Like most doctors, I feel like I prescribe medications ethically and effectively. The basic foundation for that confidence is three things: 1) Knowing that my primary motivation is almost always to help my patients. I believe that my prescribing isn’t substantially impacted by other motivations like my own financial gain, decreasing my own workload, or countertransference, for example. 2) I try to defend myself as best I can from being too influenced by the profit seeking motivations of the pharmaceutical industry. And 3) I try to resist responding to various self destructive motivations of my patients (hopefully without becoming too judgmental and pejorative of their “medication abusing”, “manipulative”, “sabotaging” desires). Prodded by Robert Whitaker’s books, I feel the need to build a more comprehensive approach to ethical and effective prescribing than I was taught or modeled or even than is expected of me. Here are four more foundations I’m building: 1) Individualized prescribing, 2) Recovery-based prescribing, 3) Trauma-informed prescribing, and 4) Toxicity-informed prescribing.
1. Individualized Prescribing
I was first taught to prescribe based upon people’s diagnoses. I was taught a rapid, highly simplified, reliable, syndromic check list method of differentiating a handful of diagnoses that have associated research driven flow charts of medications to treat them. Within this system a variety of people, for example a speed-using, foster-care-childhood, homeless person, an emotionally labile rape victim, a person with a strong family history and clear episodes of highs and lows, and an emotionally immature teenager are all diagnosed with bipolar disorder and treated with mood stabilizers and atypical antipsychotics. Even this system is often considered too time consuming and replaced with symptom-based prescribing. I was taught to treat depression with antidepressants, anxiety with antianxiety medications, psychosis with antipsychotics, and mood instability with mood stabilizers. Chart notes are supposed to reflect targeted symptoms.
I don’t find either of these approaches to be generally ethical or effective. Fortunately I have the time and support to actually get to know my patients well and to understand as well as empathize with them. We build a shared story of what their difficulties are and how they developed them. Sometimes it’s a medical-model DSM story, and sometimes it’s not. We develop a shared treatment plan that often, but not always, includes medications as part of how their life is going to get back on track. I may or may not prescribe to help overcome family conflicts, attachment disorders, violent urges from childhood beatings, the stress of a battle between God and the Devil within them, or any of a multitude of highly individualized formulations.
I believe this method increases effectiveness both by incorporating well known “nonspecific treatment factors” and by increasing engagement and medication usage. It reduces “drop outs” and “non-compliance”, arguably two of the most important mediators of ineffective treatment.
2. Recovery-Based Prescribing
It has been a good deal of my life’s work to develop and practice a comprehensive approach to recovery-based prescribing. Key values have been embedded into key practices with every patient I see, including:
- Collaborative, client-driven prescribing instead of professional driven
- Shared decision making, and shared responsibility instead of informed consent and professional responsibility
- Quality of life, goal driven prescribing instead of symptom relief prescribing
- Pursuing resilience instead of cure
- Shared journey of learning from successful and failed attempts instead of risk aversion
- Growth oriented instead of caretaking – including transitional relationships with me instead of lifelong commitments
- Basing hope on their strengths instead of mine
- Taking the long view of recovery
I have discussed each of these in detail elsewhere. In my view, developing these practices has protected the people I work with from a great deal of the damage commonly included in our prevalent medical model prescribing.
3. Trauma Informed Medications
There is a great deal of trauma and suffering associated with mental illnesses. There is also, unfortunately, a great deal of trauma associated with psychiatric treatment, including medications. While consumer/survivors used to confront us with traumatic stories of involuntary hospitalizations and confinement, of being locked up and tied down and physically assaulted, today’s stories far more commonly revolve around traumatic medication stories – medication after inadequate evaluations, mis-medications, overmedication, polypharmacy, difficulties in functioning on medications, difficulty in getting off medications, etc. While trauma-informed approaches have been developed, though not nearly widely enough used, for hospital practice, I’ve never seen trauma-informed approaches to medications articulated.
When there was a large conflict over whether antidepressant prescribing to depressed teenagers was causing an increase in suicidal thoughts and behavior, the discussion focused on the biological factors not the traumatic factors. I never heard the hypothesis that suicidal thoughts and behaviors increased because it was traumatizing to be diagnosed with a mental illness and give a prescription, even if you never took it.
When we do think about trauma and medications we tend to conceptualize it as internalized self-stigma and then see as the remedy destigmatizing education, especially emphasizing the shame- and blame-reducing aspects of illness-based formulations. Rarely do we linger over understanding the individualized traumatic impact of each prescription we write. Which of our patients feel degraded, dehumanized, discounted, pressured to conform, misunderstood, controlled, drugged up, physically harmed, over-sedated, creatively inhibited, racially persecuted, personally devalued, etc. by their prescriptions? I’ve tried to develop a plausible list to explore with people as I prescribe to try to be trauma-informed. Sometimes I won’t prescribe as a result of the likely trauma I’ll induce. Sometimes I’ll help them work through the trauma to be able to use medications less painfully.
4. Toxicity Informed Prescribing
I was taught that the way to deal with toxic aspects of our medications was to learn the side effects of each medication and balance symptom relief and side effects, including attempting to share my decision-making process with my patients through a discussion of risks and benefits and informed consent. I wasn’t really taught that even though I was usually urged to prescribe “for the rest of your life” that all of the studies of effects and side effects were short term studies, generally 6-12 weeks. I also wasn’t taught that pharmaceutical companies routinely hide the side effects to increase their profits. The Zyprexa/diabetes story was my personally traumatic lesson in “real life”.
I also didn’t notice that the side effects included in the FDA studies and the PDR systematically exclude “subtle” psychological and emotional side effects that are often very important to the people I work with including things like “I don’t feel like I can cry anymore even when I need to,” “I was able to remember more of my past and felt more alive when my medications were decreased,” “I’m less creative on my medications and I just don’t feel like writing poetry as much,” or “I’m not as quick-witted and funny as I used to be.”
Whitaker’s main contribution to my thinking is his biological hypothesis that feedback responses to medication-induced “positive” biochemical changes may be far more pervasive and damaging than we realized and that we often mistakenly identify them as re-emergence of underlying, still-existing illnesses. I was certainly aware of this possibility with addictive medications and with tardive dyskinesia, but I’d never applied that model to “my antidepressants poop out after about 9 months and I need to change what pill I’m on,” let alone to cognitive declines with schizophrenia, chronic depression and generalized anxiety, rapid cycling and mixed-state bipolar, or stimulant-induced chronic mood instability. On a gut level his hypothesis fits my clinical observations.
Taking this hypothesis seriously has led me to two prescribing changes. Firstly, I think I have to take the same precautions I do for medications known to create either tolerance- or withdrawal-based problems like benzodiazepines and stimulants and that I take with those known to cause hypersensitivity feedback syndromes like tardive dyskenesia for all medications. “If you have no side effects now, you’re never going to get any. You can keep taking this medication with minimal monitoring indefinitely” is probably not an effective and ethical approach even though it’s very common.
Secondly, as I read the long-term studies that have gotten more recent exposure, and Andreason’s unique work, I’ve come to the conclusion that neither the pro-medication nor the anti-medication sides are correct. It isn’t a question of figuring out whether untreated psychosis is damaging to your brain or long-term medications are damaging to your brain. The most likely answer is that both are damaging. The prescribing recommendations of both sides of the “or” argument – aggressive preventative prescribing to people at high risk of developing psychosis and avoiding medications while pursuing holistic, interpersonal, or social interventions while the psychosis persists and grows – are both narrow minded. The “and” approach says that it’s harmful both to medicate and not to medicate.
I’ve long suspected that “Do no harm” was a fantasy. I have to come to terms with the likelihood that I’m doing harm when I do prescribe and when I don’t prescribe, regardless of my motivations. Perhaps I can apply some of the harm-reduction principles I’ve learned to use with substance abuse. But I know how humbling and powerless and uncomfortable using harm reduction feels. I have some emotional work to do if I’m going to approach all of prescribing that way.
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Editor’s note: Due to a miscommunication, this piece was previously published in “Community Psychiatry”, when instead it might have appeared on Mad in America. We are pleased to be able to correct the error and offer it here now.
I was initially scared when my daughter was experiencing ‘psychosis’ I picked her up off the street and I was grateful she trusted me enough to get in the car. But her suffering was so painful to me that I panicked and took her to the ER. I didn’t call a time out; I didn’t think to take her home where we have a nice fire burning all winter and wind blowing through the trees, and a running brook nearby.
I didn’t call my husband my mother or a friend: perhaps someone would have reminded me of that love that exists within every mother that could have enabled me to calmly and rationally protect my child from psychiatric abuse, stigma, and labeling; that is what communities are for, even the community of marriage, to remind ourselves of our highest potential and to help one another through the difficulties on life’s road.
I needed someone to remind me of how to convert compassion into helpful action by listening, offering a cup of tea. Instead I outsourced our family’s suffering to the medical system. I made a snap decision that to this day seems fateful and doomed my daughter to a lifetime of repeated trauma. Once the decision tree is activated, the medical system acts like a machine, liability and protocols and procedures are considered solely while and the patient recedes as a human being becomes an object. At each successive turn in the road, fateful, harmful decisions can be made that can ruin a person for life or unnecessarily delay their recovery for years. Harmful words can be conveyed that destroy a person’s dignity and selfhood.
