A friend said to me recently, “Oh, he suffered such a lot. That’s over for him.”
I know their words were intended to comfort me over my son’s suicide. Our fine, excellent son, Abraham, had committed suicide a month before Christmas 2019. Nevertheless, I bridled inwardly at the suggestion, not wanting to remember Abraham as merely the sum of his sufferings—he was so much more than that.
Those times he suffered mental distress were less the mainstay of his life than the exceptions. He suffered a lot, it’s true; depression, terrible anxiety, an unforgiving low opinion of himself and—particularly during the past two years—unusual aches and pains, feeling cold much of the time and needing to be scarfed-up even on the warmest of days. (I didn’t know then that the aches and pains, akathisia, and Abe’s perpetual hypothermia were side effects of the antipsychotic drugs he had been taking for too many years.)
New Zealand’s Primary Treatment: Antipsychotics
Looking back, it is clear to me that Abraham’s mental suffering intensified after his encounters with the New Zealand mental health system. Combined with the damaging effects of the neurotoxins he was on, what exacerbated his mental distress was his fear of, and sense of betrayal by, the very psychiatric establishment he went to for help. With legitimate reason, he became terrified of the mental health system’s unlimited power to remove his autonomy and agency—how it reached into so many avenues of his life under the guise of “care” but manifesting more as “social management”—a watchful eye that could obliterate his civil rights in a blink, and annihilate his sense of self. The primary management tool is antipsychotic drugs.
“The authority to coerce is fundamental to psychiatry’s authority in society.” Dr. David Cohen, interview, Mad in America.
In spite of his considerable gifts as a musician, in spite of how much he was loved by his family and friends for his caring, compassionate nature and his sly, observant wit, finding himself unable to alleviate an intense episode of mental distress, Abraham chose an exit route that we all ardently wish he hadn’t taken. In the weeks and months following his death, the tendency is to run alternative scenarios in the mind; ways that it might have played out differently. Anything, to avoid facing the terrible loss. All these scenarios begin with the same “What if?” but never end with an answer—only more questions.
One question remains uppermost: to what extent did long-term antipsychotic drugs contribute to Abraham’s physical and mental distress? Did the drugs that were meant to help him ultimately contribute to his suicide? The simple answer is, yes.
Rather than enhancing his well-being and quality of life, neuroleptic drugs irrevocably damaged Abraham’s physical and mental health over the long term. He hated being on them; hated how they made him feel; how they dulled him down; how they robbed him of the “essence” of himself. He believed they were killing him.
We will never know what Abraham’s life might have been like if he hadn’t been given antipsychotic drugs in the first place. Might he have recovered spontaneously without having another psychotic episode? Increasing evidence suggests so. Statistics show rates of recovery are higher where antipsychotics have not been prescribed for first episode psychosis. The Open Dialogue model demonstrates that alternative treatment for psychosis is both possible and successful (and makes economic sense too).
Regrettably, nothing comparable is available in New Zealand. In 2016, when Abe took himself to Hillmorton psychiatric hospital in Christchurch, he was seeking a sanctuary, a safe place to recover from his dark night of the soul. The primary treatment option on offer in our mental health system is antipsychotic drugs. Psychotherapy has been largely phased out, perhaps because it’s seen as too expensive?
Antipsychotics may work for some. But as author David Cohen, of UCLA’s Luskin School of Public Affairs, suggests in an interview on MIA radio, the key factor is who gets to define what works. What works for the provider may not be seen that way for the recipient.
In spite of being heralded in the 1960s as a solution for mental distress in its myriad forms, antipsychotics have not been the success that was hyped (though they have been a windfall for the pharmaceutical companies). The psychiatric establishment has made no significant progress in the 60 years since they sought to lobotomise one of New Zealand’s most acclaimed writers, Janet Frame. (She was saved at the eleventh hour by psychiatrist John Money, who discovered she had won a literary prize.)
The psychiatric establishment, anxious to maintain its legitimacy, still clings to the coat-tails of scientific/biological medicine in the hope that, someday, a bio-medical marker will emerge to support “brain disease” as the cause of mental illness. In the meantime, it continues to promote the hypothesis that anti-psychotic drugs remedy a chemical imbalance in the brain—a hypothesis without scientific foundation. As the British psychiatrist Joanna Moncrieff suggests in her erudite YouTube lecture for UNE Centre for Global Humanities, psychoactive drugs may be “useful” in the short term for an acute psychotic episode. The “mind-altered” state they induce may be preferable to the psychosis the person is experiencing, but they do not “remedy” a chemical imbalance in the brain, as no bio-marker has been successfully identified.
