who could be described as more ‘neurotic’ than otherwise. I’m really thankful when I see patients that have jobs.
8)More and more patients want me to ‘collude’ with their being off work or on insurance.  They are not looking for ‘therapy’ they are actually shopping for a ‘diagnosis’ which will suit their ‘work requirements ‘ and ‘insurance concerns’. A week or two doesn’t go by when someone objects to a diagnosis because it could ‘hurt’ them and we are in conflict.  As a result I increasingly am compromised. I record “situational alcohol abuse’ rather than ‘alcoholism’ because the patient threatens me in some overt or covert way.  I can’t know for sure but I’m worn down. I also get to read consults by my university colleagues and they’ve mostly sold out. They don’t even record the personality disorder, or the substance abuse or anything that the patient might be ‘offended’ by.  Meanwhile I’m condemned outright for being patient advocate and going to the supreme court in a pro bono fight for the right of doctors to be the advocate of the patient when the courts and the state want the doctor to work for them. I was with the psychiatrists against political abuse of psychiatry and have defended the most down and out patients repeatedly against the full weight of the ‘system’ and have been smeared by association.
Ian Magrew  summarized my patient as a ‘coke addict’ in the Vancouver Sun and was 180 degrees wrong in his reporting like half the reporting in the news today. Journalists today are so collectively considered ‘bought’ or ‘sold out’ or ‘biased’  or ‘corporate’ that the ‘comments’ on their articles are essentially the equivalent of  ‘rate your journalist’.  CBC closed down feed back because of the incompetence of journalists and how unpopular journalists are for their reporting of stories. They condemned the readers as ‘haters’ never considering that their journalism was the cause of such negative feedback which extends throughout the society.  Increasingly people have to turn to the internet to get the ‘facts’ because mainstream journalism is so ‘corporate’ and ‘biased’ or often just ‘outright wrong”. In the case in point,  I couldn’t even respond at the time to the highly offensive Vancouver Sun article because the case was still in court. So  paid scribblers like Ian Magrew can write the most outrageously erroneous material without fear of rebuttal because in most cases the lawyers advise those involved not to respond to Ian Magrew’s yellow journalism as it would negatively affect their on going cases.  Ian Magrew reduced my patient to ‘coke addict’ despite her being a decade clean and sober. But his stigmatizing the mentally ill and those who suffer from addiction killed her as much as journalists have killed countless with their condescending words and careless reporting.”Loose lips sink ships” They are not held accountable for their bias and irresponsibility and mostly don’t believe in truth which is possible for those who only work in ‘words’ . There was no stigma attached to general practice but there is a hell of a stigma attached to treating the mentally ill, especially those with drug and alcohol abuse and especially those with HIV or Hep C.  The head of the American Psychiatric Association says that Stigma of Mental Illness is shared by the psychiatrists much like no one wanted the “leper doctors’ to come to dinner.  It didn’t matter to Ian Magrew that the patient died or that eventually my lawyers defended me successfully. He had his ‘sensationalism’ and got paid his pieces of silver.   He never mentioned that all the cases he condemned me in were pro bono cases, that my assistance in the court cases was because the people I assisted had been financially ruined and marginalized and I had helped them because I believed they were being bullied and abused because they were mentally ill not because they were wrong. He’s a word smith and a review of his work shows he plays to the rich and to the judges.  He plays it safe and smart.  My friend Dugald Christie who started the Pro Bono Lawyer association said the failure of the courts today is that they no longer serve the lower classes or even the middle classes. I believe Dugald Christie would say the same of  Ian Magrew.The now dead woman had been bankrupted by the courts that have made Ian Magrew a very wealthy man.  That woman’s family  had mortgaged their house and been financially destroyed by the man that Ian Magrew championed.  That man who Ian Magrew chose to champion had in deed lost his license to practice.  The judge took the child from her mother who was ruined defending her and Ian Magrew summarized her as a ‘coke addict’ despite her long and arduous road to recovery. .  Ian Magrew himself hasn’t faced being drug tested.  He can dish it out but certainly can’t take it.  The only one involved in that court who had been drug tested was the poor mother who Ian Magrew continued to stigmatize as a  ‘coke addict’.  10 years clean and sober fighting for her child didn’t count to the sanctimonious Ian Magrew who would never dare to truly offend the courts because they, not their victims, are his bread and butter.  