Wednesday, December 7, 2022

Comments by Joanna Moncrieff, MD

Showing 66 of 66 comments.

  • Hi Ron, thanks for making me go back and re-read this paper. The results are presented in a rather confusing way. First they present the proportion of time for which a person took an antipsychotic (which they suggest is more or less equivalent to the notion of ‘compliance’), then they present the average dose people took while taking the antipsychotic, then they present whether or not people had any ‘drug-free periods’ lasting 30 days or more, then whether there was polypharmacy and finally they present cumulative antipsychotic exposure (long-term dose years). Outcomes are SOFAS, remission and CGI (clinical improvement). Having any drug free periods is associated with worse social functioning (SOFAS) scores (just), but so is higher dose and cumulative dose. On the other hand, a higher proportion of drug free time, lower dose, cumulative dose and polypharmacy are all associated with better CGI scores but having or not having drug free periods is not. So it seems that overall, lower compliance is associated with greater improvement and most of the results point in the direction of higher antipsychotic exposure being associated with worse outcomes. They don’t provide data for the outcome of people who discontinued or who used low doses, which would have been more useful. And, as with the other long-term follow-up studies, much of the variation is probably accounted for by variation in severity of the underlying problem.

  • I completely agree with you that alternatives should be found to coercive use of drugs, but the Soteria project did not accept everyone – a sizeable proportion of people referred to it were not considered to be manageable in the project because they were too disturbed, and had to go to, or stay in the local asylum instead. The question of how to respond when people are really out of control and not amenable to reason is a really difficult one that I do not think we have yet resolved.

  • We are too large and complex a society to leave this to the kindness of family or neighbours – who may not be in a position to provide the level of care necessary, and even if they can, with the best will in the world, sometimes become worn down. As soon as the State steps in, it becomes a ‘service’. However, I take all your points about how this does not need to be a specialist activity. Indeed, this reminds me of the principles of the Soteria house and the emphasis on simple human contact and unintrusive support for those who were in a very disturbed state of mind, and the recognition that this could be provided by anyone with patience and commitment. I agree to some extent, but also feel that this can be challenging work, and there needs to be a structure to support people who are doing it.

    Also agree that each person is an individual with distinctive needs – this is partly what is wrong with diagnosis. It obscures this and encourages us to see people as representatives of a group label. Also agree this is a significant problem. Indeed, the other aspect of this is how does society justify welfare payments for the millions of people currently classified as ‘mentally ill’ if this is no longer considered a medical sickness. Doctors have been nominated as the gate keepers of welfare benefits, a job I am sure they would happily relinquish, but we have no other system to replace this. Studying the history of welfare in England over the last few hundred years shows it has been done differently, but also that it has always been a highly contentious issue. These problems attract me to the idea of a universal basic income, but this is not perfect either.

  • Thanks for people’s comments and good wishes! In response to the idea that psychiatry cannot reform, I agree that an institution that is founded on the idea that distress is a disease may always be compromised. However, in my view, there is a need for some sort of service for people who ‘lose their minds’ from time to time, beyond simple therapy (because there are times when people are not in a state to be able to take part in therapy). I have thought this might be best placed as a branch of social work, because people who are confused and mentally incapacitated almost always have ‘social problems’ of one sort or another, and sometimes they cause social problems too. Someone else I know suggested ‘mental health services’ should be part of housing provision. Maybe pure Szaszians would argue that such a service should only be for people wo break the law and should be a branch of the prison service. What do other people think?

  • Thank you for all the comments. I have read all of them but will just pick up on a couple of things. Yes, the study was a one sided view via the medical records, written by the asylum doctors. And yes, like today, their views of what counts as normal behaviour and what counts as mad are shaped by ideas that were current at the time. From the records of the national inspectorate, there were cases where people appealed their admission. I don’t know how many won and if there are any records of that- I didn’t come across any. There are some accounts by patients/inmates of life in other asylums at other periods, and some report shocking cruelty. Frank mentioned how there was an increase in the apparent frequency of madness when the asylums were built. I would agree, and the asylum population continued to climb throughout the 19th and early 20th centuries. The records I looked at reported several building programmes initiated to accommodate rising numbers of patients. Historians favoured explanation for this is that families, under pressure of the capitalist, industrial economy, could no longer care for their dependent or disturbed members at home, as they had done in previous eras (sometimes with the support of the local parish). Explanations in the 20th century may be different.