The First Prescription: Roaccutane
Abraham grew up in a warm and loving family environment. He was a cheerful, active child and made friends easily. At secondary school he was a talented actor and musician.
Around 17 Abraham developed severe acne. He was prescribed Roaccutane. We noticed a significant change in his behaviour; he became withdrawn and “moody,” which is not untypical behaviour for a teenager. We were concerned, but thought it would pass.
Roche pharmaceuticals—the company that patented and manufactures Roaccutane—has for over 20 years strenuously denied any causal link between this drug and mental health problems, including psychosis. However, a recent article in The Guardian has reopened the question, linking a spike in suicides in the UK to this drug.
Obviously, nothing concrete can be drawn from this except to conjecture that Roaccutane could have precipitated psychosis for Abraham. Clearly questions are re-emerging about the drug’s link to mental health problems. The fact that 8000 people are questioning it is significant.
2001: First Psychotic Episode
At age 20, Abraham went to live in Sydney with the intention of applying for the Sydney Conservatorium of Music. Sydney is a big, tough city for anyone at first, and it was a difficult time for him. He was not a heavy user of marijuana—it was a part of the culture of young musicians he was mixing in. He was drinking quite heavily and smoking the odd joint. The combination of alcohol and marijuana may have been sufficient to flip him into psychosis (not uncommon for young men of that age). He was terrified of the experience and it manifested as paranoia (not uncommon with marijuana).
Abraham, now aged 21, was seen by a psychiatrist who prescribed antipsychotics.
After that first episode Abraham wanted to get out of Sydney. He enrolled at the University of Central Queensland in Mackay for a BA in music. He struggled with parts of the course but, a naturally gifted musician of above-average ability, he completed his degree.
In the subsequent years, like many young men, he floundered a bit. But he was “compliant” in taking medication. He believed, as we all did back then, that antipsychotics—as their name implied—might resolve his mental distress just as antibiotics fought infections. But all they did was cloud his mind, making it harder to study, robbing him of vitality and motivation.
At that time, he was still using alcohol. He quit drinking four years before he died. Though it should be said that some of our best times together, the long conversations into the night—father and son, good friends—were not drunken affairs but had the convivial ease that alcohol can sometimes bring. At such times, he seemed more “himself.” Lighter.
2011: Return to New Zealand
After getting his music degree in Australia, Abraham returned to New Zealand. He didn’t want to teach secondary school, so he did a postgraduate course in early childhood teaching by correspondence with Massey University. When he qualified he began teaching in Motueka and then in Christchurch. He taught kindergarten for a year or so, but the stresses began to build up and eventually became too much to continue. He was developing new, unrelated symptoms—obsessive-compulsive thoughts. They were unusual, oddly inconsistent with his prior anxieties. It seemed to me at the time that these uncharacteristic symptoms might be related to the effects of the antipsychotics.
I had been diagnosed with low-grade prostate cancer just before the Christchurch earthquake in February 2011. The cancer became aggressive, and I had surgery in Sydney in 2013. I asked Abraham to come and look after me while I recuperated at the home of friends. I can never repay the compassionate kindness with which he took care of me. He emptied my catheter, helped me into the shower, helped me dress, walked with me. Whatever personal struggles he might have been having at the time never interfered with the way he attended to me so lovingly. It speaks clearly of a man who, maybe fighting demons of his own, could nevertheless find the clarity of mind to be fully present.
Over the years that followed, I watched Abe battle with mind-numbing antipsychotic drugs. The drugs dulled things down—everything, non-selectively, indiscriminately. For Abraham, they cast a veil over his feelings. He sometimes felt so sedated that the smallest tasks became a huge effort. He lost touch with his inner feelings, which became unavailable to him. The drugs closed off access to his own psyche—to the pathway that might have allowed natural healing to occur over time.
The psychiatric establishment would have us believe that long-term maintenance on antipsychotic drugs is the best way to avoid psychotic relapse. However, evidence is lacking in support of this. Joanna Moncreiff also points out that there is no consensus within psychiatry on what “relapse” actually means.
April 2016: Second Psychotic Episode/Hillmorton Hospital
By 2016, Abraham had become depressed and extremely anxious. Feeling he needed help, he took himself to Hillmorton Hospital. There he was prescribed a cocktail of antipsychotics (possibly Olazapine/Zyprexa/Risperidone).