The stigma against the mentally ill and those who have suffered drug and alcohol abuse is very very real and the courts despite the 10 to 20% of judges and lawyers suffering from addiction has been slow to respond.  Journalists collectively have refused drug testing and newspapers, especially Vancouver Newspapers refuse to drug test their journalists en mass despite the rest of Canadians in ’safety sensitive’ industries being subjected to this only to be criticized by actively addicted marijuana, alcohol or heroin users who act out their drug induced aggression against those who have recovered from theirs. Countless research studies in psychiatry have shown that the  Media continues to be as outdated and ignorant as Ian Magrew for they continue to stigmatize and sensationalize the mentally ill the addicted and those who serve them.   If anything Ian Magrew’s writing shows its the continued ignorance of  journalists and the stigma against the mentally ill, the courts bias against the poor, and the terrible need for education and drug testing of journalists. When will a person be ‘good enough’ for Ian Magrew.  If there was a ‘rate your journalist’ I’d rate Ian Magrew as a outright unforgivable ’toadie’, a sensationalist yellow journalist, whose biases are blatant and whose writing is downright stupid.  Half the time reading him  because of his  tangentialism I want to ask what is that man smoking. He seems a terribly spiteful little shit as well so I would guess that few would care to challenge a man who has used words to beat up on the mental ill and those who have recovered from mental illness.  I miss the days when court reporter criticized the judges for their poor decisions and held the court to a higher standard rather than such obvious toadying and politically correct protecting the authorities with the kind of reporting that was celebrated in Pravda but should not be the staple of the Vancouver Sun.  Rather than Paul Simon singing where have you gone Joe DiMaggio we should all be singing ‘where have you gone court reporters’.  Ian Magrew is to court reporting what Kanye West is to music.  Court Toady.  Were there a College of Journalists to revoke his hack license, he’d be kicked out and depend on writing jingles for marijuana for his income.
9) I’m seeing an increasingly older population with worsening health so my patients have increasing health problems, a half dozen or more right now with major cancer illness, a half dozen or more with severe Crohn’s disease, a dozen or two with unstable diabetes, a dozen or more with severe endocrine disorders, many with heart disease, ex smokers with severe COLD, Hep C, HIV, dozens with major head trauma, I’ve only a half dozen or so conventional schizophrenics and I enjoy them as a ‘break’ from the world of ‘personality disorders’ I’m usually mired in.  Schizophrenia is easier for me to treat than schizoaffective disorder but I have a dozen or so schizoaffectives.  I enjoy the helping the transgendered patients and LGB patients because like my severe PTSD patients they’ve had a whole lot of persecutions.  The torture patients I treat are surprisingly the most grateful.  I’m treating dozens of muslims, christians, catholics, sikhs, hindus, pagans, and atheists, people of every colour. .  It’s complicated.  I am a Christian and I envy my Christian psychiatrist friend whose practice is 90% Christian and white.  I’ve done cross cultural psychiatry for decades but increasingly the ‘cherry picking’ is with a colleague who works with ‘predominantly LGBT” or “women only’  or mostly aboriginals’ and then they have the advantage they can ’skew’ their practice to the ’special needs’.  There was even one psychiatrist in Vancouver who following on the YAFFIE selection only treated ‘doctors’ and was greatly admired.  
9) I ask myself daily if I’m doing a good job. I use the old fashioned criteria that includes 30 years plus of ‘referrals’ and continued referrals from the family physicians I most admire in the city.  I also receive personal referrals from the heads of several university departments and treat people from all walks of life. I’ve treated multimillionaires, many olympic athletes, famous media people, professors, and countless street people. Most colleagues I know have practices with a very narrow focus  in comparison. The family physicians I most admire are as stupid as I am because  they go the extra mile for  patients.  I love them each individually because despite most often not knowing them personally I’ve heard some tidbit about them from the dozens of patients I’ve seen of theirs over the years. Just last week I heard of one of my favourite guys who refers to me making home visits to a patient who didn’t understand how rare that was.  Patients usually don’t realize what they’ve got till it’s gone. I’ve had dozens of patients come back to me and frankly tell me that the other psychiatrists only saw them for 10 minutes and only prescribed medications or didn’t tell them anything about themselves.