    I was not making a plea for the return of the asylums, but I agree with Rachel that what we have now, for many people is ‘an asylum without walls’. That sort of system of control is more difficult to challenge and scrutinise, and that worries me.

  • Thank you Slaying the Dragon for your thoughtful comments. I look forward to them, because I know I will always learn something. So I especially appreciate your discussion of Aristotle and Christianity and the contrast between their understandings of human nature and the modern line of thought that has led to the sort of neuroscientific reductionism we see today. I agree with you that we are motivated by pursuing certain ‘goods,’ and that this motivation underpins our sense of right and wrong, and our sense of the meaning and purpose of life, but as Aristotle points out, these ‘goods’ are the product of society, at least to some extent, not something that is inherent in us. This is why, as individualism grows, and religion and social conservatism lose their hold, we struggle to find a universal basis for our beliefs and morals. Individualism has a bad name nowadays, and it is right that we are often tempted to neglect the social, but we should not forget that our sense of ourselves as indivisuals, with some power to influence events ourselves, is associated with the shaking up of centuries of unchallenged social heirarchy. I probably don’t need to point this out to an American! But I don”t think we can resolve modern existential problems simply by returning to ancient philosophy or medieval Christianity – and I apologise if I am over-simplifying your position, which as I said is definitely thought-provoking.

    On the question of mental illness/disorder, I think it is too simplictic to just blame psychiatry. I recognise that psychiatry does create many of the problems it is supposedly there to address, but there is a historical record of something that was widely recognised as ‘madness’ (lunacy, insanity etc) long before psychiatry came into existence, which caused problems for many different sorts of communities. I am not making a plea for psychiatry, but I am trying to work out how we, as a society, can respond to these problems without pretending they are medical conditions, with all the worrying implications that go along with that view.

  • In response to Concerned Carer and Dr MacFarlane,
    I continue to believe that ‘depression’ is a human response to adverse circumstances and cannot be characterised or measured as a thing that is independent of the individuals and circumstances in which it occurs. However, other people continue to make claims about “it” and about how antidepressants affect “it” that have great influence, and I think people deserve to know what little substance these claims are based on in their own terms.
    As regards the placebo effect, in randomised trials people get a lot of extra support as Dr MacFarlane points out, so the placebo effect is likely to be enhanced. There is little evidence as to what that effect is in normal circumstances, but STAR-D was probably a little closer to these.

  • Dear Neil,
    I approved your comment on pillshaming as soon as I was notified about it. It appears on my version of my website. Please let me know if you still can’t see it.
    Hugh Middleton and several other psychiatrists from the Citical Psychiatry Network signed the recent complaint about the Royal College’s coverage of antidepressant withdrawal. I did not as I have too much on my plate with trying to get the Radar trial completed at the moment.
    Also, the Critical Psychiatry Network was critical of the invitation to Charles Nemeroff back in 2013, and we managed to get coverage of it in the Independent newspaper

  • Hi Frank,
    Thanks for your reply. You make some really important points. The system of social control that psychiatry currently enacts is highly contentious, and that is why it is convenient to diguise it as medicine. I agree with you that it is wrong and dangerous to label it in this way or put doctors in charge of it. And I agree that devising any system that is consistent with human rights is really challenging. But I think it is difficult to say we should dismantle psychiatry and do nothing. I think there are situations where it is reasonable for society to have a response of some sort and I see no reason why ‘due legal process’ should not be part of this. In fact it is essential, because as you point out there are many fuzzy areas and the potential for abuse.

  • Hi Slaying the dragon,
    I appreciate that you are willing to engage with my arguments! Yes I think there are social problems that are associated with what we currently call mental disorder, but that does not mean I think that mental disorder is a term that denotes a consistent set of problems or an abstract thing of some sort.
    Mental disorder it seems to me is a broad umbrella term (and not a unsatisfactory one, but there is no good alternative), and I have been talking mainly about situations we might previously have called madness that are characterised by behaviour and speech that is bizarre, irrational, unpredictable and sometimes associated with disturbance to, or dependence on, other people, as illustrated in my examples. There may be many people who are quietly mad, yet get on with their everyday lives, I am not aure we will ever know how many, but the people who come to the attention of ‘services’ present problems of one sort or another.