About this time, he was diagnosed with schizophrenia. The label was tantamount to a curse that we, as a family, did our best to disregard. The drugs caused an alarming, rapid weight gain (about 10kg) and he hated how it made him feel. Fat, lethargic and dull-witted. He and I began reading Peter Breggin, Joanna Moncrieff, Robert Whitaker, who variously question the efficacy of psychoactive drugs.
Absence of evidence hasn’t put the brakes on psychiatry’s widespread practice of polypharmacy (prescribing multiple different neuroleptics at once).
2016-2017: Reducing the Medication
Abraham wanted to get off antipsychotics. But in New Zealand little or no assistance (or research) is available for safe withdrawal. We tried unsuccessfully for years to find an open-minded psychiatrist to help.
I once asked Abe what prompted him to try to get off his medication. Was it the anti-drug literature he’d been reading? “No, I just hated how they made me feel … they were killing me,” he replied.
He began tapering his antipsychotics carefully, gradually, with the approval of his psychiatrist at that time. Unfortunately, psychiatrists here seem to come and go, so an ongoing relationship was not possible.
As Abraham decreased the drug dosage, he lost the excess weight and began to feel more alive, more himself. He was living with his mother at the time. But soon a new rent-assisted flat became available. This was one of the better periods of his adult life. He had already quit alcohol, and he became physically fit, joined a tramping club, formed a loving relationship with a nice lady, made forward plans for his life, and generally became more engaged in the world. He began playing his guitar again.
What happened next is key to the trajectory leading to Abraham’s increasing mental distress over the next two or three years, and his eventual suicide.
The Political Context
In the mid-1980s, neo-liberal reforms changed our society irrevocably. The New Zealand Labour Party, particularly finance minister Roger Douglas, and a right-wing think-tank called the Business Round Table, were the chief architects of Milton Friedman-style deregulation, known as Rogernomics. A pervasive climate of blame developed for those on welfare—an attitude that persists to this day (although perhaps the coronavirus pandemic may change things in previously unimagined ways). Poverty was increasingly viewed as a personal responsibility.
By the time Abraham was receiving the unemployment benefit, the centre-right National government was known for a tougher stance on law and order, and social welfare. The Minister of Social Development (2011-2014), Paula Bennett, was herself an ex-beneficiary and, with the zealousness of a recent convert, her punitive restructuring of the benefit system was clearly intended to send a message to dole-bludgers, benefit fraudsters, and most of all, voters.
New Zealand now had one of the highest suicide rates in the world, child poverty was at an unprecedented high, and surprisingly, for a country that believed itself egalitarian, it had one of the fastest growing inequality gaps in the OECD.
The New Zealand psychiatric establishment’s view of “mental illness” as a purely pathological brain disease became a way of distancing itself from the social context of its times. In the disease-centred model, the “mental illness” is seen to abide with, and in, the patient. It is a perfect fit for neo-liberal ideology emphasising personal responsibility, whereby the state can disown responsibility for its more vulnerable citizens and leave that role to market forces where wealth then, supposedly, “trickles down.”
But Abraham’s mental distress never occurred in isolation—no-one’s does. All mental distress occurs within a social context, whether it be the family, the village, the hospital or the prison.
2017-2019: Pressure to Return to Work
With Abraham looking and feeling better and getting on in the world, increasing pressure came from the Ministry of Social Development and psych-services for him to return to the workforce.
The social welfare benefit Abe was on is called “Jobseeker benefit” (even the name should ring alarm bells). It was seen purely as a temporary gap-filler until a person was able to find work. His case worker was no doubt herself under pressure to show successful “outcomes.” They had a box to tick off. Abraham—on his meds—well enough to return to the workforce.
Increasingly Abraham felt marginalised, not only by the diagnostic label psychiatry gave him, but by his economic circumstances. Holding down steady employment was difficult for him—that he could rarely earn a living wage disadvantaged him immensely, adding psychological burdens to an already stressful life. At the time of his death, he was on a disability benefit. He lived for many years on, or near, the poverty line. He felt deeply embarrassed by his circumstances—though he knew that somehow, he’d become “collateral damage” of neo-liberal reforms and our risk-averse mental health system. At a time when other young men were establishing themselves with careers, or families, he felt he could never get ahead no matter how hard he tried. The social and economic context of Abraham’s mental distress is central to any consideration of causality for suicide.