10) When I was a conventional psychoanalytic oriented psychiatrist no one knew anything about me and when I was doing strict psychopharmacology no one knew anything about me anymore than they did when I was a city gp. But when I was a country gp everyone knew everything about me, the same as when I was a country psychiatrist.  Further when I began to work in the area of personality disorder, ptsd and addiction I learned that ‘story telling ‘ was one of the most effective therapies whereas if I retained the ‘aloof’ parental position as opposed to the ‘uncle or aunt’ role in therapy I got nowhere. People ‘rejected’ outright what had been told to them ‘directly’ but couldn’t reject what was told to them indirectly. Years of extra advanced training in these forms of psychotherapy, structural, hypnosis, 12 step facilitation, and strategic all contributed to a very high success rate in getting people ‘back to work’ , off drugs and alcohol or healthy and moving on from therapy.  “i want to feel happy’ isn’t what the government is paying psychiatrists to do.  One pays out of ones own pocket for a ‘feel good’ counsellor but my job as a psychiatrists is as the ‘high paid help’ We are expected to judge our therapy on ‘morbidity and mortality’ and by outcome measures such as return to work, community involvement, stopping negative behaviour.
I will never forget when I shared how broken up I was by a patient suiciding at a local conference of psychiatry and one of my colleagues 30 years older at the time, stood up and said condescendingly “I”ve practiced psychiatry for 30 years and never had one patient committ suicide.”  I will forever love Dr. Brown who was Head of Riverview at the time and had the most experience in the city with the most difficult cases, standing up to my defence saying, “I know Dr. Hay is practicing psychiatry but I don’t what the hell you’ve been doing for 30 years.”  As anyone knows that if you are a soldier and hang out in Ottawa you will certainly not shoot anyone or be likely to get wounded. As every surgeon knows if you work in the front lines you will lose a patient or two. Indeed the more ‘risky’ the patients you treat the greater the risk of the patient dying. It’s become a problem in the US with Legal medicine that patients with severe problems not only can’t get insurance for them but can’t get doctors because the doctors can’t afford to take the risk that losing a patient would have on their insurance  coverage.  Canada is rapidly moving in this direction. One of the principal reasons for patients being unable to see doctors or have a doctor under the MSP public health care system is because doctors get paid the least and face the greatest risk seeing patients.  When I worked on salary with a government agency I saw 10 patients a week at most and had countless committee meetings instead.  We all congratulated ourselves too. In Private Practice I see 50 to 100 patients a week as a specialist where as private practice generalists see 200  to 300 patients a week.  A psychologist once told me that she had seen 10 patients with anorexia and considered herself the local ‘authority’.  At the time I ‘d seen some thousand or so patients with eating disorders but consider my colleague the ‘authority’ as he did an extra year of training beyond specialist level and has seen tens of thousands of patients with eating disorders.  It matters.  My gp colleague is delivering the children of the mothers he delivered and knows his patients for decades. I have several patients I’ve seen off and on over 30 years.  I’ve seen all the family of one patient over a 20 year stretch so have an amazing in depth and extended knowledge of this patient.  One visit with me every 5 to 10 years after that first year of therapy saves the health care system tens of thousands of dollars such a case. The horrendous lack of training and competence in health care administration is that there is literally millions of dollars of duplications of services.
Increasingly no one wants to do more than a ‘consult’. Consults get paid more than ongoing therapy but if one focuses on the loyal and happy ‘customer’ then one can indeed have an ‘easy’ practice whereas I’ve always had a combination of ‘consultation’ and therapy. Increasingly the patients who I don’t think would benefit from therapy are angry with me for refusing to accept them because frankly no one is willing to see this person weekly for an hour on the ‘government’ dime and these patients who are most wanting to be in therapy can’t afford counsellors or psychologists.  One of the essential keys to ‘rationing’ scarce resources and to ‘triaging patients’ is to decide if therapy would ‘alter’ the outcome of the patients case. Hence i have some patients I see for psychiatric psychotherapy because I believe I can improve their ‘morbidity’ or ‘mortality’.  I see a patient with heart disease for many years because he was told he would die and we both enjoy seeing him outlive the ‘predictions’.  I see some cancer patients because it improves their longevity.  I further have seen some students who were failing but now have gone on to getting masters and Ph’d’s.  I have enjoyed the ‘external’ criteria for success like using the ‘recovery ‘ and ‘days abstinent’ for assessment of my work.  I also encourage patients to leave my practice when they are well or have made as much progress as I believe they can at this time, while I leave the door open for return.  If I was in a private psychology practice I wouldn’t discourage a paying ‘customer’.  Psychoanalysis started as a year long therapy and because of the lucrative nature and the desire of the satisfied customer went on for 10 or more years. This is fine in a private paying system but in a public health care system I have accepted that I have a responsibility to the group as well as the individual.  One of my colleagues saw the same 40 people for 40 years roughly. If that was in the private pay system it would be good business.If I want to go to the same masseuse once a week for 40 years and pay out of pocket for this service it’s just fine.
