How the CPSO and the HPARB Stole My Last Chance at Recovery | Part 1: The Centre for Addiction and Mental Health
A gap in medical education: The psychological aftermath of physical restraints.
Here’s me reading it- doing exactly what I’m trying to explain.
Author’s note: I write under various pseudonyms in two languages. Every month, dozens of people with severe mental illness send me messages and comments to say they’ve become suicidal, and what their life looks like after being put in restraints. They, nor I, can ever go to a hospital again; something in us breaks, and it can’t be fixed. It rewires how we see people, our trust erodes, and our sense of safety disappears. This is my own story, but it represents a pattern that medical educators need to understand.
From May 31st to June 2nd, 2021, I was repeatedly injected with sedatives and immobilized in four-point restraints (6-point restraints/shoulder straps, according to the nurses’ notes).
The introduction to this series provides context for what’s next. Please note: the self-governing Health Professions Appeal and Review Board regulates the safety and practice of medicine in Ontario at the highest level and answers to no one. They have the legal right to amend and redact any and all information in my file without my consent, notice, or audit trail. All four cases are on public record. You can read everything I claimed.
Writing the CAMH part of this series was especially hard to get through, but I’m not an anomaly. I don’t want to drag the needle back into the cuckoo’s nest, but maybe that’s where it belongs.
Going through the doctor’s notes, the nurses’ notes, and all of the desperate, and furious emails I wrote with specifics filled a lot of gaps in my memory, and I freely say that I could’ve done without the recall.
Let me be clear from the outset: this is not an anti-psychiatry rant — quite the opposite. This is the story of how I ended up in palliative psychiatric care at Sunnybrook Hospital in Toronto, and the consequences of being placed in restraints. It’s deeply painful to discredit not only health care professionals in general, but especially CAMH. I get no pleasure from feeding the narrative that psych hospitals and wards are dumping grounds for people like me to be warehoused indefinitely, or stereotypes of psychiatrists as malevolent or abusive.
It’s been over four years now, and I think about it at least once every ten minutes, and every time I close my eyes. The white wall. The locked wrist cuff.
In May 2021, we buried my stepfather (don’t worry- he was dead). His funeral was in April, and he’d asked me to oversee the Catholic aspect of it. On the day of the service, I met with Father early to review it all. I was in 4” heels, and I forgot how physics works, so I fell down the stairs. The women at the funeral home helped me with the crusty blood. We black-Sharpie-d my legs where my tights were torn, and they strategically positioned me so I wouldn’t have to get up. I didn’t want to tell anyone. I spent the next few weeks on crutches and in one of those ridiculous boot casts. Humiliating.
That fall was used as an example of my “manic behaviour” in the 911 transcript, despite the fact that no one in my family was there to see it happen. At the time, I was on the outs with both parents and one of my sisters. After more than three decades, they still didn’t know how to deal with my illness, and it felt like they didn’t want to.1 It had been simmering for a long time, and finally reached a rolling boil inside me.
Otherwise, I was doing quite well. My writing partner and I were developing two different series, and I had started doing stand-up again after years of being too sick. I was volunteering a lot, and for the first time in over a decade, I only needed to see my psychiatrist every other week. I wasn’t in remission, but I was well. I started to accept that people will always expect me to act typically, while knowing my brain is atypical. And when I’m doing well, people want me to be perfect, because with my disease, symptoms count as transgressions.
In the two years prior, I had done more electroconvulsive therapy, five months of private cognitive behavioural therapy, and we had tweaked my cocktail of prescriptions, which is tricky. I’d also quit smoking, stopped drinking, chose celibacy, and tried to control whatever variables I could.
At the time, I was not only grieving; I was weaning off the crutches, using an ankle brace, and my floors were being redone. My place was a complete disaster. This becomes a problem if you’re mentally ill, and someone calls 911. When the police walk into the home and it looks like a tornado just tore through it, that patient is going to the hospital, full stop.
I keep my place clean out of sheer terror. Because of my history, I knew I’d have to go in either way. I always do. Five cops showed up, which was not only completely unexpected, but a little excessive, no? In the end, one officer took me to CAMH. No cuffs, no separation, no safety glass. If you look at the public record (as of today) it says that I was brought in by “the cops”, which immediately creates a false narrative. She and I had a lovely conversation on the way there. She offered me a cigarette when we got out of the car. I’d quit by then, but I was in police custody, so I didn’t want to split hairs. We smoked and talked some more, before we went inside.