Abraham felt he wasn’t ready. He knew better than anyone how well he was doing. An intellectually able, well qualified man, suffering mental distress from time to time, but mostly able to return, by himself, to equanimity of mind, he grew afraid of ending up in low paid, dead-end work if he was forced too soon back into the workforce. To deflect this pressure—and to increase his options and potential earnings—he enrolled in a computer course. Initially he got excellent grades for his assignments. But the demands of the course proved too much. He began to spiral into paranoia. Fearing he was being surveilled by his computer or his smart phone, he arranged a deferment with the intention of returning to the course after a break. (Was this delusional? Isn’t that a matter of degree? Why does Mark Zuckerberg cover the camera lens on his lap-top?) Abraham enjoyed the study very much, and he was determined to better his chances of employment. Withdrawing from the computer course nevertheless left him with a dreadful sense of failure.
February 2019: Hillmorton Hospital
By early 2019, Abraham had become mentally very distressed. However, he had always retained a certain level of self-awareness—”insight,” psychiatry calls it—although this tended to fluctuate, along with the delusions that sometimes surfaced. It is likely he knew he was becoming psychotic, and he was sufficiently self-aware to take himself to Hillmorton Hospital for help. He still trusted the system at this point.
Feeling scared, he had admitted himself voluntarily, but his fear was hugely intensified when he learned he had been placed under the Mental Health Act.
I visited, and found him terribly distressed and agitated. He kept saying, “I don’t feel safe here.” He was outraged, and fearful, not to have been informed that his civil rights were totally suspended. He rightly saw as barbaric the threat—given verbally at Hillmorton—that if he did not comply, he could, under the Act, be forcibly held down and injected with antipsychotic medication. An already terrified man, in severe mental distress, threatened by the system he sought help from, grew even more terrified. I saw him getting worse in hospital.
Initial Meeting With the Psychiatrist
The initial meeting Abraham and I had with his consultant psychiatrist soon after he admitted himself to Hillmorton Hospital was extremely distressing.
What can possibly be gained by bringing an already terrified man—desperate to affirm his sanity, knowing his human rights have been denied him—into a room of eight or nine people, all armed with laptops and serious expressions? It resembled a kind of medieval inquisition—the two of us lined up against their greater numbers—the experts sitting in judgement on a very frightened man. Abraham felt humiliated. He was shattered by the experience.
Can anything truly meaningful be gleaned about a person, a patient, an individual, from this kind of purported assessment?
And what of its ethics: This can only be about power, surely?
Changes to Abraham’s Drugs
Following the meeting Abraham’s dose of risperidone was increased from 1mg to 3mg, then about ten days later to 6mg. A huge jump. Recent studies show that any alteration in antipsychotic medication, either up or down, can trigger akathisia. But the young consultant psychiatrist expressed the conviction that Abraham was suffering a relapse relating only to existing symptoms, unrelated to the side-effects of long term medication (such as dopamine sensitivity) or any changes to medication since Abraham had come to hospital.
The intention from this point, was to move forward with clozapine, the drug of last resort for what psychiatry labels treatment resistant schizophrenia. The consultant psychiatrist actively shut down any further discussion, nor did he acknowledge my letter requesting it. For Abraham, clozapine held the ultimate terror: the drug from which, he believed, there could be no return.
Abraham’s fear of forced drug treatment intensified. He became increasingly agitated and his paranoia only grew worse. I pressed for a family meeting in the hope that Abraham might be given some choice, or at least clear information, in his treatment options.
For unexplained reasons Abraham’s consultant psychiatrist was not present at the meeting ten days later; it was chaired by a different consultant with a much more conciliatory approach. Abraham eloquently outlined his fears of the hospital’s drug treatment approach and the violation of his human rights under the New Zealand Mental Health Act.
The new psychiatrist came to a very different conclusion of the situation. She removed Abraham from the Mental Health Act discharging him from the hospital the same afternoon. It is interesting that two psychiatrists, both relatively newly qualified, came to quite different assessments of Abraham.
Abraham was neither a danger to others nor to himself at this time. This made placing him under the draconian Mental Health Act all the more barbaric. The question that needs to be asked is: Should society chemically restrain people simply because they harbour unusual thoughts? Or is this merely a risk-averse procedure designed to protect the under-resourced institution unable to provide alternative treatment options, with antipsychotic drugs used as a tool to “manage” potential aggression, (even though the nurse admitted Abraham had shown no aggression at all)?