However I did two years of community medicine and public health training in addition to psychiatry so I’ve been forever ruined because I think of the health care system and encourage ‘good’ patients who ‘love’ me to leave home without me.  In fact when I’m really looking forward to seeing a patient this is one of my counter transference criteria for raising the question of termination of therapy.  With psychopharmacology in contrast there is a diminishing need to see the patient and from initial assessment period of visits the frequency and length of time of visit can reduce to the standard every 6 month or year visit or transfer back to the general practice.  Mostly patients don’t want to transfer back to the general practitioner and most general practitioners want you to continue to manage the complex medication so the system gets bogged down and waitlists grow.  Also because everyone is trying to avoid upsetting patients because upset patient complain to the college and college complaints cost the practitioner thousand of dollars a lot of ‘dependent personality disorders’ and “hypochondriac’s are seen ad infinitum with no change in their health because they are ‘addicted to their therapist’ like a drug.  I get as many complaints from refusing to continue to see a patient as I do from seeing a patient. It’s like the horror i went through getting patients off benzodiazepines  The withdrawal process was as bad as the disease and the same occurs with ’termination of patients’ in therapy.  It’s so tough that junior doctors avoid it like the plague and everyone colludes to a very expensive tea time rather than doing the work of therapy which involve ‘learning to leave home’.  I am facing a complaint right now because a patient using alcohol and crystal meth wants to talk with me and wants me to diagnose him as being well and without a mental disorder. However I have explained to such patients without giving them a psychiatric diagnosis I can’t get paid. A week doesn’t go by that a patient doesn’t expect or ask me to do something for free but they’d never do this to a lawyer or a mechanic or any other business owner.  They get angry that I won’t do something and yet don’t understand that I do hundreds of hours of pro bono work and give thousands to charity and do all manner of volunteer service but in their eyes “you’re just a selfish uncaring bastard to not do this for me.” Every day my secretaries are asked to do unpaid services for patients who are incredibly entitled.  Often someone  sees the photocopy machine or fax machine and wants the secretary to work for them doing things wholly unrelated to their mental health issues. One patient used my secretary as their answering service having her forward their calls.  I’ve lost several staff because of patients threatening and bullying them.  Only other business owners in my practice understand the whole idea of ‘overhead’ and don’t assume the doctor is a ‘free service’.
I was in charge of the suicide ward at an asylum where the suicde rate was 5 -10 per year with 30 attempts per year. I reduced it to no deaths and less than 10 attempts only to see administration wanting then to cut back the resources because the ‘problem had been solved’.  Administration in psychiatry penalizes good work. The doctors who are most rewarded do not ‘cure’ but rather maintain the illness at a ‘manageable level’.  Hence in addiction right now the doctors most lauded are those introducing ‘safe injection sites’ which do not cause ‘abstinence’ but keep people sick but alive.  It’s probably not intentional but it’s fairly factual.  The Abortionists could make more  than the Obstetricians and I’ve been offered more money to prescribe marijuana than I was ever offered to get people off marijuana.