When the doors slid shut behind me, the person I was ceased to exist.
It was the pandemic, of course. The emergency department was too quiet, too sparse. Too many crickets riding tumbleweeds. Generally, psychiatric emergency rooms are the same as regular ERs but less bloody, and more screamy. It was eerily quiet. The triage nurse sent the officer on her way. I sat for hours in the waiting room.
The 911 transcript said I was manic, and had overdosed on benzos. The call(er) also pulled quotes like “I wish I was dead”, and “…just pretend I’m dead right now…” from a televised comedy special I did, and to be fair, I can see why no one would believe I ever did comedy before. So, yes. I did say that but-
When the doctor finally saw me, I stated clearly and repeatedly: I was safe. I had no plan to hurt myself, or anyone else. I had a close network of friends, and a support system. The doctor wasn’t listening to me. I wasn’t being combative, I was answering his questions as clearly as I could, but he kept circling back to the same question, as though nothing I said made any difference. I asked him to contact my psychiatrist to clear things up. It’s usually one of the 1st things they do.
Did I look like I’d OD’ed on benzos?
He did no such thing. In fact, no one at CAMH tried to contact my doctor once- for the three days I was there. They did, however, give all of my private information to my mother when she called. She was not my caretaker, and I’d given no such consent. Isn’t that illegal? Or is that another right the mentally ill aren’t entitled to?
“…Next, specialty care must be re-imagined for patients with complex mental illnesses like schizophrenia, bipolar disorder, severe depression, and disorders complicated by co-occurring substance use. Such individuals need support over months and years, and may develop lifelong disability. They should have access to the same quality of care that we would all expect if we required chemotherapy for cancer, care for congestive heart failure, or an organ transplant.”
-Catherine Zahn, President and CEO of CAMH December 2009 - September 2021
I was honest about living with suicidality because he knew I had Bipolar Disorder. I wasn’t actively considering it, neither did I think a symptom of BD would blow a fifth year psychiatry resident’s mind, and I didn’t say that part out loud. I asked him why he was asking me questions without acknowledging what I’d already told him. Why, when I was being honest about my health and practices, would he not listen or believe me? What about me, about the way I was acting or presenting, made him question my mood or health?
We weren’t having a conversation. It was a closed loop that he controlled, and I was stuck inside it. Did he want answers? Every time I gave him one, it seemed to make him angrier. I tried to make it easier for him by showing him my blood donor app. It listed all of my medication and information.2 I still don’t know if it was the phone, or the fact that I kept answering him, but whatever fuse was left, it lit.
$2. Hear me read every post On Wax, with my witty asides and tidbits of extra information, jokes, general douchebaggery. Hear all about what it’s like to be on this end of the lawsuit for MAID MI-SUMC. I get it. $2 here, $2 there… it all adds up. Until June 20th 2025
I started to get nervous. At the time, according to my provincial patient rights (and those at CAMH), I was allowed to record the exchange between me and the doctor. I didn’t even have to ask his permission or let him know (and I knew this). I was being polite by telling him. I wasn’t new to this scenario. Indeed, it usually feels like a clown-rodeo in there, but something in the room was very off… very wrong. For once it wasn’t me. It was him. His energy darkened when I said I wanted to record our interaction.
He called in two security guards and instructed them to take my phone, and my shoes away.
I started to cry, and he told me to “settle down”. I asked if I was being unreasonable. Was it possible that someone in my position might be shaken or want answers- Bipolar, or not? I hadn’t had the best day.
Ignored. He ordered me to take an Ativan. I refused, because minutes earlier, he was asking me why I’d taken so much Ativan. For the record: I wasn’t being rude. I might not’ve been the picture of serenity, but I wasn’t a threat. I said that if he thought I’d taken a harmful amount, could he explain why more Ativan would help, and then I would take it. He wouldn’t.
