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 and so on. However, what governs the performance and behaviour of each mental health worker that a patient comes into contact with are legal, political, and economic factors that have little relationship to the needs and behaviour 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” or “double bind” or whatever. However, whether right or wrong, these concepts may have 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 a reputation as “the drug that emptied the psychiatric hospitals.” Unfortunately, what the popular media missed was that chlorpromazine 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 centres of our cities.
For psychiatrists, the medication made sense. A slogan soon emerged, “Mothers have been blamed enough”, and now mental illness had a new cause, which was chemical. Mental illness was now a “chemical imbalance” in the brain, and so 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, the situation 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 phenomenon known as schizophrenia can be understood from a sociological perspective, there just isn’t any profit in it. And besides, a psychiatrist might be sitting 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 is too comfortable with “chemical imbalance” as though this were some sort of an explanation for their experiences. I guess the term is easier to explain than Bateson’s model of schizophrenogenesis, just the word itself is enough to scare people!
I would like to see psychiatry divorce itself from the political and legal functions it serves and be replaced by practitioners who are themselves highly skilled in communication and personal change work. At present, the practitioners of psychiatry seem to form little more than a vast drug distribution network for the pharmaceutical giants, and the drugs have replaced skill and communication ability. Psychiatric nurses frequently appear to know more about drug classification than they do about 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 who 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 who threatens the homeostasis of the group. To obtain 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 biopsychiatry 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 weren’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 hits you with a stick, there is no ambiguity about what is going on, so it is less confusing. This abdication of individual responsibility is completely 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 where he was housed had ever heard of this acute and fatal syndrome. However, he was kept cool, watered, turned every 2 hours, and restrained where necessary. The nursing staff were very professional and kind about it all. Needless to say, I took a different approach. I telephoned his prescribing psychiatrist, dispensing pharmacist, administering psychiatric nurses, and social worker and invited them to come and sit by the bed to see their patient die. I wanted to reconnect them with their responsibilities and 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 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 the treatment 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 gets 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 in a psychiatric ward of all places, which, as we know, is 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 psychiatric drugs were once non-existent and many of the human maladies in the DSM-IV were either unnamed or had yet to be invented. 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 turnaround. 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 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 victimhood nurtured by psychologists, therapists, and counsellors in the 1980s assisted large numbers of the population to view themselves as ill, who, failing to find relief from their ritualised 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 it to be? Maybe none of these, but law and hard science accept only one.
There are too many issues involved in the politics of medicating people for behavioural and emotional change, but ultimately they all end up in the same place, every time a person reaches for a pill to make himself feel better, he is reminded that control over his state is an external event, i.e., 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 their day with a chemical cocktail of mood and behaviour-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” in Brave New World, the drugs can provide a welcome relief from the rigours of social living. But it seems incredible to me that whilst we imprison in huge numbers in gaols people whose preferred drug of choice is not government-approved, we also imprison huge numbers of people in psychiatric units who refused or failed to take the drugs that the government did approve and will happily forcibly administer.
How we view mood-altering and behavioural drugs depends on how we categorise them. We can have the drugs of control (psychiatric drugs) and the controlled drugs (illegal street drugs). It seems remarkable to me how the drug approval authorities so carefully screen out the drugs 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 in 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 “Mother’s Little Helper”, we have Prozac as our Social Disaster Little Helper, Thioridazine as Nursing Homes’ Little Helper, and Ritalin as Teachers’ Little Helper.
So these drugs have more than personal consequences for the individual, side effects such as tardive dyskinesia and Parkinsonian syndrome, and they produce a culture where the population is increasingly anaesthetised against the effluent of its lifestyle. Maybe someday our legislators will notice 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 regard 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 psychopharmacology 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 I have indeed 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 occurring within these environments. Ultimately, such zero-sum games end with the patient receiving drugs, electroshocks, or, in MacMurphy’s case, a lobotomy. 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 to 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 the newsgroup alt.psychology.NLP, resident NLPerson and Psychiatric Hospital Security Officer, Michael Debusk brilliantly added the following with regard 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 a 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 becomes 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 protects “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.
Follow up: Psychiatry Q&A