Within hours of arriving at the ER, she got scared and tried to run away. I allowed myself to get separated from her. Medical staff isolated her in a small windowless room with no furniture, quite similar to the holding tank at the county jail and put her in scrubs. They came to medicate her when she tried to escape. They brought in large people to hold her down. A nurse strapped her on a table using five point restraints. Each drug seemed to make her more manic. They increased the dose, higher and higher, and higher. It was the straps making her manic, she strained against them in vain, every muscle in her body rigid with effort, her forehead sweating and veins bulging. At what was arguably the most vulnerable state in her life, she was treated like a criminal.
I was presented with paperwork and kept distracted by well -intended staff members outside in the hallway. I was in a spell. I could hear her screams. I was terrified. I was not conscious. Looking back, I want to speak to that parent I was then, numb and unconscious and I want scream at her: “Get your daughter out of here! Danger!”
Instead, I was a sheep. Looking back, I was incredibly naive. My trust of medical doctors implicit; I was raised to never question their wisdom and authority. They are educated and all knowing. They are smarter than me and they are noble, sacrificing diligently for the betterment of mankind. They are the saviors of all who suffer. They go deep into jungles and inoculate little babies. They travel to refugee camps and save people from cholera; they volunteer at free clinics in big cities What a romantic notion! The spell took years to break. I didn’t know then what I know now, that I developed this delusion about doctors, partly from watching shows like Marcus Welby as a child on television and partly because the doctors in our family were revered and treated with extra respect.
It was a doctor suggesting ECT for my daughter nearly a year later that broke the spell. The standard of care was so bad, that I finally had to open my eyes. Plus, the awful educational materials offered by NAMI woke me up to what sheep we parents have become. And the wonderful people I met through MindFreedom. All of those things, started to open up my mind and I felt supported enough emotionally to do some serious introspection, reflecting soberly on my marriage, our home life, my pent up suppressed desires and aspirations, my disappointments in life, all of these things and how they had affected my daughter’s emotional development. I sought treatment for myself even though there were no supports or resources in place for our entire family. Of the more than ½ million dollars spent on my daughter’s care to date (less than four years), not a single penny was offered by the system to support our entire family to help us communicate and resolve past grievances, or help my daughter safely wean herself from harmful medications when that was clearly her desire.
Back at that fateful day, when my husband arrived at the ER, looking down at our precious daughter, he asked the doctor, scared but indignant, “Is this really necessary?” I had said nothing to protest but when my husband got there, some reason shined a dim light into that dark corner of despair. All she had done was babble a little incoherently, cry, laugh, experience racing thoughts, try to escape before they pinned her down, etc. She had not verbally or physically threatened anyone. She just threatened to leave them, as is her right!
The nurse who was the original staff member to fasten the straps, loosened her bindings at last. Instantly, my daughter punched the nurse. I can understand. The nurse was a purpetrator by any rational standard. The nurse had had her nose injured (fortunately not seriously) but it filled the staff with indignation and anger;all the blame was put on my daughter. The hospital staff called the police and charged my daughter with assault.
This was her first, ever act of violence in her entire life, unless you count when she hit her brother (he is a year older) when she was six years old.
That was the beginning of the downward slide. Four years later, nearly $700,000 bilked out of our medical insurance carrier and the taxpayers, she became much worse.At no point in her court mandated treatment did anyone who was paid to help my daughter, question the system and how it had harmed her and continues to harm her today.
I ask, who threw the first punch? My daughter or the hospital staff? Now my daughter has a police record and this is partly the basis for her forced treatment, to this day.
This little drama being played out shows the underlying violence of our system; this system is based on fear and ignorance.
My daughter was later transferred to an acute care facility where she held down again by big people and forcibly injected with Haldol. That was the most ‘psychotic’ she ever appeared. She was in a violent rage while being subjected to her first ten day hold.
We learned many things about our daugter’s ‘other life’ in the brief period that she lived independently in an apartment.
We learned about the pressures she was under to conform to my unreasonable expectations of middle class ‘success’ (work your way through college; “Ditch the music as a profession because it’s not practical”, etc.) We learned that our mother daughter relationship was not as rosy as I thought.
I learned that my dysfunctional relationships with my own family born of pride and arrogance, had robbed my daughter of the hidden wealth in our extended family so she had no sanctuary to be herself outside our household, no aunties or uncles to run to. I got busy mending fences and I swallowed my pride. I am grateful to my daughter for helping me de-freeze my chilled heart.
When she was released, as ignorant as I was, with trembling hands, I tried to coax her to take the pills; they had given her a six day supply of anti-psychotics and a medical appointment 30 days out. I didn’t ask: “How do you feel about the way you were treated?” “Were you scared?” “Were you angry?” “Are you angry with me?”
I didn’t know how to listen and engage my children; my heart was in deep freeze. Parents who don’t know how to listen to their children are making their children resort to all kinds of bizarre and dangerous behavior. Why are we penalizing the children? She was the gifted, mystical, beautiful quirky, idealistic, perceptive, kind-hearted member of our family. She was also the scapegoat; by quietly absorbing year’s of other people’s shadows, like the sin eater of the tribe.
The trauma of her treatment added insult to injury. It was so overwhelming, she temporarily lost her ability to speak. Her mind was racing with conflicting thoughts. Her emotions had to be divided and stored in her brain because her sense of self had been so shattered that to keep everything safe for future use she had to store both good thoughts and bad ones into voices. They are voices that heal and voices that harm. She had to archive her memories while maintaining a safe distance from them, without severing them altogether. Hope in small quantities can render miracles but too much hope while one is in jail with few options can drive one mad. Being disconnected from feelings brings a measure of self-protection. It keeps one from spinning a hope into an impossible delusion that will make you the subject of ridicule from ‘sane’ people.
Attachment disorder is a coping mechanism for people who have been harmed by other people. Attachment disorder can be so deep, it involves language. I believe that my daughters asks herself the following questions: “What are the words I must use when speaking to an oppressor to mitigate the harm they can do to me? What words must be kept secret? What words will condemn me to more labeling and oppression? Isn’t silence sometimes the best option even if I am labeled as catatonic and unable to speak because my brain is broken? Who can I trust? Myself? I’ve been told I am crazy. Guess I can’t trust myself! I’m angry at my oppressors but do I have a right to be angry? I’ve been told I am crazy. Crazy people are mad by virtue of our broken brains, our faulty genes. Therefore my emotions may have no basis in reality. Perhaps I need to sedate myself and become numb to this awful conflict. Perhaps they are right. Perhaps I must give up and depend on others for the rest of my life. Perhaps the best thing I can do is to become as invisible and non-demanding as possible. I will become docile and convenient. I will learn to be someone who is harmless even if I have to hide who I am. Perhaps if I become small and meek and quiet, I might be allowed to eke out a small existence for myself on a government disability income and I will be allowed to pay my own bills, and cook my own meals someday in my own apartment. Do you think the system might forget about me one day and allow me to go about my life peaceably? My hope is that I will outlive the mental health system.
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madmom,
You and your family have been through a lot. The violation of one’s civil liberties is always traumatic, but the violation of one’s mind is savage and cruel. As long as there is life, there is hope for recovery and the opportunity to fight back in small or big ways.
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Thank you for your kind words Tom!
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madmom,
Such awful abuse and suffering inflicted on one who is already at wit’s end – it’s a crime. Can I just say, though, that this is an amazing piece of writing you’ve posted here? You’ve analyzed and understood everything so well. I sincerely wish you, your daughter, and all your family the very best.
I can only imagine the outcome if your daughter and family had had a program like Open Dialogue to resort to rather than the backwards, dysfunctional nightmare that is ‘mental health care’ in the U.S.
I’m so glad you found your way to the MiA community.
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madmom I wanted to make a response, as a mad mother and mother of 3 sons who have all experienced psychosis, and whom I have had to take to A&E/ER, on occasion, or who have taken me into an acute psychiatric ward where I was detained. So we have all taken each other into psychiatry. We’re all in in together.
I wanted to say, don’t be too hard on yourself. In my experience there’s no “right” way to help a person in psychosis if the system doesn’t have a range of choices. Last December we had to call the police to take my middle son into a psychiatric hospital because he couldn’t get any crisis support and was getting very stressed. He wasn’t happy with us at the time but we had no other option. He’s OK about it now.
My youngest son went to the police himself because he couldn’t get any crisis support 18 months ago. Ironically, and annoyingly, they ended up trying to pin a criminal charge on him when he was in the psychiatric ward because of their bullying and bad practice. I fought it tooth and nail, then I was accused in a report of “psychological harm”. So I blogged about and spoke about it, everywhere. And still do. I get fed up with the blaming of mothers for a system that doesn’t work. I’m not going to take it lying down.
The more I’m oppressed the more I will speak out. That’s how it works, in my opinion and experience. Because we live in democratic circumstances. Although it seems at times like a totalitarian state. So I use social networking and blogging to have a voice. I’m in charge of my own blogs so can say what I like and take responsibility which suits me fine. I really don’t like people fiddling what what I write or say.
I accept that I’m not perfect. Who is? But I do the best that I can and forgive myself when necessary, and others. It’s not easy being a mother but there’s always another day.
All the best, Chrys
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just noticed that there’s now no “edit” button to correct grammar, not sure why?
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I am glad you prescribe ‘ethically’ but do you tell your peers when they are harming one of their patients to stand down?