    I completely agree with you that psychiatrists have sucked in many other sorts of life problems by presenting the enticing idea that they are diseases that can be easily fixed. My experience is that many people like this idea and are quite resistant to having their problems presented in a different way, but of course this follows years of mental health ‘education’ campaigns.

    But the examples I gave are not exceptional in the UK, and if you look at historical accounts, like old asylum admission papers and Poor Law proceedings you can see that these sorts of problems predate psychiatry and modern medicine and occurred before people got anywhere near what ‘expert’ care was available in those times.

    I am not saying that psychiatry represents the solution – I am saying there needs to be a social response of some sort which is not available under the criminal law as it stands, and I think there can be a better one than the one we currently have. I think its essential that people who have been on the receiving end of psychiatry are involved in shaping that solution.

  • Dear Slaying the dragon,
    Although we clearly disagree profoundly on this issue, I appreciate your detailed criticism. I think our main point of disagreement is that I believe there is a social problem that needs some sort of response, which is not just created by psychiatry. I do not think it is a medical problem, and I am not trying to defend the current system. I use the term mental disorder because it is difficult to conjure up another term, but I have tried to make clear that I am referring to a variety of behaviours and experiences that do not necessarily have anything intrinsic in common, but which cause a set of social problems that institutions like the criminal justice system are not easily able to address. The whole point of this blog is to call for a collaborative effort to imagine a better system.
    As I said to Frank above, I used to be a libertarian, but I have had so much experience of situations where people’s behaviour causes considerable distress, disturbance or danger to themselves and others that I have come to conclude, reluctantly, that some system of social control is necessary. Although you say I am offering extreme or absurd examples, I could have offered many more in a similar vein. In the first example, the man was actually taken to hospital on another occasion by members of his church, because they were so concerned about his strange and disruptive behaviour during a service. This is a good example of the point that Jeff Coulter makes, that madness or mental illness is defined by the community, not by psychiatrists. The psychiatric diagnosis or label is a technical-sounding, post hoc justification for action that has already been decided to be necessary by the local community and society in general. Of course psychiatric discourse feeds into what the community defines as unacceptable behaviour, and it has widened the range of this considerably, but as history suggests there have always been situations that ordinary people find dfficult, disturbing and perplexing and struggle to deal with. Psychiatry responds to deeper social and political needs, it does not create them, but that does not mean to say that it is the right or the best response to these needs.
    You object to the concept of a ‘duty of care’ and I agree that paternalism is dangerous and problematic. At least in some circumstances, I think we should leave people who are only harming themselves to their own devices. However, I think there are some situations where actions appear to have been impulsive, or someone is in an altered and confused mental state where we should intervene to protect people’s own safety.

  • I agree that social and economic conditions have a lot to do with mental suffering and disturbance, and I also agree that I have not done this issue justice in this blog. We know from epidemiolopgical studies that most mental disorders are more likely to be diagnosed in people who are poor, unemployed, have histories of abuse etc. I agree that being able to contribute to society is essential for wellbeing, but modern work is often exploitative and underpaid, and does not necessarily give people a sense of being valued.
    I am also very interested in the experiemnts in universal income. I think this should be coupled with providing opportunities for people to do meaningful and rewarding activities that contribute to the community and whose value is properly acknowledged.

  • Hi Frank,
    I used to be against any form of social control (in addition to the legal system), but having worked for a long time with people with serious ‘mental disorders’ I have come to conclude that it is sometimes necessary. I don’t think using the criminal law is fair or adequate in situations where people are too confused or preoccupied to appreciate the effects of their actions and yet I think that the community sometimes needs protection from danger or disturbance.
    My concern is that portraying these situations as medical conditions obscures what is really going on, making it impossible to devise a system that is fair, or as fair as possible, to all concerned.