“Current mental health policies have been affected to a large extent by the asymmetry of power and biases because of the dominance of the biomedical model and biomedical interventions. This model has led not only to the overuse of coercion in case of psychosocial, intellectual and cognitive disabilities, but also to the medicalization of normal reactions to life’s many pressures, including moderate forms of social anxiety, sadness, shyness, truancy and antisocial behaviour.” Prof. Dainius Pūras, UN special rapporteur for Mental Health, 2019.
Consequences of Abraham’s Hospital Treatment
After his final encounter with Hillmorton Hospital Abraham grew frustrated and angry with the mainstream psychiatric establishment and their drug-centred treatment model. Years of frustration and anger began to surface. He requested and received a copy of his diagnostic records. These not only contained a number of factual inaccuracies, but the medicalised approach (framing his condition purely as a pathology) upset him deeply. Seemingly quite “normal” behaviour or things he may have said were taken out of context and “pathologised” to fit the psychiatric diagnostic paradigm.
Abraham felt this did not remotely reflect him as a human being. Where in the past he had been open and trusting towards doctors and counsellors, and essentially optimistic about his future, he now felt betrayed by the system that he himself had sought help from. From then on, whatever trust he had previously possessed, was obliterated.
Abraham’s final encounter with Hillmorton made him too fearful of accessing the only publicly available medical help again. It is my belief that Hillmorton Hospital in particular, and the psychiatric system in general, failed in their duty of care.
Not long after Abraham’s funeral, a request came from the coroner for more background information that could provide a fuller picture of why Abe committed suicide. The way these questions were framed (e.g. state of mind; mental health history; medications he was on; general demeanour; unusual behavior) seemed designed primarily to reinforce the psychiatric establishment’s hegemonic narrative: people take their own lives because they are mentally ill/schizophrenic/bipolar/depressed/have come off their meds. The answers to these questions were somehow expected to establish the irrevocable link to an existing pathology, or “mental illness.” It is as if other factors are deemed peripheral, such as social, economic, and more importantly in Abraham’s case, his frustration with the drug-centred model as the primary treatment option, and his consequent determination to never again seek help from anyone involved with Hillmorton Hospital in Christchurch.
While the New Zealand mental health system would prefer to view Abraham’s suicide as the result of a clinical pathology what they need to examine is:
- The iatrogenic consequences of the treatment Abraham received from Hillmorton Hospital and how this inevitably led to his suicide
- The relationship of the Mental Health Act and coercive drug treatment in exacerbating Abraham’s mental state that led to his suicide.
Abraham became so deeply afraid of involuntary incarceration and potential forced drug treatment at Hillmorton Hospital that he chose never to return. He had genuine cause to be afraid. The basis of his fear was not delusional. He saw any return to Hillmorton Hospital as a fate worse than death.
In the months since Abraham’s death, the world has changed in unprecedented ways. The COVID-19 pandemic has linked us all, invisibly, while at the same time needing to keep us apart. Over these weeks I have often asked myself what would this situation be like for Abraham? I believe his compassionate nature would have come to the fore and he could have found a place of kindness and understanding toward others—laying aside his own distress—just as he cared for me after my surgery. He might have been valued for who he is, rather than who the psychiatric establishment wanted him to be.
And, if things could change in the New Zealand mental health system, what changes would Abe want?
- He would want compassion to be the fundamental principal in treating mental distress.
- He would want his human rights respected; a recognition of the value and autonomy of him as an individual, rather than just seeing the “pathology.”
- He would want an alternative to antipsychotic drugs as a treatment option.
- He would want truthful and open information on the side effects of drugs, including the adverse effects.
- He would want an alternative to being in a locked hospital ward to recover in—a relaxed comfortable environment—a safe sanctuary that felt less like a prison and more like a home.
- He would want the right to agree to or decline treatment offered.
- He would want support in withdrawing safely from antipsychotic drugs.
Currently there is a review of the guidelines to the draconian 1992 New Zealand mental Health Act. Rather than repealing the act itself (years away I am told) the submissions to change the guidelines are intended to give legal structure to how the act is applied. Many of the suggested changes look excellent. It is to be hoped they will be implemented. However, the hegemony of the psychiatric establishment to decide who is mad and who is sane remains fundamentally unchallenged. That is the real change Abraham would want.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.