Do you know how to recognize patient abuse and report it if you see it? Do you automatically assume that every patient who complains about psychiatric abuse must be delusional because your peers have impeccable credentials and reputations in contrast to their patients who are documented as crazy?
Are you willing to provide testimony to protect a patient from psychiatric abuse even if it carries a professional risk and puts your own medical practice under review? Will you break ranks when a patient’s future is at stake?
Have you ever mingled with your peers at gala event hosted by a pharmaceutical company? Did you on occasion, swap stories privately with your peers, about your ‘sickest’ patients or talk about one or more of your patients disparagingly, behind their backs, maybe even crack a teensy weensy joke in private about a patient, in ‘good taste?”
Would you risk your job security and your pension to defy the management of your clinic when your gut instinct told you to bend the rules for the betterment of a patient?
I don’t mean to put you against a wall because after all, you are only one person and you are brave enough to contribute to a community in which the majority of contributors identify with having been harmed by psychiatry or having a loved one who is harmed by psychiatry. You didn’t create all of these problems.
I know that psychiatrists may be traumatized by the ineffectiveness of their treatment and the anger and skepticism aimed against them by survivors. I know that you and your peers need a safe place for you to redefine psychiatry because your profession has so obviously lost its way in the wilderness.
I like how doctors and scientists came together in the eighties as a result of the nuclear threat and created ‘Physicians for Social Responsibility’ What are you and your peers going to do to protect people like my daughter?
Will you sign a petition banning forced medication and treatment and support human rights? Or will you secretly sympathize but sit on the fence to protect your job security?
I don’t suggest that you shouldn’t make a fair living to provide for your family but I suggest that you may be contributing to the problem simply by being enslaved to it financially (i.e. relying on your profession for financial security) and this binds you from doing the right thing more than you may care to admit.
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It’s helpful to have a peek inside the mind of a psychiatrist who is trying to change for the better. I felt disturbed by most of this article starting with the statement to separate oneself from other psychiatrists, “my primary motivation is almost always to help my patients.” Primary motivation? Almost always? This is concerning to me.
It also concerns me that despite everything said here, it is written by a psychiatrist who is attempting to learn from Bob Whitaker’s work. It amazes me how people can think they are doing things radically differently, when in fact what they do they still “often, but not always, includes medications as part of how their life is going to get back on track.” I am breathing deeply and refraining from attack right now.
I want psychiatrists like Mark to continue to read this website and it may be helpful to see how their minds work. Despite these and many other concerns and disturbances regarding what is said in this article, I am glad Mark is starting to think more critically about the drugs. I only hope in the future these thoughts will lead to far less prescribing and eliminate prescribing from the top 10 go to solutions for people in distress. Sure, that would take a lot more learning and lead to less income, but if you truly want to reduce harm, that is the only way I can see.
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I also need to say I don’t think there is such thing as ethical and effective prescribing in the current system.
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I do think that many of the hundreds of people whose lives I’ve seen dramatically improved by including medicaitons in their services have had “ethical and effective prescribing. Theri voices may not be as passionate or angry as many on this website, but they are valuable too.
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But the big question is whether or not they were told about the long term effects of these toxic drugs. These are not so-called “side-effects” but are direct effects of using the drug. How much true informed consent takes place when you sit with someone and decide that they need the drugs. Do you ever ask peopple what they want or would like before you give them the drugs? Do they not raise their voices because they’ve not been informed about what they’re putting into their bodies?
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Once again, you’re right on target Stephen. I was one of those patients who initially thought that psych meds were a miracle only to find out years down the road, they had caused horrific side effects.
I know I shouldn’t do this but because I feel psych meds destroyed so much of my life that I can’t get back, I constantly rue the day that I took one crumb.
But since my psychiatrist thought they were the eight wonder of the world, he never questioned me closely about what effect they were having even though I made comments of concern. He just blew me off because I was a mental patient.
My question to Dr. Ragins is how often do you review with your patients the need to stay on meds? And do you closely observe for side effects such as tremors which I had?
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agreed Stephen, thanks for saying that.
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In my opinion many of the lives you have deemed “dramatically improved“ by “medications“ will inevitably fall into the category of “angry“ survivours over the long term! In fact I am willing to wager!
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I’m willing to make the same bet and I only make bets that I know that I can win.
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Haha! Right on Stephen! and on a side note i`m tired of using the word “medications“ (even with quotes). If I have to use that propaganda term/idealogically loaded term to be among decent company then surely the other camp should have to accept my preferred terms for “medications“: chemical lobotomy, chemical acme anvil to the head, neuro poisons, mothers little social control helper etc. It`s only fair and respectful.
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None of us know what proportion “many” lives would be. It could be a small minority and still be “many” or it could be a sizable majority. Just knowing lots of people in any category – angry survivors, grateful patients, people who think meds have saved their lives, people who believe medications helped them recapture control of their lives from their illnesses so they could be themselves, people who tried to recover without medications and ended up hurting someone, etc – doesn’t make it a predictably common outcome.
I’m reminded of a friend of mine from Minnesota who was certain in 1972 that McGovern was going to be president becasue everyone he knew was going to vote for him.
The internet has helped like minded people to organize and expand their voice. Too often the outcome, however, has been to create uncompromosing gridlock rather than diaglogue.
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Dear Dr. Ragins,
To what “illnesses” are you referring?
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Agreed, thank you for saying this Chaya.
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Dr. Ragins writes:
“The internet has helped like minded people to organize and expand their voice. Too often the outcome, however, has been to create uncompromosing gridlock rather than dialogue.“
I think you are blind to the “uncompromising gridlock“ that you purvey: For example speaking of “illnesses“ (ie socially constructed (and oh so lucrative$$) fake diseases …refuted to the 50th decimal point here by others on Mad in America…quite brilliantly actually…check it out!…please?), “medications“ and the trite hot button cliches you put forth: eg “people who tried to recover without medications and ended up hurting someone“….yeah those dam violent mentally ill folks!
So yeah some “uncompromising gridlock“ is more equal than others!
I would also point out that while I respect your right to refer to people as “angry survivours“, it does strike me as rather grotesque coming from a member of your profession: I mean I would not look to the the slave holders to act as a barometer on the “anger“ level of their slaves. They are just not someone I would look to for any sort of defintion of the slaves…regardless of how the slaves or former slaves may define themselves.
It strikes me that entering that line of debate is a very undignified way to go…not interested.
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Thank you Chaya for your courage and light! You are one of the true ‘Harriet Tubmans’ of the this dreadful harmful psychiatric system, dedicated to helping people break free of psychiatric labeling and oppression and we could all learn from your courage to be. If you could find allies from within the psychiatric community to help further your work, think how many lives could be saved and how much healing could take place! i and my friends are praying for your success!
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Dr. Mark,
I respect and admire you for taking a stance on medication that is outside the norm in your field. The effort to encourage people to take responsibility for their health and to participate in their recovery is laudable.
As long as doctors hold the power to take away people’s civil liberties with out trial, the trust required for full participation in recovery will never be present. As long as doctors do not trust their patients, collaboration is a sham. When the patient says a drug isn’t working, will the doctor trust the patient? When the patient brings up a potential drug side-effect that isn’t in the FDA database, will the doctor trust the patient? When the patient experiences paranoia as a side-effect of an anti-psychotic, will the doctor trust the patient? When the patient experiences anxiety, paranoia, mania, or even psychosis on withdrawal from medication, will the doctor trust the patient? When the patient experiences trauma or even assault at the hands of medical professionals, will the doctor trust the patient? When the patient encounters stigma that makes relationships fail, even relationships with medical professionals, will the doctor trust the patient?
Or is it easier to believe that drugs are a panacea for all things, and for the doctor to use their authority to persuade or force the patient to take drugs? Sometimes I think our whole society needs a placebo for mental health. Perhaps we should come up with a harmless little pill to help all of us, patients, families, and communities, with our feelings of impotence surrounding mental illness.
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My thoughts exactly. Well spoken! The ‘collaboration’ between our daughter’s psychiatrist ‘du jour’ (it always changes every six months) and our family is a sham! As parents, we have to hide what we really feel about our daughter’s ‘treatment’ because the doctor’s authority is so absolute, his testimony could prevent us from even having contact with our daughter when she is hospitalized or prevent us from offering our home as a safe sanctuary when she is court ordered to live in a group home and take her meds!
HIPPA! What a farce! the only civil liberty afforded to patients –privacy laws—-is twisted by medical workers to hide knowledge from parents about an adult child’s ‘treatment’ so parents cannot adequately prepare a supportive community on the outside to help a child heal from psychiatric abuse while they are no longer ‘inside.’
I wish to coach my daughter on how to pretend to be ‘normal’ so she can get discharged faster and protected from psychiatric harm and abuse even though my deepest desire for my daughter is to be honest and be herself first and foremost.
Plus I no longer wish for her ‘normal’ Now that I can see the range of abusive behavior that parades as ‘normal’ and the ways in which people can legally exploit and damage other people while making a living, makes me no longer wish to strive for the ‘American dream.’ That is one of my healings. I am exorcising my financial demons and I hope the fretting over money and class that I imposed on my daughter is something that she can heal from too.
All the cards are stacked against someone who is labeled as mad. The casino is rigged.
This is not collaboration.
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“I’ve long suspected that “Do no harm” was a fantasy. I have to come to terms with the likelihood that I’m doing harm when I do prescribe and when I don’t prescribe, regardless of my motivations.” There is just no helping to be done with those as helpless as the seriously mentally ill, is there?
