Psychiatry Rant (i)
These questions came from a student who had recently read Ken Kesey's book, "One flew Over The Cuckoo's Nest." I thought the questions and replies would be worth including here.
1. You said that the only way to improve the mental health system would be to tear it down and start again. How would you start again? What would you do differently? Or do you think that there should be no mental health system at all?
The point of breakdown in the delivery of mental health provision occurs at the point of contact between patient and nurse/doctor/social worker etc. However what governs the performance and behaviour of each mental health worker that a patient comes into contact with are legal, political and economical factors that have little relationship to the needs and behaviours of the actual patient.
There was a time when research into schizophrenia was focusing not on biology but rather on the concepts of the "schizogenic mother" or "high expressed emotion", "double bind" or whatever. However right or wrong these concepts may have been made little difference once the dopamine hypothesis took hold with the advent of Thorazine. Finally, psychiatrists had something they could actually do that made an observable difference. They finally had something that was a more viable alternative to lobotomy, insulin shock and electroshock and it didn't take long for the drug chlorpromazine to gain the reputation as "the drug that emptied the psychiatric hospitals." Unfortunately what the popular media missed was that this was also the drug that unleashed a previously unseen wave of neurological illness upon its recipient population. In addition, whilst the asylums may be sitting derelict and empty, so are huge numbers of former and would-be residents in the centers of our cities.
For psychiatrists, medication made sense. A slogan soon emerged - "mothers have been blamed enough" - now mental illness had a new cause and this cause was chemical. Mental illness was now a "chemical imbalance" in the brain and so now we needed drugs to correct this. The drugs may not be all that "clean" and may have side effects, but logic says that all we need are newer and cleaner drugs.
With an estimation of 1% of any given population suffering from schizophrenia alone, this presented a huge market for the drug companies and the race was on. With such a potentially lucrative market it was not surprising that we'd soon be seeing new diagnostic categories emerge each with their own drug of choice for treatment.
Economically speaking, research into such concepts as Bateson's "double bind" makes no sense. Whilst a model of double binds can be built and the phenomena known as schizophrenia can be understood from a sociological perspective there just isn't any profit in it. And besides, a psychiatrist might be sat in the office with the family of a schizophrenic and be observing the phenomena described by writers such as Bateson, Laing etc, but what is he going to do about it? Blocking the patient's dopamine pathways with a drug makes far more sense. He at least stops hallucinating that way. Actually, he stops doing pretty much everything, but at least something is being done. It makes the family feel a bit better this way too. It explains away their own pain at seeing their relative's distress.
The net result of this was inevitable but tragically so few people foresaw it or even pay attention to it today. We now seem to have built a culture where communication and behaviour are all pathologised and diagnosable and finding an unmedicated child in our classrooms is becoming increasingly difficult these days. Rather than raising and educating our children intelligently, we now drug them so that they fit into our strange systems and models of thinking. Chemical imbalance is our excuse and reason. Pharmaceuticals are our new confessionals.
It is this practice that I'd like to tear down and start again. The public at large are too comfortable with "chemical imbalance" as though this is some sort of an explanation of their experiences. I guess this is easier to explain than Bateson's model of schizophrenogenesis - just the word itself is enough to scare people!
I would like to psychiatry divorce itself from the political and legal functions that it serves and replaced with practitioners who themselves are highly skilled in communication and personal change work. At present the practitioners of psychiatry seem to form little more than a huge drug distribution network for the pharmaceutical giants and the drugs have replaced skill and communication ability. Psychiatric nurses frequently seem to know more about drug classification than they do the structure of human experience. What seems to buffer against change are the legal implications facing anyone within this system that refuses to follow the rules - a psychiatrist that refuses to drug or electroshock will not remain a psychiatrist for very long. To this end, "The System", or to borrow Kesey's metaphor from Cuckoo's Nest, "The Combine" will remain largely unchallenged. Such social organisations become self-selecting and seek to exclude anyone that threatens the homeostasis of the group. To get tenure to research and gain acceptance of the socio-cultural aspects of the phenomena we refer to as mental illness is nigh on impossible - it goes too far against the grain to suggest that bio-psychiatry is wrong. As long as we all believe in the party line of "chemical imbalance" we are all participants in The Combine.
