“Doubly Brutish”: Forensic Psychiatry and Force

I pitied thee,
Took pains to make thee speak, taught thee each hour
One thing or other: when thou didst not, savage,
Know thine own meaning, but wouldst gabble like
A thing most brutish, I endow’d thy purposes
With words that made them known.

Shakespeare’s The Tempest, from which the above quote is taken, is very much a play about power and control and particularly about how instrumental language is in the creation and maintenance of power. To name is to supposedly make something known, to shape it in such a way that it can be understood and to impose a meaning that — true or not — will determine its future. Nowhere is this perhaps more evident than in the field of forensic psychiatry where to name is, like a magic trick, to turn ‘gabbling’ into disease, and where the individual’s ‘purpose’ is endowed with a meaning with which they have no involvement. But this is precisely what must happen, the mechanism that must be in place for the current standard of treatment to take place, for in order to force treatment upon an individual it must be justified by the inability of that individual to make meaning.

In the case of forensic psychiatric patients who have entered the mental health system through the criminal courts, this means they have been found “criminally insane” or in a state of mental disorder whereby a person is unable to distinguish between right and wrong, and as a result committed an unlawful act. They are, in other words, doubly “brutish.”

Thus if one is found not guilty of murder/assault/arson by reason of insanity, the civilised society allegedly judges it wrong to simply lock one up, for it is the insanity that is “guilty” and therefore must be dealt with, treated, rendered harmless. This means appropriate measures must be taken (which is incidentally the meaning of the Proto-Indo-European root *med- from which we get the word ‘medication”), and, inevitably, that appropriate measure is almost always medication.

The premise operating here is one that we tend to take for granted: the individual is sick and therefore must take medicine in order to be made well again. This appears to be the belief of the general public with regard to mental disorder, a belief helped along by the frequent references in the media to those who commit crimes, it is stated or implied, because they have “gone off their medication.” Mental disorder can supposedly be “fixed,” like most other ailments, with medicine.

In fact, forensic psychiatric patients are not being medicated — they are being drugged. Most are on at least one neuroleptic or antipsychotic. That latter name, however, is a red herring that suggests that the medication directly targets and neutralises psychosis, but of course it does not. Rather, it does as its previous nomenclature of “major tranquiliser” states and as the GP Notebook (a UK medical reference for doctors) observes: “[major tranquilisers] are used both for psychiatric conditions, and for other conditions in which a degree of sedation is required.” As Dr. Joanna Moncrieff observes, “their ‘antipsychotic’ effect is achieved by their ability to suppress all mental activity.” This is essentially the basis of the “treatment.” For some patients, this is desirable — they wish to feel less, to care less, though it does little to address the root of the index offence and makes the work of psychotherapy even more difficult.

But for many others, as “service users,” being forced to take medication they do not want does little to aid in either recovery or rehabilitation.

I was told I had to take medication. It was seen as the only way I could move on with my life. It was the only way my care team would trust me and accept my recovery. Any progress I had made in group therapy or in one-on-one work was distrusted or discounted. While those things were enormously vital for me (because they unlocked my strengths and capacity for self-healing) the clinic saw this work as unreliable and possibly made up. In the discussions, I felt like I had no agency or willpower – in fact it felt like those were the very things that were the problem. My own intentions and desires stood in the way of the care team fixing me. They needed me to be bacteria in a petri dish, damaged, broken, unwell, and unable to decide for myself. —A current forensic psychiatric patient in NZ (who wishes to remain anonymous for fear of retribution)

It is the practice of some forensic institutions to place patients into seclusion — that is, solitary confinement — if they refuse to take their medication. This leads to the obvious question: what is the point of this? It is difficult to perceive how this could be about either recovery or rehabilitation, unless both of these have as their foundation the complete surrendering of control by the individual to the institution. It is rather about the exercise of power. But what is wrong with that, some argue — haven’t these people forfeited their right to be treated as normal human beings by virtue of their abnormal behaviour? What is wrong with forcing people to do something that is good for them?

Apart from the obvious problem of who gets to decide what is good, a question also worth asking is whether forced medication on any level is actually good for anyone, be it the individual concerned or society at large. The accumulating evidence would seem to suggest it is not. Numerous studies (Vita et al., 2015; Murray et al., 2016; Harrow & Jobe, 2013; Insel, 2013 to name a few of the most recent) have already found that antipsychotic medication is patently not good for the individual, but this does not appear to be much of a concern with regard to forensic psychiatric patients.

The overriding tenet at work, rather, is the avoidance of risk — the risk that the “rehabilitated” patient may once again cause harm in the community, and hence it is the medication that is keeping the patient “well” and the community “safe.” The patient is released back into the community on the strict condition that they take their medication, and, for a variety of reasons, that tends to be the extent of the rehabilitation and recovery.