It is my understanding that this piece is relativism at its finest. At the end of it I get the vague feeling that not much changing is going on despite all the vast sums of paradigm-changing information he is given access to.
After I got off my meds for “bipolar”, I got into AA and found a sponsor to work the 12 steps. My sponsor is a social worker and a trained “peer specialist” within her field. She worked at a long-standing, reputable rehab for 14 years. I love this woman and she teaches me much about recovery, but I find her belief system about biopsychiatry fascinating. She has a well-defined and honed sense of right and wrong on just about everything, except what can be done with the mentally ill. Then, it is a free-for-all. I think this is far more prevalent than just her. Exceedingly harmful and/or degenerative treatments are routinely taught to be fair game for those caught in the web of the system.
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Dr. Mark,
It’s clear you are making real efforts to be caring and ethical. But near the end of your post, you state a conclusion that appears to underlie most of your article:
“I’ve come to the conclusion that neither the pro-medication nor the anti-medication sides are correct. It isn’t a question of figuring out whether untreated psychosis is damaging to your brain or long-term medications are damaging to your brain. The most likely answer is that both are damaging.”
This sets up a straw man that is commonly used by psychiatry to support its assumption that drugs must have a dominant role; and it makes almost inevitable the conclusion that the decision to prescribe at all is required for patients’ well being.
The fact is that virtually all on the “anti-drug” side are not proposing to just stand by and watch people become increasingly psychotic without any “treatment”. The choice is not “nothing at all” vs. prescribing drugs.
The “anti-drug” side simply does not accept that the only form “treatment” is drug treatment. The fantastically successful Open Dialogue model is largely drug-free – and when drugs are resorted to, they are generally benzodiazepines, not neuroleptics and are generally discontinued within weeks. Instead of drugs, Open Dialogue uses the kind of intense psychosocial “interventions” that are not available anywhere in the U.S.
Soteria House also went largely drug-free, and did as well as, or better than standard drug-based treatment. This again was accomplished with intense, patient-oriented psychosocial “interventions.”
The Agra Center in India, used drugs the least of any center in the 25 year-long World Health Organization studies. And Agra’s outcomes were markedly better than first-world drug-based treatment. The WHO’s final report concluded that as-yet unidentified “cultural factors” were the source of Agra’s remarkable 25 year outcomes. Being part of the psychiatric establishment, the WHO was shy about mentioning the obvious fact that culture without drugs had soundly beaten drugs in virtually every setting.
This web site contains the stories of many whose recoveries from psychosis began when they left standard drug treatment and found the support of compassionate fellow travellers. The recovery movement is not advocate “doing nothing” – it advocates all kinds of psychosocial support.
I applaud your determination to honor and support the “patient”. And it may be that the resources for the kind of support provided by Open Dialogue are so lacking in the U.S. that it appears there’s no choice but to at times use at least some level of medication.
But that doesn’t mean medication is the best choice – it just means that the resources for providing the best choice are currently unavailable for the vast majority of “psychosis” sufferers in the U.S.
Serious consideration of the full power of psychosocial “interventions” cannot happen when the problem is cast in terms of “no treatment” vs. “drug treatment.” If the question becomes “a full exploration of intensive psychosocial approaches based on the dignity and strength of the sufferer” vs. “drug treatment,” and if billions are spent to support and study the psychosocial side, we have a chance to get some real answers. It very well may turn out that the psychosocial wins, and the drugs become far less important than even you have assumed.
Posing the issue by setting up a straw man vs. drug treatment gets essentially no real information.
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Peter,
Thank you as always for your brilliant comments.
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Thanks a lot for your complement. I appreciate it very much.
Pete
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The usual label is “duration of untreated psychosis”. i’m not aware of studies that try to do what you suggest though it would be helpful – contrasting psychosocial treatment wihtout medications and no treatment and with medications. Even the studies that pruport to tease out the differential effects of illnesses and medications are using statistical methods, not experimental methods.
i don’t do research, but I have to say that on an everyday basis I spend far more time trying to talk people out of medications and into psychosocial treatments than i do trying to talk them into medications. Many people like the rapid relief of suffering they get with medications.
I do see people who would like money and housing subsidies and no treatment of any kind – psychosocial or medications – and we do try to acocomodate that, and often it helps alot.
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For details of a study that contrasted psychosocial treatment without medication and no treatment with medication (or as near as damn it) I suggest reading. “Psychotherapy of Schizophrenia – Treatment of Choice,” by Bertram Karom and Gary VandomBos. It was published in 1977, quite some time ago, but it is still in print.
http://www.amazon.com/Psychotherapy-Schizophrenia-The-Treatment-Choice/dp/1568212321
Karom conducted a study where first episode psychotic patients were put in three groups: 1 drug free psychotherapy, 2 drugs and psychotherapy, 3 conventional psychiatry – ie drugs and perhaps some social support.
The best result was from drug free therapy, the worst from conventional psychiatry.
Many people do indeed like the rapid relief from drugs but the longterm outcomes suggest this is harmful both in terms of recovery from the mental distress that they visited the Dr for and for their physical health.
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Mark
I hope you take the time to respond to some of the writers before me, especially to Madmon whose profound story regarding the horrors Biological Psychiatry has perpetrated against her daughter is almost beyond words. She has raised some very important questions of moral stance that demand an honest response from those working within your profession.
It is not easy for people (especially psychiatrists) working in the mental health field to post here; it requires courage, honesty, and a willingness to listen and learn. As someone once said about MIA “it is not for the faint at heart.” You might want to read some of Dr. Sandra Steingard’s postings and discussion dialogue to observe her display of these qualities.
Posting at MIA, or participating in the discussions, requires a willingness to have our world outlook on the theory and practice regarding the inhumane treatment in the current mental health system seriously challenged. This could be emotionally painful at times for some people.
Madmom’s willingness to share such intimate details of her own emotional and political transformation related to her daughter’s treatment by this system is exemplary; a true inspiration to us all. Mark, if you can emulate a fraction of this courage you may succeed here.
Your first posting, “Dr. Mark and the Village” was not a good introduction at MIA. Some readers were insulted (I know I was) by your attempt to portray yourself as the “Patch Adams of Psychiatry;” someone who was sort of nerdy, funny, and could “get down” with the mentally ill. Ted Chabasinsky spoke for me when he said something to the effect “Okay your a nice guy so now tell us what you think about the important issues.”
It came across as if you did not do any homework or investigation as to what MIA was all about. Anyone who has paid any serious attention to the content at MIA would know that most readers are keenly attuned to the issues of the power relationships between “helpers” in the field and those people needing the help, the issues of power and control especially related to forced drugging and forced treatment, alternative (more humane) forms of treatment, and most certainly the issues of the role of psychiatric drugs. As a psychiatrist writing here, to not address any of these issues in your introduction came across as deceptive and out of touch.
I want doctors to participate here. I am not anti-psychiatry; I am anti-Biological Psychiatry. I do want to know how psychiatrists are attempting to help people in more humane ways, but I also want to know what they are doing (or willing to do) to directly challenge the oppressive paradigm of treatment that currently controls their profession and dominates the entire mental health system.
As to this most recent posting, it comes across as still being stuck in the Biological Psychiatry paradigm with some attempts to “put lipstick on it.” Your new focus in this posting is on “medications” without addressing the broader issues of power and control. And of course your repeated emphasis on calling psychiatric drugs “medications” is just one indication that you still have one foot planted firmly in the “old order” and your just trying to dangle a few toes in the “new.” I am all for second, and even third chances if your willing to engage in the struggle to change the world to a more just and humane place.
“Like most doctors, I feel like I prescribe medications ethically and effectively.”
Mark, you lost me in the first sentence. I have many critical comments about this posting but I will say first: It is absolutely astonishing to me that any psychiatrist today could say they have even the slightest amount of confidence in their ability to safely prescribe psychiatric drugs at this time.
Given the corrupt nature of drug research and testing, combined with all the current knowledge we have of damage caused by these drugs, where could possibly all this hubris and confidence come from in your ability to prescribe. Any doctor that is truly in touch with reality should be scared beyond belief and thoroughly humble when it comes to these questions. This is not reflected in your writing.
Richard
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Richard I’m going to disagree or agree to differ with what you say, speaking as a survivor, of mental illness and psychiatric treatment, and as a carer of many family members who have come through the psychiatric system.
I liked Mark Ragins first article and this one too, because of their honesty, and because Dr Mark is adapting his practice “prodded” by Bob Whitaker’s writing, and with a person-centred focus. No-one’s perfect and the system’s far from perfect, which is why I speak out against human rights abuse in psychiatric situations and the use of forced treatment. I’m critical not anti psychiatry, otherwise I couldn’t be working alongside psychiatrists and clinical managers to bring about positive change.
All of my close family members have been labelled with mental disorders and treated with psychiatric drugs. About half of us remained on the drugs, the other half of us didn’t like them. I presently have one son who’s OK about being on the anti-psychotic and finds it useful, he can function fine on it and worked as a petroleum pipefitter when on it. My mother was OK about being on a depixol injection until the day she died. That was her choice, she worked full-time, had an ordered life. It wouldn’t have been my choice but neither would I have coerced her to think differently. I have a sister who is on clozapine, it causes her physical health issues but yet she lives a productive life despite her disabilities and is not against psychiatry.