Most psychiatric workers I have met are well aware of the fact that what they do merely fits into a network of social control. It is this "just doing my job" mentality that I personally seek to change - there is also the mentality of "well if I wasn't doing it, someone else would be and they might be less fair than myself." I guess they are very polite when they strap on those electrodes and this politeness makes it ok. At least when someone is hitting you with a stick, there is no ambiguity as to what is really going on, it is less confusing. This abdication of individual responsibility is totally unacceptable in any form. In 1997 I was heavily criticised for my actions regarding a patient dying from neuroleptic malignant syndrome. None of the staff on the medical ward in which he was housed had ever heard of this acute and fatal syndrome - however he was kept cool, watered, turned 2 hourly and restrained where necessary. The nursing staff were very professional and nice about it all. Needless to say, I took a different approach. I telephoned his prescribing psychiatrist, dispensing pharmacist, administering psychiatric nurses and his social worker and invited him to come and sit by the bed to see their patient die. I wanted to reconnect them to their responsibilities and to the fruit of their labours.
I am told that such an action is "grossly unprofessional." Apparently, such a fatal drug reaction is "idiopathic" and "unpredictable" as though these words make it such a fatality acceptable in some way. Living opposite a psychiatric hospital, every day I see people shuffling about with their parkinsonian syndrome, grimacing with intractable tardive dyskinesia, or pacing frenetically with akathisia and still there are morons pumping more chemicals into their system in the belief that this is helpful in some way.
Hey, all this gives me an idea - It is here that I would do things differently - psychiatric patients are all too often left on the psychiatric ward and the staff get to go home at the end of each shift. If the staff are supposed to be presenting an effective model of normality for their patients to follow, why do they leave the patient behind on a psychiatric ward of all places, which as we know are anything but normal? Maybe the patients could go and stay at the psychiatrists' home to see how normal living is supposed to be done?
2. You disapprove of medications being used to treat mental illnesses. How do you think they should be treated instead? Some mentally ill people really feel that their medications help them--are they wrong in some way?
It's not so much the fact that medications are used to treat mental illness that I object to, but rather the very concept of mental illness itself. The Bible of the psychiatric industry is a book called DSM4, it's a catalogue of human behaviour grouped by type of social deviancy. Of course, the one definition that is inevitably missing from this book is that which constitutes normal - the baseline by which we compare deviancy is conspicuously absent. You have to remember that there was a time where the psychiatric drugs didn't exist and many of the human maladies in the DSM4 either hadn't been named or hadn't been invented yet. What I find interesting are the more obviously political entries that have been removed from the DSM, such as homosexuality which until action by gay rights groups was both illegal and a mental illness. Now to think or speak of homosexuality in these 'old' terms is itself both illegal and socially deviant, which itself shows a remarkable turn around. I think it would have been unimaginable 60 years ago to believe that such conditions as "school phobia" and "oppositional disorder" would ever be considered as psychiatric disorders. It might seem incredible that there is actually a drug to give to people who persistently spend too much money, but here in the West this is as much of a reality as "Koro" of South East Asia. The cult of victim-hood nurtured by psychologists, therapists and counselors in the 1980's assisted large numbers of the population to view themselves as ill, who failing to find relief from their ritualized therapies inevitably reached out to the medical practitioners of mental health for help in feeling better about themselves. The depressed 23 year old may find that her misery is caused by repressed memories when she sees her psychotherapist, serotonin depletion when she sees her psychiatrist, lack of personal power when she sees her life coach, unfinished business when she sees her Gestalt therapist, blocked meridians when she sees her acupuncturist, negative engrams when she sees her scientology auditor, or crystals in her feet when she sees her reflexologist. So which is to be? Maybe none of these, but law and hard science accepts only one.
There are too many issues involved in the politics of medicating people for behavioral and emotional change, but ultimately they all end up in the same place - everytime a person reaches for a pill in order to make himself feel better he is reminded that control over his state is an external event - ie he is 'broken' and is unable to 'fix' himself without external intervention. This pattern appears to extend the continual disempowerment of the average citizen and encourages the herd mentality of passivity. When you have just a handful of people taking a pill to get through their day, you can maybe understand a little, but when you have such huge numbers of people beginning there day with a chemical cocktail of mood and behavior altering drugs, we really have to begin to ask, just what is going on here?
Yes, many of these people do in fact feel better with their psychiatric drugs, like Huxley's substance "Soma" of Brave New World, the drugs can provide a welcome relief from the rigors of social living. But it seems incredible to me that whilst we imprison in huge numbers in gaols people who's preferred drug of choice is not government approved, we also imprison huge numbers of people into psychiatric units who refused or failed to take the drugs that the government did approve and will happily forcibly administer.