11) But increasingly I don’t want to justify myself. I’m looking forward to dying because most doctors I know don’t see themselves being able to ‘afford’ to retire.  Further none can find anyone to take over their practices so are even more hated for ‘abandoning’ their patients.  I dreamed of a ‘retirement’ or even ‘cherry picking’ a ‘safe practice’ by avoiding seeing any of those people who are ‘haters’ and ‘complainer’s and ‘liars’. My favourite Rate Your Doctor complaints are the active ‘crack addict’ who worked for me and hurt so many of my patients because she lied so much about her past and was promoted by a minister and some men who subsequently told me were her customers.  I fired her because she hurt a number of my patients but the damage this psychopath did to my patients and practice was amazing. In spite she also wrote a half dozen ‘rate your doctor’ complaints.  My other favourite is the old millionaire alcoholic I saw with a 40 ounce habit a day who wanted to see me for psychotherapy to talk about his ‘stress’ but became incensed that I diagnosed him as having ‘alcohol abuse’ in the first ‘assessment hour’.  As a psychiatrist I am required to make an assessment in 1-2 hours and was criticized by the licensing body when I had not made one in 5 sessions, apparently 3 sessions being some ‘unwritten maximum’ . Our
Royal College Examination requires that we have a diagnosis after 1-2 hours.  I have reviewed dozens of diagnosis from university departments and all of the psychiatrists there would not pass their Royal College exams today for their ‘missing diagnosis’ .  The diagnosis they most often ‘miss’ are ‘drug and alcohol abuse’ and ‘sexual diagnosis’ and anything deemed ‘political incorrect’.  They are “playing the game’ and are not doing their job of setting a high standard but cowardly doing ‘feel good’ psychiatry and avoiding at all costs anything that could be controversial such as a ‘axis II diagnosis’.   So ‘sins of omission’ are rewarded and ‘sins of commission’ condemned.
12) My windows were shot out.  Countless times I’ve had empty bottles smashed at my door step.  My cat was killed. My dog was murdered. My girlfriends car had empty beer bottles smashed on it. My family have been threatened and I have had my life threatened repeatedly.  Right now a man is emailing me telling me he is going to kill my dog.  Every one of these cases has involved a diagnosis of drug or alcohol abuse and in every occasion the person’s job was affected because they were told if they didn’t get ‘treatment’ then they would not have their job, so they have tried in every way possible to ‘kill the messenger’.  If only doctor hay  had not diagnosed them as ‘drug and alcohol abuse’ then all these bad consequences would not be occurring.  I have to date met with very mixed  support from my superiors but continued to do what I was taught and followed the laws and recommendations.  But a day doesn’t go by that I don’t think of retiring or just ‘cherry picking’ is the answer.  On really bad days, I think I’ll completely sell out and become a  court reporter.  I could go into administration and escape the front lines.  The trouble is I don’t think they want truth or experience. The key today is in constructivism and marketing. Propaganda, political correctness and platitudes.  There is physician assisted suicide.  Get in on the ground floor like with early abortions when the extreme cases were being used to sell another of today’s  most lucrative death industries.   Death sells.  Follow the money.  Get with the program.  Do no harm and patient advocacy are clearly ‘on the wrong side of history’.  It is 2016, to quote Trudeau.

Alternatively I could just not read "Rate Your Doctor" until they allow "Rate Your Judge".

William Hay, Psychiatrist

I am thankful for my name. Wiliam has served me well.  I use the formal, long version, though have been nicknamed Bill or Will throughout my life. The name Hay is a name I acquired from my parents.  My grandfather was a Reeve and my father a man admired as a leader.  The problem for me was ‘psychiatrist’.
I had no problem being, William Hay, Physician.  Today I still commonly introduce myself as such.  The stigma against the mental ill which is so prevalent in this country also applies to their caregivers.
I’m proud to tell people that I was accepted into surgery and did a year of the three or four required to be a surgeon.  Mine was a surgical internship and my electives had been in plastic and orthopaedic surgery as a student.  I had concluded in my training that I wanted to be a missionary doctor and that best equipped missionaries were surgeons.  I was reading a lot of turn of century history at the time.  The problem was my wife, another doctor, by the time I was an intern, didn’t want to be a missionary. She wasn’t even a Christian per se.  She wanted to work in the university and stay in the city.  She wasn't adventurous and certainly didn't like camping when I introduced her to the wilderness.  Our marriage never did work out.
In those days, and the tendency remains, I thought if something was ‘good’ , like obviously being a missionary to me was, others would see it as such.  Today I know a whole group of people think missionaries are idiots.  My wife hated the idea of my becoming a psychiatrist.  She loved the idea of being married to a surgical resident.  She didn't like psychiatrists, possibly because she'd grown up surrounded by severe mental illness and wanted a life as far away from that as possible.
When I announced I wasn’t going to return to surgery and wasn’t going to stay a family practitioner, but rather I was going into psychiatry, my wife was ashamed.  My medical colleagues collectively expressed their astonishment.  The jist of their concerns were summed up in these repeated exclamations,
“You’re such a good doctor, you don’t have to be a psychiatrist’.  When I entered psychiatry it was thought to be a place where only the lowest level of doctors worked.  Often immigrants entered the country by agreeing to work in asylums because even psychiatrists didn't want to work in asylums in those years.