For me the issue in psychiatry is the use of force and that we need a range of alternatives for people who are experience psychoses. Some folk don’t mind being forced but I really didn’t like it. We are all different and therefore will require different treatment. One size doesn’t fit all.
I hope we get more psychiatrists and clinicians writing on Mad in America so that we can we a multifaceted and productive dialogue and debate. Whatever it takes to bring about a paradigm shift and real positive change.
Cheers, Chrys
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Hi Chrys
Just to clarify my above posting. My criticism of Dr. Ragin’s approach to prescribing psychiatric drugs was NOT the fact that he was giving these drugs to his patients. Some people may want or need some type of drug at this time in our history in order to deal with extreme forms of psychological distress. After all, even if all new psychiatric drug prescriptions were stopped today there would, by necessity, be many years of sophisticated tapering regimes that would have to be developed and perfected to help those people who are now dependent on these drugs.
My issue was with the doctor’s hubris and over confidence that he (or any doctor for that matter) could possibly know what is a truly safe and ethical way to prescribe these types of drugs at this stage in history. Given all the scientific distortions promoted by Biological Psychiatry we know so very little about how these drugs affect the brain in the long term. I believe we can say with some confidence that they cause more harm than good. Testimony from almost all MIA writers bears this out.
So yes, doctors need to be struggling to be more ethical in their approach and write about it. However, I believe it should come with a FAR greater sense of humility and caution, and a willingness to admit just how much ignorance and helplessness we should all be feeling about these difficult questions.
Biological Psychiatry cannot be reformed or refined; it needs to be dismantled. I have not yet been convinced that Dr. Ragin is trying to work outside this paradigm of so-called treatment.
I stated above that I had many problems with Dr. Ragin’s posting starting with the first sentence. So now let’s take a look at part of his second sentence:
“3) I try to resist responding to various self destructive motivations of my patients (hopefully without becoming too judgmental and pejorative of their “medication abusing”, “manipulative”,
“sabotaging” desires.”
I am trying to “resist” being too sarcastic or “judgmental” in my response, but this use of language to describe people with this level of psychological distress is reflective of incredible arrogance and ignorance.
It is precisely Biological Psychiatry’s ability to seize upon and expand on our culture of addiction by promoting its own version of legalized drug pushing, that contributes to creating these negatively labeled symptoms (he has identified) within a very vulnerable section of the population.
These behaviors he is describing with such negative and judgmental language are actually different types of coping mechanisms that people are forced to develop for survival purposes within a very cruel world; they are thoughts and behaviors that come out of conditions of deep trauma and pain. And they only exist in a very small segment of those people actually taking psychiatric drugs today. Where is the understanding, compassion, and empathy using this type of language?
If there is one thing that I have learned at MIA, its that language (and especially the transformation of our language) that is so very key to making a clean break from the “old Order” and creating the “new.” The good doctor has a long way to go.
Richard
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“It is precisely Biological Psychiatry’s ability to seize upon and expand on our culture of addiction by promoting its own version of legalized drug pushing, that contributes to creating these negatively labeled symptoms (he has identified) within a very vulnerable section of the population. ”
This is very true. Cocaine is illegal, but cocaine-like drugs are fine if prescribed to children (Ritalin).
This should be disturbing to any rational person. Cocaine is bad, so bad that its mere usage is criminalized, if consumed by consenting adults. However it is OK for so called “doctors” to put children on Ritalin. Contradiction anyone?
I am not even getting into the fact that it has been reliably established that neuroleptics are neurotoxic and that its continued usage damages the brain irreparably. Few so called “illegal drugs” are known to destroy the brain the way neuroleptics do.
Yes, biological psychiatry is, at this point, beyond repair. I don’t see any hope in the attempts at reforming it. It has to be dismantled by making coercive psychiatry history. People who want to destroy their neurons with psychotropic drugs should be free to do so but nobody should be forced to take these drugs nor should they be presented as “medicines like insulin”. Information about the toxicity of these drugs should be presented to anybody willing to engage in its usage.
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As a mother whose child killed himself 15 days after being prescribed a drug that both the manufacturer and my government have admitted is the most likely cause of his suicide, I of course agree with you totally. I am now told that the prozac he was given is close in chemical composition to methamphetamine.
Had my son taken a street drug he would have known he was taking a risk. Because it was a prescribed ‘medicine’ he did not. The drug didn’t behave differently because it was handed out by someone in a white coat rather than a jacket with a gang patch.
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(reply to Maria)
In fact, the first prescribed antidepressant WAS methamphetamine! http://www.google.com/imgres?imgurl=http://curezone.com/upload/_G_H_Forums/History/Norodin_a_Brand_name_for_methamphetamine.jpg&imgrefurl=http://curezone.com/ig/i.asp?i%3D38784&h=700&w=494&sz=60&tbnid=6tY97-K_HMYoQM:&tbnh=92&tbnw=65&zoom=1&usg=__Lzf2okx1BdAaBmk-t4FWRXMYHX0=&docid=TSvsu_HedtwnkM&sa=X&ei=gsdkUr3GGIfa4APN-IFg&ved=0CC0Q9QEwAA
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“It has to be dismantled by making coercive psychiatry history. People who want to destroy their neurons with psychotropic drugs should be free to do so but nobody should be forced to take these drugs nor should they be presented as “medicines like insulin”. Information about the toxicity of these drugs should be presented to anybody willing to engage in its usage.”
Exactly. In addition to this, quality, effective alternatives to drugs must be seriously developed and offered. These two tasks are imperative and urgent. Anyone disagreeing with this, should have their head examined….
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It isn’t possible to have choice over the use of force. Either the use of force is legal or not.
Our choices are mediated by the people we have contact with, what we have read and seen on the TV and our Dr’s prescribing preferences. So in other countries, and people quote Western Lapland a lot, your family members may not have been offered the choice of the drugs they take and may have had outcomes that were just as good. Or they may have taken them but for very short periods.
Individual choice and medical practice are different but related issues.
Psychiatric drug use is much wider than individual choice too. The outcomes of different treatments have social consequences as well as individual ones. Early death and long term disablement are associated with major tranquiliser use, which is the basis of Whittiker’s book, Anatomy of an Epidemic.
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” It isn’t a question of figuring out whether untreated psychosis is damaging to your brain or long-term medications are damaging to your brain. The most likely answer is that both are damaging. ”
I just hope that you realize that animal studies have proven the neurotoxic effects of neuroleptic drugs, whereas the supposedly toxic effects of psychosis remain not only far from proven, but often use the very same studies that prove the drugs are damaging and then just blame the damage from the drugs on the “disease”. Ask yourself this: did the monkeys have schizophrenia?
Your conclusion there just doesn’t seem reasonable to me. You’re trying to balance a known harm with an imaginary one, truly not even theoretical in a science sense because there’s no real evidence for it.
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Oh, but not only that, but you seem to still be completely O.K. with using these drugs in non-psychotic patients. Do you have evidence that whatever their problem is, is causing harm to their brain to offset the harm from the drugs? Is being upset over an abusive childhood harmful to the brain? And even if it were, how would that make it O.K. to further harm the brain with drugs? Doesn’t it make sense that if a brain is suffering harm, then the last thing a doctor should want to do is add more harm? How does the possibility of the existence of harm justify doing more harm? That’s like saying “Well, the person was already damaged goods when I got a hold of them. So what if I gave them tardive dyskenisia.”
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Have you considered social prescribing? There is a lot of good evidence to support the prescribing of things other than drugs.
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I deeply appreciate your voice articulating an honest attempt to develop a personal framework for responsible, relational, respectful prescribing practices.
I’m a little saddened by the negative snarky tone of comments, but I also appreciate that this is a community heavily represented by persons who have been brutalized by psychiatry and medicines arrogant, inhuman objectifying practices and that anytime doctors, psychiatrists or any other type of “mental health” professional enters the dialog it can be a bit trauma triggering and feel a little scary.
Speaking only for myself, I’d like to try not to hold an impossible to meet standard of perfection for persons who wish to contribute their voice to the dialog here. I’m not looking for an excuse to be offended and then righteous. I’m looking to continue to bring more and more people together to support each other and talk about the growing awareness/acceptance of the fact that our “best practices” as given to use by the most powerful institutions are too often destructive, dangerous and brutal.
If we can agree on that, then my hope is that we can give each other some “room” to go through our own growth journeys as we find our way from a place of “this is what I was taught / have been told for decades / have been trained to believe” to a place of “this is what I understand to be most accurate, best supported by genuine evidence, and most truthful.”
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snarky
adjective \ˈsnär-kē\
Definition of SNARKY
1 crotchety, snappish
2 sarcastic, impertinent, or irreverent in tone or manner
im·per·ti·nent
adjective \(ˌ)im-ˈpər-tə-nənt, -ˈpərt-nənt\
rude and showing a lack of respect
I shall assume that you mean the second meaning of snarky. Actually, by my reading, none of the comments here are snarky. Although some are negative, or a mix of positive and negative, no comment seems sarcastic. As for whether some comments may be rude, it seems that none of them are personal attacks against Dr. Mark. All of the comments are speaking either of their own experiences or about research. Many comments have welcomed Dr. Mark or have expressed admiration for viewpoints of his that depart from the mainstream.