  • Dear registeredforthissite,
    I agree with you that labelling someone with schizophrenia or other diagnosis is not helpful and can be damaging, particularly because people fail to realise (psychiatrists often included) that the label does not refer to an underlying entity or cuase of the beaviour, but is simply a description of the behaviour. And I agree that it is important to try and understand the meaning of the behaviour, and how it relates and responds to the individuals current circumstances and personal and cultural history. I agree this is an important part of trying to help people, as I stressed by referring to the work of RD Laing and other in my previous blog. But i think we should not hide from the fact that what we refer to as mental disorder can soemtimes cause real distress and distrubance to people (individuals and those around them) and sometimes actual danger, and I think some sort of social response is needed. I think this could be done by a variety of agencies. Possibly it could be done by family and friends, but my experience is that they often feel overwhelmed and are desparetly looking for help. I suppose I am really just arguing for an open and transparent debate about how we address these situations fairly, in a way that causes the least damage to the individual, but also respects the needs of others.

  • I agree that we should give people time to recover without drugs, as some people will certainly do. However, where psychosis is protracted I do think it is worth trying the use of antipsychotics. I think these drugs can sometimes suppress psychotic symptoms enough to enable individuals who are wrapped up in their psychosis to interact with the outside world again, and resume a more ‘rational’ form of behaviour and communication. If people then feel they would rather not take the medication, I completely agree they should be able to stop it.

  • I think there are plenty of people who do feel miserable and stressed, especially if they are financially insecure, lack employment, social support etc. But I agree with you that the fact that Pharma and doctors have been telling people they might have a brain disease and that they need drug treatment is likely to have created legions of people who feel vulnerable, fragile and dependent on services.

  • Ron, Frank and Richard,
    thanks for this dicussion. It is really interesting to hear how you and others have experienced ‘psychosis’ and how it might relate to academic theories. Just some arbitrary thoughts:
    I think rationality is necessary to connect with other people and the world, but not sufficient – there needs to be some emotional connection too. I agree that ‘wisdom’ must be aquired, even cultivated, but I also think (although I will have to give this some more thought) that ‘reason’ is a potential of human beings that that will be manifested in most conditions to some degree (think of the complex and logical thought processes required to hunt sucessfully, for example).
    I also think the issue of validation by others is complex. I agree that madness can be seen as the result of a ‘perpetual dialogue’ with oneself and that connection with other people is essential to living a functional life. On the other hand, as Ron highlights, other people can be a source of misery and also pressure to conform to immoral and sometimes irrational beliefs and actions. Sometimes it is necessary to detach oneself from the crowd, which can be dangerous and lonely.
    I think if you take a Wittgenstinian (or Hegelian) point of view on this, we get the understanding and concepts we use to think for ourselves from our shared social world and language. It is from being a social animal that we have the ability to be individuals.

  • Hi Ron, thank you for making this point. I understand people’s anger about the often nasty treatments that psychiatry inflicts on people, thats why I have spent much of my life desconstructing the evidence for drug treatments. But there are real problems out there that are not just created by psychiatrists, psychiatric drugs, or the mental health system. I want to think about how we, as a society, might approach these problems without medicalising them.

  • Thanks for this. I understand why you are asking. What I am trying to say in these blogs is that although the behaviour we call ‘mental disorder’ is not a disease, some of it does nevertheless present a problem that society needs to address, and indeed always has addressed in one way or another, long before psychiatrists appeared. I am trying to work out a fairer and more transparent way of doing this that does not involve labelling people as ‘diseased’ and thereby invalidating them. In my ‘day job’ I try to help people to find alternatives to drugs for managing their distress, and when nothing else works to use drugs as safely as possible to help suppress distressing or debilitating (usually psychotic) symptoms. Sometimes I am involved in use of the Mental Health Act (sectioning people) when someone’s behaviour is out of control and posing a danger to themselves or others. This is, I acknowledge, a form of social control, but I think it is sometimes necessary. What I am uncomfortable about is that the process is presented and understood as if it were a medical procedure which it is not, and which prevents it from becoming more transparent and accountable.

  • Dear Slaying the Dragon,
    I agree with you that we should jettison the concepts of mental disorder and mental illness but I do not agree that that will make the problems we now refer to as mental disorder go away (or at least not the sort that I see, or most of them). I also think you are wrong to imply that Szasz felt there were no problems to deal with. He wrote many times about how the term mental illness/schizophrenia refers to behaviour that bothers or disturbs people (the sufferer or other people around them). The example I gave is not rare in my sort of practice, it is quite routine, and people with these and more severe problems have been documented throughout history. I don’t know what things are like in the States, but in the UK resources are far too thin to be locking up anyone who is not pretty badly disturbed.

