BACKGROUND
In the last ten years or so, the anti-psychiatry movement has been gaining adherents, and has been growing more focused and more outspoken.
But we are not a unified group. I, for instance, take what I think would be considered a fairly extreme position. I believe that there are no mental illnesses; that the clusters of thoughts, feelings, and actions labeled as mental illnesses are better conceptualized as habits that have been acquired in accordance with the normal principles of behavior acquisition or as understandable responses to extreme life stressors. I further believe that conceptualizing these problems as illnesses has been disastrous for the individuals involved, and for society in general. In particular, I believe that psychiatry’s promotion of the idea that all problematic thinking, feeling, and behaving is caused by brain illnesses and can only be treated with drugs is causing extraordinary levels of physical damage to their clients. It is also severely stigmatizing and disempowering. As a culture, we are losing the notion that people can improve their lives through effort and application, and through mutual assistance and support.
It is my contention that psychiatry, as a profession, promotes its own interests and the interests of its pharmaceutical allies over the interests of its clients. Psychiatry’s wake is littered with severely damaged people, to whose plight psychiatrists seem largely indifferent.
Other people, who would generally see themselves on the anti-psychiatry side of the debate, adopt more extreme or less extreme positions than mine. This is not, in itself, a problem. Disagreement and dialogue are healthy, and help us sharpen and refine our concepts.
But there is one area where the disagreement is seldom aired or even acknowledged. This is the question of pharmaceutical drugs, or, as the psychiatrists like to call them, “medications.”
TO DRUG OR NOT TO DRUG. THAT IS THE QUESTION
What we’re talking about here are the pharmaceutical psychoactive products that psychiatrists (and indeed other physicians) use to “treat mental illnesses.”
I call these products drugs, because if the conditions being treated aren’t illnesses, then it makes no sense to call them medications. But there’s an immediate problem. Benzodiazepines clearly fall into the category of drug as I’ve defined the term above. However, benzodiazepines are routinely used by physicians to help a patient relax or even doze off during a painful or uncomfortable medical procedure. Under these circumstances, although these products have considerable potential for addiction, I think a case can be made for calling them medications. But when prescribed for long periods to help a shy person cope with social difficulties or a fretful person relax, I call them drugs.
In my view, the drugs used by psychiatrists to alter people’s thoughts, feelings, and/or behavior are functionally equivalent to the drugs that you can get at the street corner. People buy these drugs for essentially the same reasons: to alter their thoughts, feelings, and/or behavior.
Another thing that pharmaceutical drugs and street drugs have in common is that, whatever psychoactive effect they might or might not have, they all take a toll on human tissue. They all cause damage.
Which takes us back to the original questions: Do the drugs have any legitimate function?
This, apparently simple question, actually contains two quite distinct components;
1. Should people be allowed to use these drugs?
2. Should physicians be encouraging people to use these drugs?
With regards to the first question, my answer is yes, but with certain safeguards in place. I don’t think governments have any business dictating what their citizens may or may not ingest. Besides, the so-called War on Drugs has been singularly unsuccessful. I believe that the money squandered on prohibition would be better spent on creative programs designed to educate people on the damage caused by drugs, and on helping addicted people find a way out of their chemical entanglement. In my view, whether or not a person ingests street drugs or pharmaceutical products, or anything else, for that matter, is essentially his/her own choice. I have written on these matters here.
The second question – should physicians be encouraging people to use these drugs – is simpler. My answer is no. Apart from the exceptions mentioned earlier for genuinely medical procedures and related matters, physicians should not be encouraging people to use psychoactive pharmaceutical products for extended periods of time, merely to alter their thoughts, feelings, or behavior. These products, used in this way, have no legitimate place in the practice of medicine.
If we accept that depression is not an illness, then the amelioration of depression is not a medical matter. If a person goes to a physician and says that he is depressed, the correct response from the physician, in my view, would be to explain that depression is not an illness, and to provide the person with a list of people/organizations, etc., that might be able to help.
The problem with this, however is that psychiatry has been very successful in promoting the falsehood that depression is an illness, and this falsehood has entered into our cultural fabric, and is firmly embedded in our social, political, and legal systems. If a physician who were to take the line that I’ve sketched out above, he would be out on a very thin limb with regards to liability. He/she would also be vulnerable to sanctions from licensing boards and professional associations.
The essential point of this is that those of us on this side of the debate have a great deal of work to do, not only with regards to publicizing the specific damage done by pharmaceutical products, but also with regards to the disempowering, but deep-rooted, concepts that drive and legitimize the practice of bio-psychiatry. The extent to which the concept of mental illness is embedded in our culture is, perhaps, the biggest challenge that we face.
Another area of valid concern stems from the fact that, at the present time, literally millions of people are consuming psychoactive pharmaceutical drugs daily. In many of these cases, abrupt cessation would be disastrous. Any proposals to extricate medical professionals from the inappropriate marketing of these products needs to take cognizance of this reality. Detoxing from drugs can be extremely dangerous, and I see a legitimate role for properly trained physicians in this process.
WHY DO PEOPLE TAKE PHARMACEUTICAL DRUGS?