It may well be true that some comments can be viewed as negative, depending on ones perspective. For example, my call for trust on the side of prescribing psychiatrists could be taken as critical. On the other hand, it could be taken an honest eye-level expression of how stigma effects the consumer-psychiatrist relationship. Do I expect my comment to be given equal weight to any comment made by a psychiatrist? Absolutely. Mad In America is about hearing all the voices.
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Andrew (and Mark),
I think that the best analogy that I have come up with to explain the animosity that many of us feel towards psychiatry is sex, not rape but sex. Think about it. Sex can be a great experience if done willingly, with the right person and with “all the information”.
Now, most complains against psychiatry relate to experiences of coercion (think “rape”, there is no such thing as a “benign rape” experience), unprofessional psychiatrists (like that guy/girl with whom sex was awful) or lack of information about the potential consequences of sex (like that guy/girl with whom you agreed to have sex, the experience in the short term was great but he/she gave you an STD -AIDS in the wost case- and he/she did it hiding information from you).
Note that this analogy breaks when it comes to the support from society to those who have suffered from psychiatric abuse.
Society criminalizes rape and knowingly giving somebody STDs, yet it condones coercive psychiatry and knowingly prescribing poisonous drugs and hiding the secondary effects from patients. It’s like some rapist or serial STD transmitter excusing his/her behavior on the victim having had something positive out of the experience. This is how I personally feel when some psychiatrist comes here defending the evils of psychiatry, ie, coercion or knowingly prescribing poisonous drugs to patients who are kept in the dark about the dangerous consequences of these drugs.
Just as there is very little hope for reform in a serial rapist or a serial STD transmitter, I expect very little from psychiatrists who defend these evil practices of psychiatry. An “ethical psychiatrist” would understand that a great deal of evil has been caused by these practices and would stop defending them. Actually, this is how it usually goes with psychiatrists who have abandoned the dark side. They realize that they have caused a great deal of gratuitous pain to a lot of people and they try to make up for that.
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I find nothing “snarky” about the comments. I don’t think that we’re imposing some “impossible to meet standard of perfection for persons who wish to contribute their voice to the dialog here.” We are demanding honesty and a willingness to see more than the drugs as the surefire answer to everything.
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I can’t see how there is individualised prescribing because neuropletics and even ‘mood stabiliers’ can be prescribed to anyone irrespective of diagnosis and none of these drugs specifically target an experience such as hearing voices or paranoia
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By individual prescribing i mean beginning not with a diagnosis, but with the person’s story , their experiences,and their goals and wokring with them using shared deciions making to see what medicaitons at what dosages improve their lives. Some people feel they’re being experimented on with this tiral and error approach, but the individual variation between people is so great, even within any diagnosis or target symptom, that there’s no way to make more than an educated guess as to how the medicaiton will effect andy give person. Someone will think med A is a lfe svare, while another peorson with similar symptoms will be made worse or have serious side effects. Medicating effectively is a coolaborative, time consuming process of learning together. It’s hard.
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Is this typical in medicine? (if you can consider prescribing mood-altering chemicals to people with emotional/life problems “medicine”) Do the effects and performance of non-psychiatric drugs also tend to vary so wildly from person to person that it’s essentially a crap shoot each time they’re given as to whether they’ll make the person better, worse, or no change at all?
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Yes, actually it is reasonably common for there to be a wide range of responses to medication. There are the people who are allergic to certain drugs. There are people who metabolize certain drugs faster or slower than others (which is shown to be the case with some psychotropic drugs: Abilify). For example, there are cancer drugs that must be dosed according to a genetic test, because a dose that is therapeutic for one person would kill another.
Unfortunately, we do not have much science for psychotropic drug response. The current best practice is to personalize the prescriptions. But this requires a practice that is truly respectful of the consumer.
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They did a DNA test on my son after he died. He was an intermediate metaboliser with mismatched allelles. Lot of good finding that out did me after his death. Toran was a victim of the Russian Roulette psychiatrists play with our children when they prescribe these drugs.
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Yes, medicine is more individualized trial and error than we would like to think. But psychiatry is ever so much more so for several reasons: 1) When we’re using a medication, like penicillin or Tylenol, tha has a very low toxicity profile, we can safely give dosages larger than most people really need and call that the “normal dose” and nobody notices the individual variance. 2) When we’re dealing with a realitvely simple organism like bone marrow, or kidneys, or a pancreas both the underlying biological mechanisms and the individual variation are likely to be less than when dealing wtih the human brain – the most complex thing in the universe. 3) The brain has an incredible amount of interactive feedback loops and plasticity in it. Keep in mind that Whittaker’s main thesis is not that meds are directly toxic. It is that meds that are intially helpful, but then trigger feedback responses from our brains that are harmful to us over the long run. In effect it’s our brain harming oursleves – and our brain’s responses are highly individual. As an medical analogy, steroids sometimes cause acute toxicity, but they also cause harmful feedback loops within our immune systems that cause damage years down the road. 4) There are high rates of palcebo effects and placebo side effects (much more studied short term than long term) that could be renamed “triggered self healing” and “triggered self harm” that seem to be psychologically mediated and are often even more important than the biological impacts. (That’s one reason why I personally focus so much on treatmetn relationship, trust, personal buy-in, and personal meanings of medications when I prescribe.)
All of this is not meant to say that it’s a “crap shoot” – doctors should prescribe whatever you want as fast as possible and move on to the next patient. It’s meant to say that effective prescribing requires lots of time and relationship and consideration of lots of different factors like I outlined in the blog posting I started this conversation with.
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And yet the families I work with didn’t have lots of time. Their children died from SSRI induced suicide within days of being prescribed. In my son’s case, 15 days. In light of other comments you have made I feel the need to add that the causal relationship between the drug and his suicide was assessed both by our regulator and the pharmaceutical company as ‘probable’ so I am talking causation not correlation.
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And if a patient comes to you changing their mind and wants off of medications, what do you do?
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People feel they are being experimented on because they ARE being experimented on! I’m glad you seem to acknowledge this fact, but I think it is best to be honest about this to the clients. That’s kind of what I think Moncrief is saying – rather than “I’m treating you for X disease or condition,” it’s more, “This drug sometimes makes people feel who feel like you do feel a little better, though it can also make you feel worse in the following ways.” Of course, the same could be said about marijuana or alcohol, which makes me seriously wonder if this kind of experimenting is very different from going down to the bar after work to toss back a couple before having to go home and face your family, or taking a couple of hits in the morning before heading off to deal with your crazy boss, because you won’t react as much if you’re high.
Taking substances can sometimes make people feel better, but I don’t think that’s a new discovery. It doesn’t seem much like medical practice to me.
— Steve
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Dr. Ragins states:
“Within this system a variety of people, for example a speed-using, foster-care-childhood, homeless person, an emotionally labile rape victim, a person with a strong family history and clear episodes of highs and lows, and an emotionally immature teenager are all diagnosed with bipolar disorder and treated with mood stabilizers and atypical antipsychotics. Even this system is often considered too time consuming and replaced with symptom-based prescribing.”
I give Dr. Ragins credit for admitting this despicable treatment of rape, domestic/work/community and other violence mainly perpetrated against women and children of stigmatizing/blaming the victims with the latest fad fraud of the life destroying bipolar stigma among others to subject the victims to deadly neuroleptics and other toxic drugs to perpetrate further abuse, violence, betrayal, physical/emotional/psychological/spiritual destruction, retraumatization and disempower them so much they will be dis-abled from escaping, confronting or exposing their abusers since the mental death profession exists to aid and abet such abusers in power like themselves.
Sadly, biopsychiatry pretends to just focus on the so called symptoms of the bogus bipolar of so called labile moods after emotional and physical rape when they know all too well they are scapegoating, vilifying and turning the tables on the This is done by making the abuse victims appear to be “crazy,” violent, abusive, delusional, paranoid, having a permanent, severe “mental illness” of bipolar that will require being poisoned for the rest of their greatly shortened, disabled/destroyed/ostracized/discredited lives and the real villains of the piece to silence and discredit them. This has been documented quite well by those like Dr. Carole Warshaw, Psychiatrist and Domestic Violence Expert, Dr. Judith Herman and Dr. Frank Ochberg, both psychiatrists and trauma experts and all to many others that shows that despicable biopsychiatry/Big Pharma cartel prefers to prey on the victims of their cohorts in crime rather than their fellow perpetrators since they are easier, more numerous and more profitable targets. Obviously, there is a reason why biopsychiatry refuses to address malignant narcissism and psychopathy that grows more rampant all the time per world authority Dr. Robert Hare since it hits too close to home.
I find it appalling that Dr. Ragins admits he’s been taught to only use a few diagnoses like bogus bipolar disorder. The reason for this fraud is quite obvious in that the creators of the junk science DSM, drug companies and their front groups like NAMI, our corrupt government and many others have perpetrated the outrageous deceit that vile stigmas like bipolar and schizophrenia are biological, genetic and/or chemical imbalances requiring life long “treatment” (torture and robbery of all human, civil rights to aid and abet the victims’ original abusers). Thus, insurance companies have been forced/complicit into paying for this horrific fraud and demolition enterprise perpetrated against countless lives in the guise of treating bogus, voted in DSM stigmas with the most lucrative bipolar fraud fad by poisoning the victims and permanently disabling them and destroying their entire lives including children, careers, finances, homes and everything that ever mattered to them. Obviously, anyone colluding in this demolition enterprise against the vulnerable to allow them to be abused and raped with impunity while punishing the victims of these crimes is seriously lacking in any conscience, decency, morals, empathy and humanity.
