A previous post on this site described the ‘treatment’ doled out to Garth Daniels by the Mental Health Services (MHS) in Melbourne, Victoria. Briefly, the 40-year-old Daniels has spent about fourteen of the past twenty years in mental hospitals. He has been given every known psychiatric drug in large doses; he has been shackled to his bed for long periods, including 115 days in 2015, of which 69 days were consecutive; and he has been given electroconvulsive therapy (ECT) three times a week for about 34wks with apparently no limit intended.
In hundreds of reports and hearings, Daniels has been characterised as an “extremely violent and unpredictable paranoid schizophrenic.” Professor after professor has described him as suffering “a brittle psychosis” that requires extreme treatment. He has been seen as quite likely the most dangerous man in the state’s entire history. While the total cost to the taxpayers has been well more than $10 million, the benefits of this prodigious diversion of resources to one (rather small) man have been underwhelming. The cost to Daniels and his family has been incalculable.
On Wednesday, May 18th, Daniels had what was probably his 102nd consecutive episode of ECT. As always, he told the staff that he did not want it and did not consent to it; as always, he got it. Later on the next afternoon, Garth arrived in Brisbane to join his family who moved here recently. When the hospital realised that he had gone, he was immediately posted as a missing person, but this notification has since been rescinded. If he were to return to Victoria, he would immediately be taken into custody, and the ECT would resume. There are no plans to return.
It is now five weeks since his last episode of ECT. At present, he lives in suburban Brisbane with his parents. Twice a week, he attends for psychiatric treatment in a building with absolutely no security facilities whatsoever. He continues to take the same fairly small dose of medication he was prescribed when he was in the hospital. Other than that, for the first time in twenty years he is entirely a free man. He is meeting people and starting to make friends. He sits in coffee shops and watches the passers-by or visits some of Brisbane’s many scenic spots, and plans to resume his much-interrupted photography course. The only official communication from his doctors in Melbourne said that he should be apprehended forthwith and immediately returned to the hospital to continue ECT. When asked which particular statute would permit him to be snatched off the streets and bundled on a plane, there was no response.
During his lengthy career as a patient, this man has been seen by something like 400 individual psychiatrists, professors, and registrars (residents in training). Over the years, his treatment has been directly approved by successive chief psychiatrists of Victoria. Even the minister for mental health, Mr. Martin Foley, felt obliged to comment on his case to dampen criticism. The Royal Australian and New Zealand College of Psychiatrists (RANZCP), the professional and academic body governing psychiatric standards in this country, is only twenty minutes’ drive from his hospital. As Daniels’ father previously worked for the RANZCP, the College has been very familiar with his case for years.
When asked to account for their actions, MHS states only that it “…provides treatment to all its mental health patients in accordance with the law and appropriate clinical guidelines.” The RANZCP does not comment on individual cases. Any complaint to the Victorian Medical Board will be heard by some of the 400 psychiatrists who have seen him, or their teachers, or their students, or their friends. In such a small and close-knit professional community in such an isolated and conservative city as Melbourne, an independent assessment of the merits of his case is simply not going to happen.
None of us have a crystal ball but his position now seems much better than at any stage in the past. So far, there has been only one incident to cause concern. While walking through a local shopping centre with his parents, he turned and saw two security guards walking toward them. Their uniform is very similar to that of the Victorian Police; thinking they were police coming to arrest him, Garth panicked, but the guards walked past. His parents tried to settle him, but he remained edgy and irritable for the rest of the day. That evening, he began acting in a way they had often seen in the hospital, saying things like: “My schizophrenia is really bad tonight, I’ve just had a visual hallucination.” His agitation settled after a 90-minute consultation and, the next morning, he was back to normal. His parents were clear that, in the past, this type of behaviour had led to restraint, further ECT, and more drugs.
Some people are of the view that all mental disorders can be relieved by a warm and accepting atmosphere, but I can’t agree. If a person gets better with a cup of tea and a friendly chat, he wasn’t mentally disordered and shouldn’t go anywhere near psychiatrists with their hospitals, their drugs, and their ECT machines. While some mental distress will get better with calming, empathic support, some need a lot more, but we do know that even the most transient forms of distress can rapidly be made worse by a heavy-handed, punitive or panicky response. Permanent mishandling will necessarily produce continuous suffering.