“You can be a surgeon, you don’t have to be a psychiatrist”.  The hierarchy in medicine was from the ‘seen’ (surgery is so obvious) to the ‘unseen’ - the work of psychiatry is by far the ‘subtlest”.
“You’re a real physician, you’re not going to get along in that quackery’.   As a ‘real physician’ this meant, that I was a scientist.  I’d come into medicine with a mixed arts and science background.  My arts background made me ‘suspect’ to those students whose only interest had been science or technology.  I felt I had to ‘prove’ myself as a ‘scientist’ and that having done theatre and arts and english, liking music and writing, well, I was suspect.  I ‘proved’ myself with outstanding performance and knowledge in biochemistry and a gift for surgery.  So having ‘proved’ myself, here I was’ forfeiting’ my ‘membership’ in the ‘elite’ medical group of the ‘scientist doctors’ or ‘surgeon doctor’ to become somehow ‘less than.'  This 'elite' group has made an ironic comeback with in recent years as the respect for medicine declines and everyone is turning to superstition versus science in the true quackery of so many 'alternative medicines' and 'health food stores'.  People don't want 'scientists' or 'technicians' as much as they want 'physicians' but I never could explain my decision to be a psychiatrist because that was what was most "needed" back then and I can't explain this to them now.
The real ‘money’ in medicine was in surgery and internal medicine.  The psychiatric patients were predominantly poor in comparison.  The richest doctors were surgeons and internists and the poorest were often psychiatrists. The billing schedules from the start were always against the psychiatrist.
We were often mixed up with ‘psychologists’ and psychologists were considered collectively as ‘flakes’.  Mostly the psychologists were girls and the counsellors were usually people who couldn’t do the heavy lifting, like radiology technicians so ‘just talked to people’.  They were likened to ‘high school teachers’.  Doctors were university men.
As a family physician and a flyin doctor in the north I’d seen that the ‘greatest need’ was in psychiatry and addiction. I’d become interested in ‘non compliance and ‘non adherence to medical regimen.  This was only addressed at my university by psychiatrists.  It was called ‘resistance’.
Alternatively I considered ‘immunology’, a fledgling speciality pre HIV, because it too discussed the idea of the organisms' ‘rejection’ of transplants, and ‘immunological vulnerability’ to disease.  
In surgery and infectious disease, the emphasis was on the terrible external environment.  Bad things like bulletts entered good bodies and good surgeons took out the bullets and returned people to wellness.  Bad bugs entered good bodies and good doctors made good drugs to kill bad bugs and restore people to healthiness.  I consider 'regular' medicine like playing chess (I played chess at university) whereas psychiatry was like three dimensional chess. In psychiatry I was juggling a lot of ideas whereas in medicine I was usually just following protocols.
My first patient who died that upset me so much had been given excellent care. His doctors had all given him good drugs and he had good education and all should have been well but he and his family rejected the ‘education’ and he didn’t take his medication and therefore died.  Nothing all the kings soldiers could do would put humpty together again.  I felt a personal failure despite having done above and beyond the call of duty.  I 'd pulled out all stops to save this man and in the end it changed my interest from surgery to understanding 'noncompliance' and 'resistance' and a renewed interest in 'spirituality'.
That’s when in research  I learned first that 30% of all patients are ‘non compliant’ and another ’30% of patients spontaneous remit.  I'd always been interested in 'placebo' effect and became even more interested in 'psychosomatic medicine' when it was a fledgling idea. Further in a lot of populations 50% of patients didn’t follow their treatment and in psychiatric patients the number was as high as 80% of patients. 80% of patients didn’t take their medications.
My  colleague, rich, and loved by drug companies always saw a patients lack of progress directly a consequence of the medication so he prescribed a newer more expensive medication. I went to the patients homes and found that their drug cabinets were full of unused medications.  I asked why they didn’t take their medications and learned a wonder of information about how humans behave which was wholly overlooked in the pharmacy training at the university.   I remained poor and eventually didn't even teach whereas my colleague because the richest and most admired and favoured physician and psychiatrist because he was the principal representative of the pharmaceutical industry. Their greatest promoter and richest retainer.  I continue to look in drug cabinets and do home visits and believe thats where the real money of medicine is.