    I am not trying to say that there is a thing called mental disorder that is a bit like disease. But I do think there are certain patterns of behaviour that can be problematic in various ways to other people or to the people themselves. Some of these are characterised by what I referred to as an impairment of reasoning, but I was not trying to argue that this should be judged by psychiatrists. I think how we judge it is complex, and there should be a democratic debate about how to do it. In the US this used to be done by a jury – I would be interested to know whether you think this would be better or worse than having psychiatrists doing it?

  • Hi Nancy and others,
    I think neuroplasticity is interesting. I agree with Frank that sometimes it probably reflects compensatory mechanisms in response to drug induced damage. However, I think it also shows us how our brains reflect our lives and activities. If we do more of certain things, parts of our brains grow in response (the famous study of taxi drivers in London, for example).

    On the issue of subjective experience, of course, some people go to psychiatrists voluntarily because they feel unhappy, worried or confused, but others are taken to psychiatrists by others- family members, the police etc. In these cases the individual’s behaviour is bothering other people in some way, but they may not be distressed or want help themselves. So I don’t think it is the subjective state that is the key factor in these situations. Even when someone is asking for help for themselves, often it is social factors, such as not being able to go to work or fullfil other duties, that precipitate help-seeking, rather than just the way someone is feeling.

  • Thanks Frank. I always thought we would agree on the ‘diagnosis’ of what is wrong with the current approach, but as you say, we may not agree on what is to be done. I really value your comments though, because I certainly do not have the answers- only more questions. I think you hit the nail on the head by pointing out that if we ditch the pretence of science and objectivity (i.e. the idea that ‘mental disorders’ are diseases), we are left with a highly contentious political issue, where one group of people are making judgements about another. I am looking forward to your thoughts about the next couple of blogs.

  • Hi Julie,
    most of the physical tests done when assessing a possible case of Alzheimers disease are to rule out other possible causes. The diagnosis is a clinical one, made on the basis of the memory loss and cognitive problems, not on the results of physical tests. As I said, there are differences between the brains of people with Alzheimers disease and people without as a group on MRI scans, but the scans are not diagnostic. You can have a normal scan and still have Alzheimers, or an abnormal one and not have it. I don’t know what test the man you described had, but there are no diagnostic tests for Alzheimers.
    I can see how the confusion arises though. I just looked at a few sites and they do not make this clear at all. However, the NHS Choices website does state that: ‘There’s no simple and reliable test for diagnosing Alzheimer’s disease’
    I think this is interesting. It suggests that even where questions of biological aetiology are not really in doubt, there is an inclination to give an impression of more certainty than really exists.

  • Hi Sa,
    I am not saying that what is diagnosed as severe depression or negative schizophrenia are caused by brain dysfunction/damage. I am saying that in some people with these presentations, brain dysfunction may turn out to be the cause.
    I recognise the situation that Paul Morrison describes. Sometimes it is accompanied by some more familiar psychotic ‘symptoms’, sometimes not. I agree with him that helping someone who is in this state is really difficult. I don’t recognise the miraculous effects of clozapine that Paul describes, but I have seen it help some people who have been very troubled by persistent psychotic experinces to care less about them.

    I don’t think we know what happens without drug treatment any more. We can look back and see that some people who presented in an apparently psychotic state recovered (e.g. John Perceval, a 19th century English gentleman who had a severe psychotic breakdown, and spent a couple of years in various asylums, before making a full recovery, and going on to lead a ‘normal’ life, while campaigning for asylum reform- you can access his incredible personal narrative here:
    However, from my exploration of early 20th century asylum records, there were also those who remained psychotic for years. The problem is mental health problems change profoundly with history and it is always difficult to know whether the problems people had then are the same sort of thing as those people have now.

  • Dear Nick and others,
    I haven’t heard of the polyvagal theory of distress but the vagus nerve is part of our arousal system, so it is bound to be affected when we feel distressed. I agree with Steve that biological markers of distress are more likely to be secondary, or correlative than causal.
    Also love the walking analogy.
    The point about Tuke is that, as Andrew Scull’s work shows, there was a debate in the 19th century about whether asylums needed to be run along medical lines. Asylums existed before doctors became closely involved in them. This suggests they fulfilled a social function, not a medical one, and that as you say, they might have developed differently if the medical framework had not triumphed.