Yet owing to the many documented unpleasant effects of the medication and a lack of education regarding what happens if one abruptly stops taking any kind of psychotropic drug, many do stop abruptly. Issues of noncompliance with neuroleptic medication are nothing new (see Young et al., 1999; Löffler et al., 2003; Moritz et al., 2009; Adelugba et al., 2016). The majority of patients will stop taking them at some point — this is almost entirely predictable, but what is not predictable is the effect the abrupt withdrawal will have upon the individual. We know that neuroleptic use alters the brain; we know that antipsychotics work on, among other things, on dopamine receptors, but what we do not know is how each individual will react to either the commencement or withdrawal of these psychotropic agents.

The more we learn, the more we recognise the unique complexity of any one individual intellect, the stronger the conclusion becomes that the individuality inherent in our brain networks makes that of fingerprints or facial features gross and simple by comparison. —Roger Sperry (Winner of the Nobel Prize for Medicine)

The equation then looks something like this: many of the patients enter forensic institutes with pre-existing drug and alcohol problems which are often the result of attempts to manage their own unwanted emotions — the effects of this ‘self-medicating’ may have much to do with the original index offence. Within the institute, illegal drugs are swapped for legal drugs such as the major tranquilisers, and this medication regime is strictly enforced, for although patients are constantly drilled in “taking responsibility,”when they do attempt to take responsibility for their own health and lives, they are often dissuaded from doing so – initiative is not highly prized within the forensic system.

On release into the community, the supposition is that these patients will continue to take their medication because a) it is what keeps them “well” and b) it is a condition of their freedom, but as a myriad of studies have shown, that they will stop doing so (abruptly) is almost guaranteed. And again it is what happens next that is entirely unpredictable in terms of effects on the patient, but predictable in terms of the outcome being regarded as a “relapse.” Something does not add up here if the idea of risk is to be taken seriously, for the avoidance of risk is supposedly about reducing unpredictable factors, particularly when they are preceded by largely predictable factors such as withdrawal or rebound symptoms. But it is as if those predictable factors simply do not exist because they do not fit into the systemic equation which looks like this:

Forced Medication + Forensic Patient = Risk Reduction

Rather, the more obvious equation is the following:

Forced Medication + Forensic Patient + Freedom = Freedom from Medication

It is difficult to imagine a system that could do any better at ensuring the failure of its patients, and in doing so it accomplishes the very opposite of what it claims — it increases risk for all concerned. For example, Clozapine, after decades of being considered the antipsychotic of last resort, has once again become the drug of choice for many clinicians after regulations governing its use were relaxed. B it also appears to the antipsychotic most closely associated with supersensitivity psychosis:

In two patients with chronic schizophrenia, who were on clozapine medication for more than 6 months, a sudden withdrawal of the drug resulted in a very pronounced deterioration of the psychosis within 24–48 hours.¹

And:

Withdrawal from clozapine has been observed to lead to “atypical” clinical characteristics or a “rebound phenomenon,” manifested in two interwoven clinical forms: (1) psychotic exacerbation, and (2) cholinergic rebound. The underlying pathophysiological mechanism of this phenomenon is postulated to be a result of cholinergic supersensitivity. In this paper, the “rebound phenomenon” will be discussed and exemplified by three case histories in which abrupt cessation of clozapine led to serious deterioration and psychotic exacerbation, and one case in which gradual titration from the drug was employed in order to preempt this hazardous occurrence.²

More recently, Alicja Lerner, a medical officer with the FDA, presenting at The International Society for CNS Clinical Trials and Methodology 11th Annual Scientific Meeting in 2015, noted that

The discontinuation/withdrawal syndrome consists of 2 clinical aspects:

• 1) recurrence of symptoms of the treated disorder in patients, sometimes more severe

• 2) discontinuation/withdrawal effect: which can include other signs and symptoms, which typically do not represent a relapse of the underlying condition, but are related to the disruption of neuro-regulatory changes established during drug administration. The specific symptom profile of discontinuation syndromes depends on the pharmacology and pharmacokinetics of the drug being administered and neurotransmitter system affected.

“Known withdrawal symptoms” were cited for both antidepressants and antipsychotics.

So what is the answer? That very much depends on what are we trying to do. Are we really trying to help people put their lives back together, or are we merely trying to seal up their cracks with medication by temporarily removing problematic emotions?

This is not to minimise the seriousness of the reasons as to why people end up in forensic psychiatric hospitals, but it is to point out that in being placed there, a decision has been made regarding the state of mind of the individual that then requires care and real treatment. One does not end up in a forensic psychiatric institute through a healthy manner of coping with life, and currently we do little other than to confirm and enforce the powerlessness of the “service user.” In so doing we deceive ourselves and those we claim we are helping: we offer force and subjugation as though these are the ways to make an individual sane, and we do not have the defence of insanity for our own methodical and deliberately brutish behaviour. We, in the end, quite effectively create a reality from which for many there is only one means of escape.

Sometimes a thousand twangling instruments
Will hum about mine ears; and sometime voices
That, if I then had waked after long sleep,
Will make me sleep again; and then in dreaming,
The clouds methought would open, and show riches
Ready to drop upon me, that when I waked
I cried to dream again.

(The Tempest, 3.2)