I also saw that the most difficult patients to treat in my family practice were the ones with mental illness. They were the challenge and the businessmen doctors didn’t like these patients because they didn’t get better like ‘good’ patients did.
There was a fine line between ‘bad’ and ‘mad’ and everyone, despite their expressed ‘liberal’ and ‘politically correct sentiments’ about the ‘mad’ ultimately treated them as ‘bad’.  They were ‘non compliant’ and ‘resistant’ and ‘difficult’ and as doctors became family men and businessmen and pharmacists vied to prescribe, all people wanted to make money and have a good job and go home to their families with patients who came sick, got better quick and went home themselves. No one wanted psychiatric patients. And no one wanted addicts. These groups were complainers and angry and didn't get better.  This was the time before 'lifestyle disease' became a fashionable word.
Most mental illness is life long.  The ‘chronic’ diseases are a waxing and waning sort. They have relapses and recurrences and there is a ‘vulnerability’ that causes patients with psychiatric illness to often slowly deteriorate overtime or not quite get back to where they were. Or, even if they do succeed very well, whose to say they won’t have an episode a decade or so down the road.
Whereas we never looked at people who had recurrent respiratory infections as having ‘weak’ lungs because of the ‘bad bug’ idea of infectious disease, we tended to look at people who had recurrent depression as ‘weak’ because psychiatry focused on the ‘vulnerable’.  Indeed psychiatrists who focused on 'trauma' or 'stress' or 'toxic workplaces' were no more welcome than were jail doctors who faced with treating bones broken by guards questioned the breaking rather than just setting the fractures. There's 'preventative' medicine and 'preventative medicine'.
Psychiatric patients were therefore called them ‘weak’ and especially those  with addiction, a part of psychiatry.  They were told  ‘buck up’, “man up’, ‘quit your crying’, ‘toughen up’.  Don’t be silly.
It’s 25 years later and I’m still calling myself, William Hay, Physician, without any concern but when I say, I’m William Hay, Psychiatrist, I’m hesitant.  When I am an ‘advocate’ for a patient who has heart disease or is in a wheelchair or has infection, I’m seen as ‘doing my job’.  A physician is supposed to be an advocate for his patient.  It’s part of the code of ethics for physicians.
I am an advocate for my patients.  As a Christian I am a healer and know that Jesus was a healer and he was also a teacher and advocate.  Part of my becoming a physician, when I could as easily have been anything else, I was a straight A student in Arts and Science at the university, the golden boy, a very large part was that I was a Christian. The finest doctors I’d known were Christian to that time in my life.  When I studied the history of medicine I saw that the truly religious, not just of Christianity but of every religion were the ones who made the greatest contribution to the healing sciences.  Religions in general took care of the sick.   My hero was Albert Schwietzer.
But to be an advocate of a psychiatric patients, worse, an advocate of an addict, or even a former addict, was to be akin to the "despicable."  Even St. Peter denied his association with Jesus when Jesus was condemned by the courts.  I saw that psychiatric patients and especially the addicted were condemned by society at large.  I was condemned by ‘association’ from the time I said I wanted to be a psychiatrist.  25 years later I am still condemned by association. I’m the modern equivalent of the ‘leper’ doctor.
Advocating for the addicted and mentally ill makes one ‘bad’ and as everyone knows psychiatrists are ‘mad’ already.
So William Hay, Psychiatrist is still a thing I hesitate saying despite years of experience, years of healing, years of amazing restoration of health of thousands of individuals and the overwhelming evidence that what I’ve done as a psychiatrist is deeply ‘good’, I’m still afraid to be associated with the ‘fallen’ .  Just like Peter, I fear ‘association’ with Jesus. I fear association with the mentally ill and especially those in recovery because they, and we are punished.  
This is today, when all surgeons and all internists know that they are working in the area of 'chronic illness' and that their patients all suffer mostly from 'psychosomatic' illness. As psychiatry has learned it's somatic aspects with MRI and beneficial somatic treatments like surgery and medicine, the rest of medicine and surgery has had to come to grips with it's psychiatric aspects and especially address the issues of non compliance and non adherence to medical regimen.  
William Hay, Psychiatrist.
William Hay, Advocate of the Mentally Ill and Addicted.
It still doesn't sit as well as William Hay, Physician.