To be clear, I love Ativan. Like, a lot. Big fan. Who isn’t? It wasn’t about that. It was that his reasoning didn’t make sense, and I refused on principle. I wasn’t going to accept treatment that made no sense. I know what happens at the hospital when psychiatric patients don’t take the medication we’re prescribed, I’ve always complied, and the moral of the story is, just do what they say. It doesn’t matter, just do what they say.
He said that if I didn’t take the Ativan, he’d inject me with it, and that’s exactly what happened. They restrained me, and injected me. I never understood why both were necessary. I never knew why either one was. I don’t even know why I was on a hold for seventy-two hours.
Some people deal with trauma through humour. I’ve always been one of those people. Maybe I cause trauma with my humour, but that’s neither here, nor there. I have two friends who are doctors, and they always told me there’s no room for jokes in medicine. Maybe they meant just mine, but either way, I didn’t learn that lesson. Doctors are serious af about being serious af. Zero jokes. Still, I’ve never met a psychiatrist who wasn’t mildly amused, or didn’t at least tolerate it (which I realize is a low bar when I hear it out loud. Shit. Was that my career, too?).
Did I make a couple of jokes? Yes. Any at his expense? No! Were they all gold? Not all of them. Did I have time to workshop that set, first? I did not. Do I ever want to hear about a shitty crowd in Barrie, or Vaughan again? Uh-uh. This was the worst. Crowd. Ever.
I coded-black, and he gave me a code white, if you will.3
I was 99.9% terrified and upset. It’s not my fault I’m hilarious. I was not laughing and crying at the same time, because then- fair game. Even I would be like, “I get it”. It’s just how I am- sometimes I giggle. I’ve always been big into giggling, appropriately timed or not. Just ask everybody who was at my grandmother’s funeral. Or the deliberate silence at Midnight Mass on Christmas Eve in the Cathedral every year.
It didn’t make a dent in how upset I was.
For three days, every time I was lucid, I had to yell so they could hear me outside the room I was being held in- for my phone, a doctor, my phone, a mental health advocate or lawyer, my phone, some water, my phone, food, a doctor, my phone… When I could get up to ask, that meant lock down my ankles. Legs apart. Wrists. Don’t get itchy, or cry with a snotty nose. Shoulders. Honestly, I don’t remember being in shoulder straps, but reading about it was like having it happen in that moment (it’s not written in the doctor’s notes, but it is in the nurse’s notes). I can hear my heartbeat in my ears just typing this. Injections. I mean… That was the gentlest treatment I got.
It felt like an out-of-body experience- watching his face as they held me down.
His job wasn’t to like me. His job wasn’t to find me funny. That wasn’t part of his professional obligation. Recognizing human emotion is. Recognizing that some people, sometimes process trauma through humour. The fact that he didn’t- or wouldn’t- recognize that? What are they paying him for?
I did throw in a joke as I was going down, and in retrospect, I really regret it. Because I’ve since punched-it up, and now that joke is fucking hilarious.
As the two men bent over me to spread me out like a dying starfish, I begged him to recite the 1st sentence of the Hippocratic Oath. I pleaded with him. I kept asking him to tell me something- anything, about that oath he took or why he’d wanted to become a doctor in the first place. I reminded him my life was in his hands. Had he forgotten? I asked him to consider how this would affect me long-term. I asked him to look at me. I asked him why he was doing this to me. I asked him how any of this was helpful. I asked him to please reconsider what he was doing. I asked him to take a minute.
I asked him to stop. I was breaking. He was breaking me.
My ankle was still swollen. When the guard was putting me in restraints, I asked him to be careful. He wasn’t. He squeezed it with the thick, locked strap. I asked for ice. I never got any. It was never even documented. They did, however, write that I was wearing ripped jeans, had no shoes on, and my toenails were painted red. He didn’t mention my ankle. In his description of me, he tried to paint a picture of some ragged, unstable woman off the street. Even if that were true, it should have nothing to do with the care a patient receives. I understand that sometimes appearance can matter clinically, if there’s serious hygiene neglect. It doesn’t matter that those jeans were distressed couture, but it does matter that he’s the one who took my shoes away.