Regardless of his initial diagnosis (and I am not convinced it was schizophrenia), for 69 days last year, Garth Daniels was tethered to his bed and given injections which induced intense physical and mental agitation (akathisia) as well as a skin rash. He could neither move around for relief nor scratch himself. When the nurses came to give him the injections, he swore and spat at them, so they gave him more. I suggest that this falls within the definition of torture. Many victims of torture never recover, so it is probably going to take more than a change of scenery for Garth Daniels to overcome the legacy of twenty years of standard psychiatric ‘treatment.’
Let’s look at some of the facts and opinions surrounding this case. For clarity, they are listed as a series of problems identified by his psychiatrists, and resolutions they could have adopted if they were so inclined. The list proceeds from the most general to the particular.
Problem 1: He needed treatment for schizophrenia.
Resolution 1: There was absolutely nothing in the files to suggest any of his many psychiatrists had taken a history sufficient to justify this diagnosis. Certainly, nothing in his present behavior would count as firm evidence for what is generally regarded as the most severe and immediately recognisable mental disorder.
Problem 2: He needed involuntary treatment for his schizophrenia.
Resolution 2: In no other diagnosis can treatment be imposed by law. HIV/AIDS, diphtheria, syphilis, TB, Ebola, Zikavirus, you name it: people can choose whether they want treatment. Yes, they can be quarantined, but that is for the community’s safety, not theirs. A cancer patient can opt to terminate treatment and die, but schizophrenia? No, you must take whatever the state’s agents determine, but take care, because attempting to kill yourself will earn you more.
Problem 3: He needed to be detained because of the risk of violence.
Resolution 3: People cannot be held indefinitely in preventive custody just because they have a potential for aggression. Daniels has never been convicted of breaking the law, yet he was detained in a high-security forensic unit (Thomas Embling Hospital) for two years. In fact, his record of aggressive behavior is trivial. I routinely deal with much more aggressive and threatening people.
Problem 4: He needed to be held in a locked ward because he was likely to run away.
Resolution 4: He is now living with his parents and comes and goes as he pleases, and he doesn’t run away.
Problem 5: He needed massive doses of drugs to save his life.
Resolution 5: There is now a very substantial evidence base to argue that orthodox psychiatric treatment of schizophrenia makes it worse. In this country, people taking psychotropic drugs in the long term die, on average, nineteen years younger than their undrugged peers. In the US, that figure is twenty-five years, probably because they are exposed to larger doses with less supervision. And how solid is the evidence base for the notion that people with schizophrenia will necessarily die as a result of their condition? It’s actually very weak: in less-developed countries, such as Thailand where I worked in 1981-82, people often don’t get medication because they can’t afford it. Mostly, they get better quicker and have a lower relapse rate than their heavily-drugged western counterparts (see also Wunderink et al., 2013).
Problem 6: He needed huge doses of drugs to control his agitation.
Resolution 6: Lowering the dose of psychiatric drugs stopped the akathisia, and his agitation has now resolved. Perhaps that’s overstating the case: he was on the same dose of medication in the hospital in Melbourne as now, and he was agitated there but not in Brisbane. I could say that spending time listening to him is almost certainly contributing to his more settled mood, but biological psychiatrists eschew ephemeral explanations such as empathy so we’ll say that everything is due to the drugs.
Problem 7: He needed huge doses of drugs to control his delusions.
Resolution 7: In fact, there was only ever one primary “paranoid delusion” recorded, and after discussing it at length, it seems to have faded away. There were some secondary “paranoid delusions” recorded, such as “You people are poisoning me, you’re trying to kill me, the whole thing is a conspiracy to torture me.” They seem to have stopped when he crossed the border, although he remains petrified that he can be arrested and shipped back to Melbourne. He requires frequent reassurance that he is perfectly safe walking the streets of Brisbane and that the police here have no interest in him. He is aware his phone can be tracked, but he still carries it.