Some days William Hay, Psychiatrist is a truly frightening thing to call myself.   It's like putting a target on.  It's like wearing general’s stripes on a helmut in a war zone. It's  like painting a red cross on an ambulance in a war with people who see illness as weakness and weakness as something to be exploited. That’s like saying to the rich, I’m poor, and waiting for the condemnation and laughter.  That’s not something one says openly in a world of ‘survival of the fittest’.
William Hay, Physician. That’s something societies at large have grown to accept and live with. Physical illness isn’t viewed superstitiously or as ‘malingering’.  But mental illness is.
Mental illness and those who treat mental illness and the advocates of the mentally ill are actually ‘threatening’ to those who are the most mentally ill themselves but conceal this as people who have secrets and lies do.
People who are hiding mental illness, especially those with alcoholism or doing cocaine,  for instance, or pedophilia, or sex addiction, or sadism, like to ‘punish’ the mentally ill to distance themselves from themselves.  But that’s something psychiatrists know.
William Hay, Physician. I can live with that.  William Hay, Psychiatrist, most days I’m too cowardly to say that.  Just like William Hay, Christian, is hard for me to say.  Christians are the most persecuted group in the world.  So what’s worse in a secular insane society, William Hay, Psychiatrist and William Hay, Psychiatrist and Christian.  Might as well, lock oneself up in the asylum.  When I worked there and lived there I knew as we all did that the bars on the wall were to protect us from the outside.  We didn't want patients to escape, not because they were so much a risk to society but because society was so harsh on them.  Jails were where people were locked up to keep them from escaping by comparison.  Jails protected society from criminals.  It's a subtle difference but then psychiatry is 'subtle'.  
Anyone who ‘advocates’ for the mentally ill and the addicted has painted a bull’s eye cross on their forehead for enemies to take aim at.
Much easier to be William Hay, Physician.
William Hay, Psychiatrist.  I don't know.  It takes a better man to wear that title.  I think I'll wait for the cock to crow a few more times.

Integrating HIV with Addiction Treatment in Community and Custodial Health Care Services - Adeeba Kamarulzaman - ISAM 2013 Kuala Lumpur

(These are my rough notes that hopefully will give an impression of the depth and breadth of the research and researchers work-W.Hay)
The co existence of HIV in iV drug users is as low as 10% in countries where approaches have been taken to address this early. In Malaysia theres as high as 50%.


With HIV treatment TB is the cause for mortality.
Prevalence of undiagnosed pulmonaryTB among prisones is 12%  - we are instituting a tb screening program at entrance to the prisons.

HIV Epidemiologic Researahc on Outcomes (HERO) study
Longitudinal studying of HIV infection in drug users
Have high mortality.
HIV infected  IV users 7.5/1000
Unaffected IV users 1.5/1000


Modelling of combined and high coverage intervention to prevent HIV infection
Opiate agonist therapies reduce HIV
British Commbia Research Study presented showing benefit of giving retroviral therapy to those who use IV drugs

IDU(intravenous drug users) - of those with HIV only 25% are receiving retroviral therapy
IDU's often present later in the course of their HIV infections
IDU's underrepresented
-Barriers to 'seek,test, treat, and retain'
requires active outreach and overcoming the stigma that surrounds substance abuse and HIV

Addictophobia - exaggerated fear, aversion, distrimation agains drug users
since the beginning of HIV idus have been villified
Apathy - to the suffering
Inattention to adolescent , street youth, women who inject drugs
Criminal Justice System -
Criminal Justice System in Malaysia
- prisoners 40,000 9137/100000
high prevalence of mental ill, mandatory HIV teasing 6% prevalence, methadone introduced in 2009 to 12 prisons, hybrid health care system (Ministry of Health and Justice System)
No form of HIV treatment in compulsory treatment

CDDC survey
2 of 6 HIV positive
80% of all HIV known by both programs
Fair proportion didn't know their HIV status.
Comprehensive care is being provided now in different Malaysian community
Project Harapan has been started to improve situation
Implementaltion Factors
-patient factors -tb related comorbidity, disclosure
-staff factors- clinician concerns, security concerns, repeated educational sessions
Institutional level - we've been fortunate the the 2 director generals for the last 5 years have been fully behind us, we have national task force, integrating criminal justice and public health, anti retroviral treatment not that available.
needle exchange has been done as well,