By Dr. David Laing Dawson

There were many times over the years, while attending committee meetings, planning sessions, administrative meetings, that I found myself thinking that many of the people who populate these groupings lacked imagination.

They were unable to imagine how their arrangements of good sounding words might be enacted, acted upon, or interpreted in the future, by real people in real social, professional and legal contexts.

In committee, on paper, the words and their alignment, sentences and paragraphs, sounded good. They signaled good intentions, inclusive values, sympathy, empathy, caring, freedom, choice, empowerment…..

But these words, to some of those committee members, were not merely vague symbols of very complex human behaviour, they comprised reality in and of themselves. How humans might absorb and then act upon those words was not something many could imagine in their mind’s eye.

I don’t think I had ever heard the word Aphantasia at the time. Though it was used to label a missing or diminished skill as long ago as 1880, it was not a part of any psychology or psychiatry curriculum in the 20th century.

But, it seems that at least some of the people in those groups were not simply not using their imagination, their brains simply could not visually imagine, could not form in a “mind’s eye” a picture or a video of people using and responding to those words, in real time, in a real context. They only imagined the words themselves. If asked how this might “play out” with real people in real time they drew a blank.

At the time it struck me as notable that many if not most people (men mostly) in administrative positions read journals, biographies, business articles. Seldom did they read novels. On the other hand I always thought that the consumption of novels, both great literature and trash, was an essential education for psychiatrists, psychologists and counselors of any stripe. An applicant for any of the training programs for these professions who did not like novels and/or preferred journals and biographies should be steered into a different line of work.

At the time my observation was just an off hand criticism, and sometimes an expression of frustration. But perhaps it accounts for so much failed policy in real life, so many mandates, laws, acts, policies, directives resulting in what we usually describe as “unforeseen negative consequences.”

Unforeseen, I now think, by those who have some degree of Aphantasia.

Coupled with, I suppose, those more common human traits of expedience, wishful thinking, ambition, and acquiescence.

Hence Ontario’s Mental Health Act, the “unforeseen negative consequences” of which have been well documented by Marvin Ross and many others.

It really sounds good on paper. Individual human rights are protected. The public will be protected. Unless incompetent or without capacity to make such decisions patients can choose to take or not take medication. It was assumed doctors would still do their utmost to treat illness and reduce suffering. The very ill, obviously in need of treatment, will receive treatment. Right?

At least until you imagine the enactment of the words of the Act, in a highly functional mind’s eye:

A psychotic person is brought by police to the emergency department of a busy hospital at 8 pm, and then waits (agitated, increasingly frustrated) until 11 pm when a tired, overworked psychiatrist comes down to assess this person in an uncomfortable room or cubicle in the emergency department. The police are still waiting, beside this patient, or just outside the door of an examination room, or in the corridor on a busy night, as they must, until a decision is made. They do not like waiting around. The psychiatrist’s options are limited. In theory he/she could offer the person anti-psychotic medication for the night and then talk with them tomorrow, but the Emergency Ward is not equipped for an overnight stay of an agitated patient. Besides, this psychotic person will likely refuse medication anyway. And unless he hits a nurse he can’t really be held down and given a needle. And the choice of medication is limited until we are sure he has not consumed any substances that would interact badly with anti-psychotic medication.

This psychiatrist could offer a bed on the psyche ward as a voluntary patient, but in reality there are two outcomes to that offer: 1. simple refusal, or 2. acceptance after about two to six hours of discussion/persuasion, then agreeing, then not agreeing, (did I mention the psychiatrist has already put in a 12 hour day), and he or she will know the ward staff will be very unhappy about having to prepare a chart, assign nurses, use the last remaining bed on the ward, for a patient who will likely, within an hour of admission, ask to step outside for a smoke and then run off. (And run off through the rest of the hospital because these same managers and administrators have put the psychiatry ward on the top floor of the hospital – thus creating the omnipresent fear of a psychotic man running through the surgical or infectious disease ward seeking the hospital exit, thus requiring a strong lock plus security at the door to the Psyche ward )

And, in reality, when we say psychotic patient, we are talking about a man or woman who believes he or she is bringing the word of God to people, being hunted by the CIA, tortured by radio waves, can live on air alone, is Queen, or King of Kings, or simply cannot put a coherent sentence together, and can’t really pay attention to the doctor because other voices are shouting insults at them, telling him the police are spying on them, and is exalted, or terrified, or very, very confused, or all of the above at the same time.

It is now one A.M. This patient is calmer but wants to leave. The doctor knows this person needs treatment, and that with treatment suffering will be reduced, a much better life awaits, and the inevitable deterioration of physical, psychological and social life associated with psychotic illness will be prevented. The doctor knows this person should be in hospital and treated, or supported and treated by an around the clock team in a safe non-hospital environment. (which may or may not exist and if it does exist in this community there is a 4 month waiting list). And this person will likely refuse treatment even when involuntarily detained. This will lead to unhappy and abused nursing staff. Besides, he can’t be detained, involuntarily admitted, unless he poses an imminent danger to self or others. Reasonable words. But what is “imminent” and what is “danger.” Well imminent danger to self implies suicide. So this can be resolved by asking that question and by the patient answering in the negative. “I’m not suicidal”.

Imminent danger to others. What does that mean?

At this point it is easy to predict that if allowed to leave the hospital, this person will inevitably get in more “trouble”, but the nature, timing, and severity of that trouble is harder to predict. So imminent danger to others might be narrowly defined as assault or attempted murder or murder within the next 24 hours. So let’s ask that question. “Are the voices telling you to hurt someone? Do you intend to assault or murder anyone?”

It’s two AM now. The police are restless. Their shift should be over. The Emergency staff want this resolved. The psychiatrist starts work again at 9 AM. And this person/patient still believes that perhaps he is the son of God, can live on air alone, and that his family has been taken over by aliens, but he says he is not suicidal, and doesn’t want to hurt anyone, and by now he knows he should reveal as little as possible to this psychiatrist, and that he is more likely to be let go if he promises to attend an outpatient clinic next week, and it’s a warm summer night, and it’s 2:30 AM now, and the psychiatrist still has a half hour of paper work to do, so……….

(note: the word “imminent” was removed from the ACT in 2000 and replaced with “serious” as in “serious bodily harm to self or others.” because of disparate interpretations of the word “imminent”. But now the ambiguity rests with the words “serious” and “bodily” – which seems to exclude slower deterioration of body and mind, damage to vocational, family, financial and social life. And does it include the damage a period of psychosis does to the mind and the brain itself? )

And once admitted involuntarily we still have the problem of a patient in Ontario, though deemed by doctors and later by a review board, to be mentally ill and to pose a risk of serious bodily harm to self or others, still being allowed to refuse treatment, because the capacity to make such a decision is not judged on the fact of being or not being delusional. For in the creation of these rules they failed to imagine a time when a person, dangerous to self or others, definitely suffering from schizophrenia, and believing he was born of the stars, or being persecuted by Aliens would or could pass a capacity test as narrowly defined by lawyers.