Problem 8: He needed protracted and probably unlimited ECT as drug treatment of his “brittle schizophrenic psychosis” had not been successful.
Resolution 8: Does anybody remember this nostrum from first-year medical school? “If the treatment fails, reconsider the diagnosis.” But psychiatry doesn’t do that. Psychiatric diagnoses are only ever ratcheted up, not down again (unless it goes sideways to Borderline Personality Disorder). Could 400 psychiatrists be wrong? Well, they can if not one of them has taken anything approximating a proper psychiatric history, in which case the whole thing becomes an exercise in groupthink, not science.
It is necessary to emphasize the point about taking a history. Psychiatrists like to say they are specialists. A specialist surgeon has certain skills that she learned and applies; a specialist obstetrician has a skill set and knowledge base that a village midwife doesn’t; a specialist radiologist can tell more from a x-ray than a law-enforcement officer, however well-intentioned the latter. For psychiatrists, the specialist skill set consists of two parts: knowing how to take a history from a disturbed and uncooperative or hostile patient, and then knowing how to manage the information the history has yielded. But modern psychiatrists can’t take a proper history because they weren’t taught how. The reason they have lost this vital skill is that they believe they don’t need it. They think that DSM says it all; ask the pertinent questions and the answer will drop out the end, which will also dictate the treatment. The arduous business of taking a history is left to nurses with check lists, who were never trained in this skill either.
Problem 9: He needed to be shackled to control his aggression.
Resolution 9: It would seem the shackling exacerbated his (very minor) aggressive tendencies. My experience is that shackling people makes things worse, not better.
Problem 10: He needed protracted and probably unlimited ECT to control his aggression.
Resolution 10: Stop the ECT and listen to his complaints, and the hostility fades away (so far).
Problem 11: He needed involuntary ECT as he had “unreasonably refused consent.”
Resolution 11:
Part a): What would constitute ‘reasonable’ refusal of ECT? No psychiatrist has ever been able to answer this question. Psychiatrists who use ECT take it as given that if they recommend ECT, they are doing so reasonably; anybody who declines the experience is ipso facto acting unreasonably so his opinion can be over-ruled. The fact of the matter is that when a psychiatrist decides to use ECT, he is admitting he has reached the limit of his skill set.
Part b): Anybody ‘offered’ ECT must give “informed consent.” But the information on which the approval is based, never includes a statement that some psychiatrists use ECT a great deal while others, seeing virtually the same patient population, use it rarely or not at all. It is entirely a matter of chance, not of science, which psychiatrist the patient sees. If patients were told that, very few would consent – but they’d get it anyway. Many psychiatrists are wedded to ECT.
Problem 12: He needed involuntary ECT as he was incapable of giving consent.
Resolution 12: Now we move into Kafka’s territory: the psychiatrist said Daniels had a memory defect and could not remember the advantages of ECT after he had been told them, so he was, in law, incapable of giving consent. Why did he have a memory defect? ECT (and yes, he still has a memory defect).
Problem 13: He and his family were repeatedly told by numerous psychiatrists that the ECT would stop if he consented to take clozapine.
Resolution 13: In most states of the Commonwealth, this is a criminal offence known as “demanding with menaces.” Putting that aside, and all its implications for a caring, empathic psychiatry, one would like to know how he could be capable of consenting to this especially toxic chemical, one he had had before and didn’t tolerate, yet he couldn’t consent to ECT?
Problem 14: Once he moved to Brisbane, he should have been arrested as a “dangerous person.”
Resolution 14: The Victorian Mental Health Act doesn’t apply in Queensland, and he hadn’t done anything that warranted his detention under any act in this state, so that went nowhere.
Problem 15: He should be arrested and returned to Melbourne as a “missing person.”
Resolution: 15: He wasn’t missing, he and his family knew exactly where he was, as did a number of other people. But regardless, missing persons can’t be arrested nor can they be shipped across state borders.
Problem 16: Four hundred or more psychiatrists and trainees agreed he was a “very brittle paranoid schizophrenic with a tendency to extreme violence.”