How we view mood and behavioural altering drugs depends on how we categorise them, we can have the drugs of control (psychiatric drugs) and the controlled drugs (illegal street drugs). It seem remarkable to me how the drug approval authorities so carefully screen out the drug of control - a psychiatric drug is permitted to make you feel better, but it mustn't be allowed to make you feel too good. It's allowed to improve your state, but not too much. With the drugs of control we basically have mood modifiers and behavioural modifiers. Some are designed to make you feel the right feelings others to make you behave the socially and legally approved ways. For example, a socially isolated single mother in a urine stained tower block might have Prozac to make her mood better in her dire situation, meanwhile her son might be given Ritalin at school so that he sits still long enough for the schooling to take effect. Meanwhile, her neighbour receives a bi-monthly depot injection so the voices from the walls don't drive him too mad whilst the guy upstairs shoots speedballs and smokes crack. As long as our mother takes her daily dose, she shouldn't mind so much. Whilst Librium used to be "Mothers little Helper", we have Prozac as our Social Disaster Little Helper, Thioridizine as Nursing Home's Little helper and Ritalin as Teacher's Little Helper.
So these drugs have more than personal consequences to the individual side effects such as tardive dyskinesia and parkinsonian syndromes - they produce a culture where the population is increasingly anaesthetised against the effluent of its own lifestyle. Maybe sometime our legislators will noticed that it is time to redesign.
The psychiatric professional tells the patient that the drug is in the patient's own best interests, then securely locks the door behind him when he leaves the ward at the end of his shift. Our politicians and lawmakers seem to do the same.
With regards to testing whether the psychiatric drugs are safe to take, I suggest the following approach - if ever prescribed a psychiatric drug: Ask the prescribing psychiatrist or the administrating nurse to first take the drug themselves for a week. I suggested as part of my nurse training that this was the best way of learning psycho-pharmacology, rather than attending lectures. We could all try the drugs for ourselves, it would help build that all important "empathy" with our patients. Naturally, this suggestion didn't go down too well. When I tell my colleagues that indeed I have tried most psychiatric drugs to learn of their effects, they look at me incredulously - I'm told that this is "dangerous". Hmmm ..
3. The book "One Flew over the Cuckoo's Nest" was written in the `Sixties. Do you think the mental health system has changed since then? Is it an accurate portrayal of life in a mental institution?
No. As far as I can see, in the intervening 40 years between Kesey's experience and my own, little has changed. The tension between MacMurphy and Nurse Ratched and the power games played out between them is an accurate portrayal of the madness occuring within these environments. Ultimately such zero sum games end with the patient being drugged, electroshocked or in MacMurphy's case, lobotomised. This is where the ultimate power game ends. My good friend Clive, who spent nearly ten years surviving psychiatric institutions tells me that the way to survive is too keep on the good side of all the staff. It was Clive that encouraged me to keep a graph of medication rates plotted against the staff off-duty. The results were 100% predictable by all the patients on the unit, but not by one single member of staff. We can find a Nurse Ratched in almost every psychiatric facility who manages to locate and identify whatever problem she seeks to find.
(Addendum: On newsgroup, alt.psychology.NLP, resident NLPerson and Psychiatric Hospital Security Officer, Michael Debusk brilliantly added the following with regards to this last point: "My department soon learned that when a particular nurse was working, a call for restraints would be guaranteed at some point in her shift. And do you want to know something really funny? All that stopped when she got breast implants.")
Whereas in Cuckoo's Nest, MacMurphy's thought crime is ultimately punished with lobotomy, this aberration of treatment has since been replaced with industrial strength drugs of control. It's interesting to note, that some neurologists comment that differentiating between a lobotomised patient is indistinguishable from a sedated patient on neuroleptic medication such as thorazine. It is also interesting to note that other neurologists are promoting modified lobotomy once more as a cure for certain ills. It seems that we are going full circle, and as the public at large become increasingly disturbed by the human waste of their lifestyles clogging up their city parks, we will inevitably see the return of the Asylum. The Asylum, protect "us" from "them" or vice versa. Clive is very clear about this. With the propaganda that increasingly passes for education these days, it will be both.
Psychiatry Rant (ii) Here's the follow up