  • Dear Slaying the Dragon,
    thanks for your comments and for sticking with me this far! I agree that for Szasz what is important is that the terms ‘disease’ and ‘illness’ relate to an objective biological abnormality, but I was just trying to differentiate the two terms.
    The unit I worked in was for people who had become addicted to alcohol or street drugs- sorry if that was not clear.

    I am writing these posts because I think there is a lot of confused thinking in the philosophy of mental health literature, and because I am trying to engage with Szasz and work out the implications of his thought for both how we understand mental disorders and how we (as a society) might respond to them. I presented these ideas initially to a group of psychiatrists, most of whom were pretty hostile, and certainly were not fans of Thomas Szasz. What I was trying to do was provide a philosophical defence of Szasz’s views, using my knowledge of other philosophers like Wittgenstein. So I know that a lot of what I am saying is obvious to the MIA audience, many of whom will know Szasz better than me, and sometimes I am responding to criticisms of Szasz that most people here would not make, but many others do.

    I am not trying to justify psychiatric coercion. Personally I believe that some form of coercion is occasionally necessary, but I do not think it should be based on a medical framework. I think we need a new legal framework. I know you think we have an adequate legal framework in the existing law, and that is a very powerful argument, but I think we probably need something more.

    I hope that helps and thanks for your patience.

  • Hi Frank,
    I agree with your comments above. I also agree that psychiatry, or any social response to what we currently call ‘mental illness’ or mental disorder, is not an objective enterprise. But to me this is not the problem. Psychiatry is a social and political activity, like education or the criminal justice system. Society makes decisions about how it wants it children to be brought up, or what people should be punished for, and it creates institutions that reflect these values. Another society might chose to address these issues differently. They are not ‘objective’, but most people would say that we need some form of education system, and some form of rule of law. The problem with psychiatry, in my opinion, is that it is dressed up as science, that is as something objective. This means it does not receive the scrutiny it deserves, and that it would have if it was acknowledged to be a ‘subjective’ or political activity.

  • Hi Steve,
    really well put, and I completely agree. Biology is involved in all our behaviour, of course. We are biological beings, after all. But when a situation is brought about by a bodily condition, like hyothyroidism or diabetes or whatever you care to name, this is a distinctive situation that we call a disease. It calls for distinctive response, that involves acting on the bodily mechanisms that are causing the problems (or symptoms, as they are rightly referred to in this context).
    What this means, I believe, is that when negative emotions or unusual behaviours are not driven by a specific bodily mechanism, we should approach them as we approach other human behaviour. We understand it by looking at the interaction between each unique individual’s personality and proclivities and the social environment they have been immersed in. As you say, this means there is no one size fits all understanding of something like ‘depression’ and no universal forms of help.

  • Hi Steve,
    previous comment meant a s a general one, but in reply to your points, I prefer the analogy of a painting. The brain is like the canvas and the paint, the ‘mind’ (our thinking self) is the picture. This analogy makes clear that understanding the one is a different activity from understanding the other. For one we need to analyse the material properties of paint and canvas, for the other we need to understand the meaning of a picture, which is quite a different sort of thing.

  • What a great site this is with people bringing insights from thinkers as varied as Aristotle, Buddha, Deleuze and Daniel Dennett. Thanks to everyone for all the comments – critical ones included! It is plenty of food for thought. Next one coming soon- please stick with me.

  • Hi Frank, thanks for these thought-provoking comments. You bring up a really important point. I am not trying to say that knowledge is consensus. I know Wittgenstein can be read like that, but I don’t think it is the correct reading. Wittgenstein and Heidegger are talking about the conditions for the possibility of knowledge- not knowledge itself. They both believed in science, and that scientific findings were determined by the nature of reality and not by consensus. But you have to have consensus on how to designate things (i.e. you have to have a language) for any scientific investigation to be possible and for its results to be shared. I would agree that prehistoric societies had knowledge, but they had language too. You may not need writing or indeed speech, but you do need some shared form of communication for there to be what we regard as knowledge in my view.
    The next blog is getting back to Szasz and the concepts of disease and illness, and will make the main argument much clearer. Thanks for your patience!