“Officially,” people take psychoactive pharmaceutical products because they are mentally ill, and their physicians have prescribed them. In reality, however, people take these products either:
– because they feel better taking them than not taking them
or
– because somebody is using the products to control their behavior
Generally speaking, people take antidepressants and sedative hypnotics because they like the effect that the drugs produce. Physicians and patients collude in the sickness game, but everybody (including physicians) knows that if you want some Prozac or some Valium, you just go to a doctor and say the magic words (“depressed,” and “anxious”) and you’ll get what you want.
I’m not saying that these people aren’t miserable or unhappy or worried or whatever. They usually are. But they are generally happy to take the pills, at least initially, and they very often report that they feel better. But in the long run, matters almost always deteriorate. The similarity to street drugs is striking.
Let me be clear. I’m not saying that people shouldn’t take these products. If they choose to take them, let them take them. What I’m saying is that we need to stop pretending that they are medications, and that they are being used to treat an illness. We need to liberate both “patients” and doctors from this charade. You can’t “treat” depression or anxiety by taking pills. And “treat” is the wrong word anyway, because depression and anxiety are not illnesses.
The control issue centers on the neuroleptic drugs. These are perhaps the most dangerous of psychopharma’s products. And people don’t like them. They are touted as anti-psychotics, but in reality they damp down all cognitive activity. They also cause neurological damage, and after people have been using them for a while, it’s difficult to distinguish between behavior that stems from the original problem, behavior that stems from the dampening effect, and behavior that stems from the neurotoxicity.
Neuroleptics are often given to people who say and do “crazy” things, especially if they also behave in an aggressive or agitated fashion. By and large these drugs are fairly successful in controlling aggression and agitation, at least in the short term.
Most people hate taking these drugs, and they often stop taking them on their own initiative. There is a good deal of evidence that people who take these pills do a good deal worse in the long run than people who don’t. But in the short run, they do control aggression and agitation in many cases.
So the question becomes: is there a legitimate role for neuroleptics in the suppression of aggression and agitation?
But, here again, a complication arises, because we have to distinguish between people who are behaving in a “crazy” manner and those who aren’t. Nobody is suggesting an injection of Haldol for a group of gang members brawling over territory on a Saturday night, or a husband and wife throwing dishes at each other. The police resort to other methods to control aggression and agitation in those kinds of circumstances.
So the question becomes: is there a legitimate role for neuroleptics in the suppression of aggression and agitation in people who have been labeled mentally ill?
But there’s an unspoken assumption tucked inside this question: that people who are “crazy” are different in some fundamental way from people who are not crazy – that there’s a sharp dividing line between the former and the latter – and that people who are crazy are simply not amenable to the normal de-escalation methods that are routinely employed with others.
Each of these assumptions is an integral component of standard bio-psychiatry, and indeed within this system, neuroleptics are routinely used to control aggression and agitation. However, this is seldom acknowledged in these terms. Instead, it is claimed that the neuroleptics are being used to “treat mental illness.” The individual is “off his meds” (i.e. not receiving “treatment”) and needs to “get back on his meds” (i.e. resume “treatment”).
The problem with having a drug that makes people docile and subdued more or less instantly is that there is a strong temptation to use this drug in a widening range of situations, and for increasing lengths of time. At present, neuroleptics are being used routinely to suppress “difficult” behavior in children, nursing home residents, and residents of group homes, in addition to their long-standing use within the mental health system, even though it is often the dynamics of the facility that precipitated the aggression or agitated behavior in the first place. As long as psychiatrists can persuade themselves that they are engaged in the benign activity of “treating an illness,” they can avoid asking these two critical questions:
1. Are there other options?
2. Am I, or the system I work for, creating or contributing to the problem?
During my career, I have seen a number of violent incidents, in some of which there was real potential for serious injury. It is sometimes argued that a neuroleptic injection might have a legitimate use in this kind of situation, as a safe way to de-escalate a violent incident. In this regard, I have two concerns. Firstly, if the principle is established – in a mental hospital, say – that neuroleptic injections may be used to control aggressive or agitated behavior, then it’s easy to start seeing this as the normal and appropriate way to deal with these kinds of situations. In particular, it’s easy to neglect those long-established methods for preventing aggression that work effectively in other contexts, namely: treating people with respect, listening to their concerns, making accommodations to their particular needs, recognizing their uniqueness, etc.. In other words, by treating them like people rather than broken brains.
My second concern is that if neuroleptic injections are considered good instruments for controlling “crazy” people, why aren’t they used to control “ordinary” people? The use of chemical tranquilizing agents in the mental health system is a very tangible way of promoting the notion that mental health clients are fundamentally different from ordinary people. The particular irony of this is that, in my experience at least, many of these differences are in fact the result of damage inflicted by the system, e.g. tardive dyskinesia, chronicity in “schizophrenia” and depression; apathy; reduced expectations; etc…
I find it difficult to see any legitimate use for neuroleptic drugs being prescribed for extended periods of time. Indeed, it is my belief that the marked increase in the use of these products, in people aged 2 to 102 for an ever-widening range of problems, is the most destructive thing that psychiatry has ever done. And that’s saying something!