Obviously, PTSD would be the least offensive label for victims of domestic/work/community violence, scapegoating, mobbing, bullying, but that label does not allow for making the victims permanent patients/victims to exploit their health insurance or Medicare/Medicaid for life. Sadly, biopsychiatry has done all in its power to discredit the PTSD label with constant lies that the victims are responsible for their normal reactions to abnormal events mainly perpetrated by malignant narcissists and psychopaths including those by our military industrial complex creating many traumatized combat veterans. Yes, rape victims in the military are also tortured, betrayed and scapegoated with the horrific bipolar as Dr. Paula Caplan has documented so well. That’s why biopsychiatry plotted to incorporate all trauma/abuse symptoms in the vile, bogus, defamation/degradation ritual of the bipolar fad fraud stigma.
I would hope Dr. Ragins would be a bit less glib and truly see the huge harm he is doing when stigmatizing/blaming and scapegoating already vulnerable, traumatized abuse, rape targets with the pernicious bipolar stigma only meant to malign them to allow their abusers off to get away with body, mind and soul murder and other crimes against humanity.
So, yes, I would agree with Dr. Ragins that this is unethical to say the least while it also minimizes this despicable, lucrative “practice” that deceives and brainwashes so many while destroying countless lives. Obviously, this whole predatory enterprise is about social control and robbery of all civil, human and democratic rights and has nothing to do with health at all whatsoever. It is more equivalent to the Nazi Holocaust and only differs in that all of humanity except the current psychopaths in power are the targets of such predatory deceit, manipulation, conning, exploitation and destruction via biopsychiatry. This is well described in Dr. Robert Hare’s books, Without Conscience: The Disturbing World of the Psychopaths Among Us, and Snakes in Suits: When Psychopaths Go to Work. The book and web site, Political Ponerology, does a good job of exposing these literal snakes on a macro scale.
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I would really favor many more diagnoses instead of the present trend of broadening and boradening a few diagnoses. I think “rape trauma vicitm” would be a reasonable diagnosis – it has a known cause, common problems, and useful treatments (primarily psychotherapeutic and mutual support and political advocacy to make meaning form suffering). My point was that burying this in Bipolar makes it more likely to get various medications instead of specific therapy along with the truamatic impacts of the diagnostic process that you describe.
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Thanks, Dr. Ragins, for sharing this. To others, please see the review of Dr. Moncrieff’s new book, The Bitterest Pills. I will also be writing about this. One of the many points she makes in the book is that our disease centered approach (which is criticized in the post) is that we are left with some fundamental questions about how to best use them (if ever).
This diease centered approach is what fueled the notion that waiting and helping people before introducing drugs is bad for the brain and it is what contributed to our being blinded to the impact of drug induced brain changes vs “disease” induced changes. I plan to write more about this book and this conversation but having a dialogue with someone like Dr. Ragins is pretty critical to the prospect of effecting change in our system of care.
Sandy
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I agree with your critique of the disease centred approach which is partly why I like the idea of Formulation as a viable alternative to diagnosis as proposed by Lucy Johnstone’s articles on this site.
So instead of, “Rape Trauma Victim,” as a blunt diagnosis a formulation would be a short written description of the persons problems, their strengths, what caused the problems and what might help. This would be written collaboratively. This then becomes a professionalization of what are very everyday concepts and practices. It normalises human distress instead of medicalising it
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Dr Mark Ragins wrote, ““I’ve come to the conclusion that neither the pro-medication nor the anti-medication sides are correct. It isn’t a question of figuring out whether untreated psychosis is damaging to your brain or long-term medications are damaging to your brain. The most likely answer is that both are damaging.””
Several scientific authors have questioned the idea that untreated psychosis is damaging to the brain. There are so few people who have experienced psychosis who have not been drugged it may not be possible to know what the effect of psychosis is on the brain.
So I wonder where he came up with the idea that both are damaging?
I like Bertram Karom’s idea that schizophrenia is chronic terror syndrome. Now I do not think schizophrenia is a valid diagnostic category but chronic terror might be. Is chronic terror damaging to the brain, or indeed the body? Probably, but perhaps not irreversibly in most cases. Are drugs a good way of treating chronic terror. Probably not but they might relieve the symptoms for some people. But then so would many other things.
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My guess is that Mark is not talking about untreated psychosis being physically damaging to the brain. The damage in that situation may refer to damage regarding other areas in the persons life such as loss of relationships, financial, and possibly traumatic experiences that may come during that period the person is going through that period. It is not a damage that can be scientifically quantified. I think that there is probably a pretty unanimous agreement with people interested in mental health that it is not good for a person to experience a prolonged state of distress and anguish. (that is a key part of much of these models being looked at as effective treatments that do not have a minimal medical component). They use a quick response when the person begins to experience concern.
It is an extreme example but take for instance a man that has been homeless for 10 plus years and has non treated mental health issues. Has a lot of apparent distress yet has difficulty focusing due to hearing voices and has difficulty organizing his thoughts. He is open to meeting with people and discussing issues in his life but there is a lot of difficulty with getting very far in conversation. It would be apparent that this person receiving no treatment has been damaging in his life. If he is interested in possibly taking a medication to see if he receives any benefit from it would be a pretty clear cut good use of trying a psych med. Is this going to improve his life very much maybe and maybe not. And of course there are million different ways that this persons life could go after trying or not trying a medication as each person is different and there are many factors both positive and negative beyond what he has been prescribed.
I can easily think of times where I have seen where medications have been damaging to a persons life while at the same time can think of where it has been a part of a spectrum of other “interventions, treatments, what ever you want to call it” that have led to a positive change in a persons life.
I think when ideas such as all psychiatric medications should be done away with as they are damaging, it negates a lot of peoples experience out there. (you can say that their perception has been blinded by propaganda and being told, but whose perception isn’t shaped by these factors)There are a lot people that report positive benefits in their lives from taking or having taken meds in the past. What would there lives have been with or without having taken the meds? Does the benefit that they see from taking the med(s) out way the harm? Hard to say as each person is different and there are factors in each persons life that can not be measured in a study.
Therefore knowing that there is damage caused by taking medications however if there are going to be medications prescribed it would be great to know that the Dr. you are sitting across from actually takes this into account along with may other factors occurring in your life and is wanting to come up with the least damaging with the most beneficial outcome.
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1 I have problems with the idea of mental illness. I prefer the concept of mental distress. So a homeless person may well be distressed for all the ten years they were homeless. I’m not sure how this relates to drugs though.
2 research by MIND in the UK found about 20% of people found the drugs on the whole helpful. About the same as find placebo helpful.
I cannot say the positive effect is placebo but I can say the drugs have the potential for serious harm and so Dr’s and the rest of us have a duty to investigate just how much is placebo and how much is not.
Here is a link to a document that quotes from the report: http://www.mind.org.uk/information-support/drugs-and-treatments/medication-stopping-or-coming-off/
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I did mean physically damaging, but I’m not a confident biologist. NAncy Andreason’s long temr study of brain volume published in the last year concluded that both medciation load and psychotic relapses indepndently correlated with loss of brain volume. Note that we tend to move from correlations like that into cuase statements like meds or psychosis cause brain damge that haven’t actually been proven. Aslo note that her conclusions are statistical conclusions, not experimental ones. To my eyes what was stirking aobut this paper was that the graphs of the acutal data looked like scattered dots all over the page. The statistical lines seh drew didn’t really capture the heterogeniety of the data. My main conclusion was that any given person mihgt experience an incredible range of outcomes both with and without meds and with and without brain damage.
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I need to say that my comments may have been challenging to some so I want to clarify my position on psychiatric drugs
I think there are two ethical ways of prescribing psychiatric drugs:
1 do not prescribe them – there people who do this
2 do as outlined in the above article, ie in a low a dose and for a short a time as possible and in negotiation with the client.
On the whole though having seen good psycho-social interventions and seem the damage of the drugs I prefer good psychosocial interventions. Mainly they are not avaialable
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Your posting made me wonder something i hadn’t before – many people on this blog believe that the damage done by poor prescribing (or even “good” prescribing) is so much that we should rely entirely on pscyhosocial repsonses to serious mental illnesses.
Many of the common pscyhosocial responses, especially to “unmedicated” people are strikingly damaging in their own right.
This week, for example, I worked with people who had been 1) evicted because he broke windows and threatened people, 2) had a restraining order to stay away form her family because she tried to smother her 2 year old, 3) were arrested because he set a fire in an alley to stay warm, 4) pepper sprayed in the face by a stranger they yelled at and they assaulted on the street, 5) were evicted for not having any money to pay rent because they felt too worn down to work anymore but were rejected for SSI, and 6)were pimped out by her boyfriend to get street speed she was addicted to.
Maybe we should be comparing the toxicity of common “psychosocial interventions” with the toxicity of common medication interventions.
We don’t live in Gheel Belgium. we don’t even live in a particularly tolerant society. Forgiveness and acceptance and reconciliation (my favorite psychosocial interventions) are pretty rare.
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Dr. Ragins,
The interventions that you mention are _social_ interventions, not _psychosocial_ interventions. Indeed, our society is not terribly kind to a lot of people. But that doesn’t mean that we should throw up our hands and reject well-thought-out psychosocial interventions.
Indeed we do not live in Belgium. However, according to our American sense of competitiveness, we are quite capable of providing the best treatment in the world to our citizens. Why don’t we do exactly that? Why do other countries have lower rates of mental illness than us?