He just couldn’t take me in. Who I was, what I was doing there, or even what I looked like. I wasn’t a person to him. I was a woman with a Bipolar diagnosis, flagged for suicidality, who was in the emergency department, and I was “non-compliant" for not taking the sedative. He was a clinician with a fragile ego, no time or attention to spare, and, with what I imagine to be some kind of risk management paranoia.
It wasn’t convenient for me to be lucid. Dealing with trauma by laughter and jokes doesn’t fit the psychiatric script (despite their obsession with comedy and mental illness). I was articulate, and I “challenged” him. Recording him meant accountability. He wasn’t using any new information to help, he was just scared by it, and I think that loss of control triggered him to punish me the minute I started asking questions.
But what do I know? I’m a crazy woman. He’s a doctor.
It’s worth noting that my blood tests showed 0.0% benzodiazepines in my system, which means that’s not what he injected me with, and I was telling the truth. I wasn’t an “inconsistent historian”, I was being force-fed drugs that I do not take, because of how they affect my behaviour. I do not remember having blood drawn at all, or giving any urine sample.
Doctors can restrain patients with apparent impunity. There doesn’t seem to be any meaningful oversight or accountability for these decisions. On the public record, the attending physician made it very clear that she never saw me, because she never had to see me. I was just your average, everyday woman, in and out of restraints and consciousness, for 3 days. All of my patient progress notes were slight variations of the first doctor’s, which were mostly copied from the 911 transcript. The notes got my address, religion, sexuality, and income wrong.
The most egregious assessment he made made was, patient looks her age. How dare you, sir. How dare you.
The official paperwork that gives psychiatrists the authority to legally hold someone in the psychiatric hospital/ward against their will, was botched. For the record, I understand that unfortunately, sometimes there is no other way than restraining a patient. This was not that. At all. Further, I won’t pretend to know how patient progress reports- or whatever the files are called- work. But my files are filled with 11 pages of doctors notes that are blacked-out. Let me emphasize that before the pretend gag-order, I showed that file to a whole bunch of people. This was some kind of clusterfuck.
Comparing the nurse’s notes in my medical records to the doctor’s patient notes is, as they say in medicine, “super fucked-up”. They don’t quite match. Further, their notes read that I refused a Covid test- and that’s why I had to stay in that room (in the emergency department). I was vaccinated, but beyond that, I was volunteering and took Covid tests all the time.
Had I actually refused a Covid test, I believe it would be a better argument for me being “a threat to myself or society”, than I actually was.
On the third day, a nurse came in quickly, rushed. “You’re going home,” she said. “There’s a doctor coming to talk to you, but either way, you’re going home.” It felt sudden- like I was being released before someone changed their mind. I had been in restraints just a couple of hours before. The doctor came in on her heels and asked what had happened. I told him. He said, “I’m horrified.” I said, “You should be.” I remember thinking that was the rudest thing I’d ever said to a doctor. He told me he wanted to talk to my psychiatrist, but either way, I was leaving right now. 4As I waited for my Uber, the sun I hadn’t seen for days stinging my eyes, the psychiatrist came out to tell me he spoke to her, and I was seeing her first thing in the morning.
And then I left. I just walked away. It was over. And I was free. All it took was one doctor doing his job.
In my entire life- I never thought I could be well. I had a brief stint of remission once. Many doctors had tried to help me and many did. It never stuck. But for two years, there was a maybe? in the air. What a fool I was. I allowed myself to believe I could do something that, by default or design, this world was never built to allow. I thought maybe this time, I could live. We all knew I didn’t want to, but I’d started to believe I might be able to keep trying.
“There's an old saying in Tennessee- I know it's in Texas. Probably in Tennessee, that says, fool me once, shame on- shame on you. Fool me- you can't get fooled again.”
―George W. Bush, Nashville, Tennessee, September 17, 2002
I didn’t need those three days to remind me of how little credibility and respect people who suffer from mental illness are afforded- and of all people, in all places. How easy it is to dehumanize the vulnerable. How casually those three residents and attending physician forgot what it means to carry the weight of doing God’s work. A lot of shit has to go right to become a doctor. It isn’t a means-to-an-end job. It’s being a fucking healer. They tore me apart.
I’ll quit bragging- but I’ve been in a lot of psychiatric wards and psychiatric hospitals, in a lot of places, for a lot of years. I’ve been in psychosis more than once. I’ve never been restrained. Not even close. It’s just never come up.