Resolution 16: ‘Extreme’ means ‘at the limits of human experience, the point beyond which there is no return.’ I agree that mass murderers, such as the perpetrator of the gruesome Orlando massacre, show ‘extreme violence,’ but I will submit that spitting and swearing aren’t quite in the same league. But back to the four hundred psychiatrists, their serried ranks marching in lockstep toward the future of psychiatry as “clinical neuroscience” (Insel et al. 2010; Insel & Freund 2012). If everybody simply memorises DSM5, and criticism is suppressed (McLaren 2010), then science degenerates into an echo chamber. What happened was the ’emperor’s new clothes’ effect, where everybody is too scared to question the diagnosis for fear of being regarded as stupid. Be assured this effect is very, very powerful in medicine. And a “brittle psychosis”? That just means, “We don’t know what to do,” but the expression can be recommended to trainees because it fools a lot of senior people, including ministers of the crown.
Problem 17: That’s Victoria’s problem, it would never happen here.
Resolution 17: Sorry, it happens everywhere, all the time. However, Queensland’s mental health act has a hidden catch. Nobody is allowed to publish any material that could serve to identify a person who has an action before a mental health court. Essentially, everything is suppressed. That means a patient’s relatives can’t go to the media or their member of Parliament and complain about the treatment. And, being in a locked ward, the patient can’t contact anybody himself because his phone is removed. If the relatives try to smuggle a phone in or a letter out, they can be permanently barred from visiting with no appeal.
Finally, we come to psychiatry’s problem, which I can only indicate briefly. Modern biological psychiatry says that all mental disorders can be reduced to particular cases of brain disease, with no questions left unanswered. I have argued at great length that this project is non-scientific and will necessarily fail (e.g.,. McLaren, 2011). Through the obsession with biological reductionism, we are completely missing the point of mental disorder. The cause of this problem is that the drug companies have colonized modern psychiatry. The historic collapse of the psychodynamic models left an intellectual void into which the pharmaceutical companies quickly moved. Our profession is now little more than a profit centre for Big Pharma, and what a tidy little profit it is.
For example, 10% of the Australian adult population is now taking antidepressants, and that figure shows no signs of levelling. In their drive, the drug companies have been aided and abetted by intellectually naive and ethically unscrupulous academic psychiatrists who willingly dance to the tune of the wealthy pipers who control the flow of research money. Modern psychiatry has become a joint venture of the surveillance state and transnational corporate capitalism, generating obscene profits for some of the most venal companies on earth (Whitaker & Cosgrove, 2015).
Moreover, the case of Garth Daniels shows that the so-called “review process” of mental health tribunals and courts is little more than an enforcer for the corporate state. One should not expect psychiatrists with the power to rectify this situation to do so. Partly, they have lost control of their field, and partly, they are making too much money. Fundamental reforms never come from those who profit from the status quo. That is psychiatry’s problem, and that’s how Garth Daniels got his problem. Whether he can survive his decades of “treatment,” only time will tell.
References:
Insel TR, Cuthbert BN, Garvey M, Heinssen R, Pine DS, Quinn K, Sanislow C, Wang P, 2010: Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders. Commentary: American Journal of Psychiatry 167: 748-751
Insel TR, Freund M (2012). Shedding light on brain circuits. Biological Psychiatry; 71:1028-9.
McLaren N (2010). A life of its own: the strange case of the biopsychosocial model. Chapter 7 in Humanizing Psychiatrists: Toward a Humane Psychiatry. Ann Arbor, Mi.: Future Psychiatry Press.
McLaren N (2011). Cells, circuits and syndromes. A critique of the NIMH Research Domain Criteria project. Ethical Human Psychology and Psychiatry 13: 229-236
Whitaker R, Cosgrove L (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave MacMillan.
Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ (2013). Recovery in remitted first-episode psychosis at 7 years of follow-up of an early dose reduction/discontinuation or maintenance treatment strategy: long-term follow-up of a 2-year randomized clinical trial JAMA Psychiatry. 2013 Sep;70(9):913-20. doi: 10.1001/jamapsychiatry.2013.19.
