“Doubly Brutish”: Forensic Psychiatry and Force

Aimee Inomata, PhD
6
1286

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)

Show 2 footnotes

  1. Ekblom, B., Eriksson, K. & Lindström, L.H. Psychopharmacology (1984) 83: 293
  2. Durst R, Teitelbaum A, Katz G, Knobler HY. Withdrawal from clozapine: the “rebound phenomenon”. Isr J Psychiatry Relat Sci 1999; 36(2):122-8

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6 COMMENTS

  1. This aptly describes not only the condition of the “patients” in the forensic side of the “hospital” where I work but the condition of the rest of the “patients” in the units that are not forensic. A very large number of “patients” not on forensic units come from jail. The “hospital” has turned into one, large forensic unit. The system was bad enough as it was but now the law and legal systems have their fingers in the pie and the mix makes for a very nasty tasting pie for the people labeled as the “patients”. The “hospital” even has its very own court that is part of the city court system. If you aren’t compliant enough for your psychiatrist in the community mental health center that psychiatrist can swear out a petition on you and you will receive a summons to appear in our court. This can happen to people who are not court ordered for treatment as well as those that are court ordered. If you don’t kow tow deeply enough and show the level of compliance that your psychiatrist thinks she or he deserves you are up for grabs and the summons will be in your mail box. And if you decide to not appear in court on your assigned date they will send the deputy sheriffs to your front door that very afternoon and you will be dragged down to our “hospital”. It’s all about compliance and power and putting us in our rightful places.

  2. Aimee,
    Excellent article; thanks for pointing out what is happening in non-euphemistic language.

    Recently, on another forum, I made a related comment about the state of psychiatric treatment and their conceptualization of distress:

    “If we step back a great deal further and look at this state of affairs from a 30,000 foot view, what psychiatrists – and to be fair many other mental health workers and members of the public – are doing is to apply a Newtonian, mechanistic, linear, Krapelinean viewpoint to a dynamic, constantly-changing interpersonal world that is more quantum-like, relativistic, unpredictable, and relational. In so doing they perceive very little about the lived experience and potential of the people they label, and by degrees their minds become frozen, in terms of being unable to see the distressed human beings before them as a person with potential rather than an illness to be managed.

    I believe that the mechanistic, Newtonian, Krapelinean approach to understanding human behavior is so powerful, and so deeply toxic, that it often ruins the minds of many mental health workers to the point that they are wholly unable to see severely distressed people as their fellow human beings, with the potential to become just as well as any of us. These professionals become instead unwitting agents of a corporate assembly line which produces innumerable drugged invalids year after year. They are like fish swimming in a mechanistic ocean, the toxic water of which obscures the human potential of those they treat to varying degrees, and leads them to inadvertently choke the life out of those they diagnose and drug for far too long. It’s pretty horrific to think about, but I think everyone here knows there is some truth to these words, especially those of us who have almost died because of this approach.”

  3. Thanks for this post. Seen as “doubly brutish”, oppressed by two systems, the criminal justice and the mental health systems, forensic patients generally have it worse than the rest of us, and they don’t thereby cease to need our support, in fact, they desperately need us to save them from a living burial and collective forgetfulness in some cases. The insanity defense, in many instances, can equal more time served in both systems under more callous attendants. Forensic patients really need more people on their side if they’re ever to be liberated from the dual systems of oppression they suffer under.

  4. I have represented forensic psychiatric “patients” for 15 years. I go to their monthly treatment plan reviews, advocate for their preferences with their treatment teams, and litigate for them in the criminal or mental health court system. This is my entire, full-time law practice in Illinois.

    I can honestly say that no forensic “patient” who is released into the community on a presumption that he or she has gained “insight” and will therefore continue to take psychotropic medications will ever do so, if they can possibly avoid it. Every one of them will stop taking meds as soon as they believe they can get away with it.

    The “insight” they gain in the institution is all about how to lie convincingly, even to themselves. Nobody ever believes, deep down, that the drugs are restorative or good. They only know that it might be difficult to stop taking them. Sometimes they look for someone to blame for that, and for revenge.

  5. This article is sublime, and vivid in the tragic ironies it poses.

    “…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.”

    Aside from “the insane are running the asylum” coming to mind from reading this statement, I’m also struck by the utter lack of self-awareness, self-ownership, self-perception, self-control, and the slew of projections occurring here. I find this to be typical of the mental health industry, as it is entirely based on projecting shadow onto others. That’s the problem, and where the chaos, deceit, stigma, oppression, discrimination, and ultimate power struggles begin.

    “We, in the end, quite effectively create a reality from which for many there is only one means of escape”

    Which implies that we can effectively create a reality from which people do not feel the need to escape, but more so, can embrace as the gift of life, in which one can manifest well-being, grounding, and robustly good feelings, rather than chronic ones of defeatism, powerlessness, and alienation. That would require full ownership of one’s experience, and that is not so easy for a lot of people. But it does empower one to make desired changes in their reality, starting from within.

  6. Nice read, thanks. Any kind of “forced psychiatric treatment is torture,” thus it is morally wrong. As to “their ‘antipsychotic’ effect is achieved by their ability to suppress all mental activity.” The psychiatric industry needs to awaken to the reality that the antipsychotics can create psychosis via anticholinergic toxidrome, the neuroleptics do not have an antipsychotic effect, quite to the contrary.

    https://en.wikipedia.org/wiki/Toxidrome

    Plus withdrawal from the neuroleptics can also result in a super sensitivity manic psychosis. The antipsychotics create psychosis, both while on them, and after weaned from them. The neuroleptics create the negative symptoms of “schizophrenia,” too.

    https://en.wikipedia.org/wiki/Neuroleptic-Induced_Deficit_Syndrome

    ” … 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.” Well said.

    Today’s psychiatric practitioners are the most deceived and deluded people on this planet, and/or they are the most hypocritical. Their arrogance that they have a right to write other human beings life stories, and that they are better, more insightful, or more intelligent than their clients, who they do not even know, is anti-American. Today’s psychiatrists are every bit as scientifically invalid and evil, as were the Nazi psychiatrists. And according to their own medical literature their number one actual function on this planet is aiding, abetting, and empowering child molesters by silencing child abuse victims en mass, which is illegal. Most of today’s psychiatrists likely belong in jail given that “the prevalence of childhood trauma exposure within borderline personality disorder patients has been evidenced to be as high as 92% (Yen et al., 2002). Within individuals diagnosed with psychotic or affective disorders, it reaches 82% (Larsson et al., 2012).” And all theses child abuse victims are force fed the “psychosis” inducing neuroleptic drugs.