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I’m not saying not to use psychosocial interventions. My program and myself probably use more of them than hardly any other program.
I’m saying that our present society won’t pay for, support, or even tolerate good psychosocial interventions. That’s what makes this whole thing a society wide issue.
One of the huge appeals in my opinion of the “Medications allowed us to empty the psychaitric hospitals” narrative is that it allowed society to reincorporate many people who had been forcibly excluded because we created a new category of people – “People with mental illnesses who are compmliant with their medications”. Most people are far less frightened of that class of people than of mentally ill people in general and more willing to accept them and that has been one of the main foudnations for what limited antistigma and increased tolerance we have achieved – even though it’s a very flawed line of thinking.
Last night a twenty year old woman hit and ran killed someone while driving 90 miles an hour in Los Angeles. Her father’s defense to the newscasters was “She has a mental illness and I think she’s off her medications.” Presumably he’s hoping that she can get back on her medications, be forgiven, and return to a normal life. This category of “forgiven” mentally ill people becasue they’re now medication compliant include people who get the social rewards of being released from jail, hospitals, conservatorhip, get their children back, get to drive, get to return to work in sensitive jobs, get section 8 housing or SSI. Most people in our society are only wiling to extend these powerful “psychosocial” responses to people who follow their doctor’s orders and take their medications. We’re contiually criticized by visitors for spending so much time and effort and human caring on people who “won’t cooperate and take their medications”. Creating a “counterculture of acceptance” takes a lot of work.
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Dr.,
You don’t think it’s at all disingenuous to describe the actions you listed as “psychosocial interventions”?
And yes, forgiveness and acceptance and reconciliation and support and inclusion and attention and love are too rare in our society. So instead of stressing how critical it is for our society to become more the way it needs to be to support human life and flourishing, we should make peace with the idea of replacing these healthy and necessary values and actions with prescription drugs. Replacing love and all the rest of what we actually need to function on earth with a daily pill that will play with our thoughts and emotions. This philosophy and approach is so damn dehumanizing.
You know, if people want to make up for the lack of their basic psychological, social, emotional needs being met with various kinds of mood- and mind-altering substances, that’s their choice. But the least we can do is be honest about what is actually taking place. Taking psych drugs to deal with our thoughts, emotions, and behaviors is no different than drinking to deal with our problems, or relying on any other kind of psychoactive drug. yet one of these is condemned in our society, the other supported. Doctors need to be honest about what it is they are actually doing and we need to clear up the hypocrisy on this issue.
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Mark,
Glad you’re contributing to this site.
In terms of some of the responses… many of the people on this site have either been personally harmed by psychiatry personally, or have family members who have.
Which makes MIA is a tough audience.
What can I say?
Duane
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As many here have agreed, psychiatric drugs mostly proven useless, toxic, brain damaging and often causing suicide, violence and a host of other physical ills that greatly shorten lives by an average of 25 years, we should not be calling these lethal DRUGS “medications” just because biopsychiatry sold out to Big Pharma and helped create the illusion/delusion that the bogus DSM was scientific, valid or medical when it is 100% fraud per Dr. Fred Baughman, Neurologist and many others. Even Dr. Thomas Insel, Head of NIHM, has acknowledged that the DSM is more like a dictionary of names or as some say a book of insults with no validity or science behind them whatever.
I would like to see some people so stigmatized and harmed by this fraud start suing their doctors and the APA since most if not all of them know/knew the DSM is total fiction with books like The Selling of the DSM, Making Us Crazy, They Say You’re Crazy, Toxic Psychiatry and many others available to the general public for decades. This is especially the case now that Dr. Insel has admitted the DSM is invalid and totally lacking any evidence, which a vast number of people have known for decades.
Dr. Allen Frances, editor of DSM IV, had the unmitigated gall to say that “the collective fantasy of science behind the DSM was good for psychiatry and patients” after admitting that “defining mental disorders is bullshit…you can’t define it” when admitting the truth to Gary Greenburg, author of The Book of Woe, which exposes the whole fraud of the DSM Big Pharma/ biopsychiatry cartel. Frances even admitted that the DSM is similar to unidentified areas on old maps labeled “dragon territory,” that he believes help people feel better because these areas like bogus voted in “mental illnesses” have a name even if equivalent to fairy tales with no validity or science/evidence to back them up. Too bad the millions of people conned by such psychiatrists who failed to warn the public when they sold out to Big Pharma in the 1980’s have had their entire lives destroyed due to this fraud, with a huge number of them women and children as is typical of psychiatry. Moreover, many people are unaware that Dr. Frances was a major player in the Texas Medication Algorithm scandal to push the lethal neuroleptics of J%J for marketing and profit for the newly invented bipolar in the first place for adults while serving as a mentor for Dr. Biederman when he preyed on children in the same way to push J&J’s neuroleptics for the bogus child bipolar he single handedly created with another massive, fraudulent epidemic resulting in the infamous death of a toddler, Rebecca Riley. Thus, I think the crimes of the KOL’s of biopsychiatry and their cohorts are far more egregious than any Dr. Raglin listed for the so called dangerously mentally ill. The web site 1boringoldman by a psychiatrist details many of biopsychiatry’s/Big Pharma’s crimes against humanity.
Bob Whitaker has written one of many articles about the many studies that have shown that the bogus fraud claims that so called mental illnesses are brain disorders due to chemical imbalances of the brain along with bogus gene, heritability claims and other lies all debunked by experts including Dr. Jay Joseph on this web site prove that such biopsychiatry/Big Pharma fraud has increased stigma for those in severe emotional stress or trauma exponentially. Thus, I believe the “taking one’s meds” to be accepted by supposed normals is just part of this massive evil and fraud that made billions for this corrupt cartel. It just isn’t so. Biopsychiatry creates the stigma and as Bob Whitaker says, their bogus anti-stigma campaigns used to deliberately create more stigma and psychiatric abuse/slavery in the guise of medicine might decrease stigma if they just told the truth rather than pushing bogus scientism or fraud to put it bluntly.
http://www.madinamerica.com/2010/11/%ef%bb%bfthe-successful-creation-of-a-societal-delusion-and-the-increase-in-stigma-it-has-spawned/
Further, Dr. Thomas Szasz exposes the fact that by biopsychiatry pretending it deals with actual diseases to justify its coercive, dangerous, deadly practices, it robs innocent people of all their rights and every other aspect of their lives when falsely accused of being “mentally ill” due to life problems/crises by biopsychiatrists while aiding and abetting dangerous criminals with the insanity defense to destroy all justice and ethics. Of course, both categories of people are treated the same way with the innocent abused and coerced all the more and routinely stigmatized with the latest fad fraud bipolar disorder. One psychiatrist admits that bipolar was created to hide all the character disordered along with the traumatized women insulted with the bogus borderline stigma (Dr. Judith Herman, Trauma And Recovery) since so called personality disorders aren’t paid by insurance and trauma is paid less than the bogus bipolar claimed to be biological.
Thus, some of the behaviors that Dr. Raglin describes are criminal and should be dealt with by the criminal courts with related punishments while those like the rape and other abuse VICITIMS I cited above should be left alone by what has become the mental death profession for them as it robs them of their mind/body/spiritual health, reputations, careers, child custody, freedom, homes, money and everything else that matters since the whole DSM scam was created to deliberately deny all life problems/crises, abuse, bullying, mobbing, violence and other crimes against the innocent while aiding and abetting the abusers in power along with the toxic social stressors and poisons they force on the rest of us.
Thus, the crimes Dr. Raglan lists among the so called “mentally ill” pale in comparison to the psychopaths in power creating the Wall Street melt down, ongoing biopsychiatry eugenics/euthanasia DSM drugging for billions, the junk food/tobacco industry, GMO companies like Monsanto, etc. Dr. Robert Hare, world authority on psychopaths, has agreed with the book and DVD, The Corporation, that corporations do tend to behave in a psychopathic manner all too often since their only goal is profits regardless of the deadly costs to others. He described their employees in books like Snakes in Suits and Without Conscience as have all too many others in this modern dangerous world.
Again, I do give Dr. Raglin credit for reading Bob Whitaker’s books and seriously questioning what he was taught by schools and various corrupt authorities or KOL’s in power. I also greatly appreciate the fact that he is willing to “do nothing” or no harm to those who have life problems/crises or toxic stressors/abuse in their lives if he can’t really help them or if they can be referred to more appropriate agencies. He makes the good point that he like others are between a rock and a hard place without other forms of treatment available, but that’s because the APA and others in power decided to “dance with the devil” per one APA president when psychiatry was waning and they jumped on the supposed life boat of Big Pharma while drowning their so called future “patients” without a life boat in the process.
As more doctors like Dr. Raglin speak up and challenge the current bogus stigma and meds only approach as many others are doing now, there may be some hope for a paradigm shift in the future. So, I do really appreciate the efforts of those like Dr. Raglin and Dr. Steingard who reconsider the evidence and do all in their power to change or at the very least minimize current harmful practices while admitting what they don’t know and can’t do. Unfortunately, Dr. Insel and his cohorts are determined to continue the bogus search for brain diseases to waste more billions on this evil eugenics agenda so that the psychopaths in power can continue to blame their victims’ diseased brains for any stress or trauma reactions to their ongoing horrific thefts, predation and gross abuses of power and democracy.
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