By commission and omission, the nurses5 and doctors didn’t just violate my patient rights. They continue to rob my headspace, and my health. They took any life left in me and sucked-it out, like laissez-faire vampires. I can say “I’m safe, I have no plans to hurt myself, blah blah…” and I can really mean it, but what good did it do me? Where do I go now, when I need help? If you look in my eyes like the doctors refused to do, you’ll see- there’s nothing in me that lives. I’m devoid of life and hope.
These doctors robbed me of my newly-found, desperately sought after, and long-awaited good health. For the first time in decades, I finally got healthy with adamant, and relentless hard work- and lots of help. All of the rape-trauma therapy I did? All the ECT, all of it- everything we tried was for nothing. It’s all gone now. I can’t tell the difference between being well or not, and honestly? I no longer care. Would you?
Do you believe I’ll overcome this trauma? That it won’t forever haunt me? My doctors tell me they believe I could recover. What else are they going to say? Could you suffer that, and ever be the same? Could your partner? Your child? Your dog? Do you remember what you were doing three days ago? Have you ever been pinned-down for thirty seconds? Completely immobilized?
CAMH refused to give me my patient records from my stay. It took doctors getting involved- rather, people who mattered- to finally get them, six months later. There were (11) pages completely blacked out- it was heavily redacted.
By that time, The CPSO investigation was underway. I was trying to recover in Nova Scotia; I was able to bypass the Atlantic-Bubble by way of compassionate exemption, because I was undeniably ruined. I can’t function independently anymore, but if I could, I would’ve stayed in NS forever.
CAMH also refused to give me all of my medical records, or speak with me regarding my complaint.
A year and a half later, when Patient Relations at CAMH finally did meet with me, it was thanks to The Empowerment Council’s intervention. I asked Lucy Costa (from the Council) to come with me. I had prepared a list of questions for that meeting. I walked her (Jenn) through everything, and she took me seriously. She cried when I told her what had happened. I hadn’t had any human touch at all for four months before that day. After the meeting, I hugged both women. Over a month later, we met again, and Jenn gave me as many answers as she could. Not everything, of course- nothing that would hold CAMH accountable- but she tried. I wasn’t there to take down the hospital, or any doctors. That was never my intention. It had nothing to do with it.
It’s that it was a teachable moment. Now it’s just resentment that undoubtedly bleeds into their work.
At each stage of the appeal process, I admitted I couldn’t possibly be right about everything- but that I was being honest about what I knew. That was a huge mistake- at the end of it all. I don’t care.
I did want a hard copy of every single thing that happened. CAMH couriered over a thousand pages. It wasn't enough, but I was grateful. It was almost enough. All I wanted was to talk to the doctor.
He opened his own practice four weeks later. He was ready.
I can’t meditate anymore. It’s what I did when I was locked on the bed. My mind is infested with a residue of horrors you can’t let yourself imagine. It nests, and waits. My hair’s always on end, and it’s rotting me from the inside-out. It's disgusting, and it won’t stop. My throat starts to close when I look at texts, pictures, videos, and emails of who I was, what I used to be- and the sharp decline of my health, the collapse of my life, and the crushing madness I carry now.
I might’ve lived. I was already applying for MAID, but I could breathe for a minute. My friends miss me. My family. Every single day, I wish that psychiatrist killed me. What the four doctors did was inhumane. Unless it’s not. In which case, let’s go back to lobotomies. And give me one, please.
For years, two of my closest friends made an annual donation to CAMH in my name. Eventually, I asked them to reroute it to Médecins Sans Frontières. It seemed a more fitting reflection of what healing should mean.
The 911 call was made out of genuine concern. My family and I have worked through our differences, and they are extremely supportive.
I haven’t been able to donate blood since I was released on June 2nd, 2021.
Hospital codes: Black = bomb White = someone dangerous on the loose, get the net!
When they gave me my shoes back, the laces were “just gone”. My laces in my sneakers were straight-bar laced. Someone went to some trouble to take them out.
I could not bring myself to make a complaint at the nurses’ college at the same time as the physicians’. I wish I had.