  • Thank you to everyone for bringing up these important issues, that for me really get to the heart of the matter. First thing to say is that I don’t think anyone is locked up because they have a diagnosis. People are committed to ‘hospital’ because their behaviour is problematic to someone else (usually their family or the local community), and the mental health diagnosis is the post hoc justification for the current system with which we manage such behaviour.

    What evolved into mental health legislation started out as a branch of the law, but that grey branch that concerns itself with social disorder. In England, it was magistrates (local officials, who still exist and still deal with petty crime) who first had the authority to commit people to asylums. They were originally called ‘Justices’ and before that ‘Keepers’ of the Peace. As soon as you medicalise this system, as we have done with psychiatry, you disguise the very real democratic problems it involves- i.e. how do we balance the interests of some people against others. I don’t have the answers, but I think we do need some system for managing some of the behaviour that the mental health system is currently charged with.

    I know that Szasz believed that there should be legal measures for people who lack ‘competence’ (he mentioned this in a couple of talks I saw him give in the last few years of his life). I don’t think he ever described what he had in mind here in any detail, but it seems to me he is describing a system that includes some of the functions of the modern mental health system, but one that operates under a different framework.

    I am really interested to hear what other people think, especially people who have had experience of the mental health system, so thank you again for your comments here.

  • Dear Slaying the Dragon,
    thanks for your comments. You describe political philosophy as a rationale for control over nature and control over man, but I see it as a series of considerations of how human beings can live together and how to manage inevitable conflicts. Thomas Szasz was not an anarchist. He believed in the need for society to have rules of conduct. What he objected to, I believe, was the medicalisation of those rules, such that the fact that they are politically devised rules, and therefore to some extent inevitably arbitrary, is obscured.
    In his book, The Meaning of Mind, which someone on this site recommended to me, he appears to approve of the idea that the ‘insane’ should not be accorded democratic rights; that they have, through their behaviour, forfeited the right to be part of the political community:
    He says, “In short- the Greeks excluded non-responsible persons – infants and others unable to control themselves [including women, of course] from membership in the polis. We include many persons unable to control themselves, exemplified by the insane- as members of the political community. Indeed, we insist on according them the right to vote and thus the opportunity to control those members of the community who are able to control themselves and who support those who are unable to do so.” (P 104).

    This highlights that Szasz believed in political forms of control and that these can take many forms and can also be (like medical control) profoundly disempowering.

  • Hi Nancy,
    thanks for your comments. What Wittgenstein suggests is that knowledge is inherently third person- i.e. shared and public. The first person perspective is not appropriately thought of as knowledge (on this view) – it is experience. Heidegger’s slightly different take is that basic, ‘primordial’ knowledge is the familiarity we have with our environment from being embedded in the world. On this view, there is no real distinction between first and third person- our experience is inherently connected with the world around us.
    I don’t think either view contradicts the way you describe the teaching of the Buddha, but both Hediegger and Wittgenstein would emphasise that our first person life is understood by others through our outward behaviour, and that both are shaped by, and cannot be seen in isolation from our particular social, cultural and historical context.

  • I am not claiming to speak for all ‘critical psychiatrists’ but what I feel is that some problems of living need a social response of some sort – whether that is to help the individual or to protect the community. I don’t think the response should be fundamentally medical, but I do think that medical interventions can sometimes play a part. I think that sedatives of various sorts, including antipsychotics, can be helpful if someone is acutely manic or psychotic, for instance. I am concerend about their long-term effects, but for some people I think the benefits probably outweigh the harms of long-term tretament- just probably not nearly as many as currently take them long-term.
    So I agree that any institution that is based on the idea that mental disorder is a disease is problemmatic and that we need to fundamentally re-imagine our current responses (although I do not have a blueprint for the future, and would be most interested in other people’s ideas). But I think medical or pharmaceutical expertise of some sort will still have a small but useful role to play in a new system.

  • Hi Steve,
    thanks for your comments, but I don’t know why you think I am defending modern psychiatry through philosophy. I am critiquing it in a way that leads to the conclusion that it is misplaced to view mental disorders as medical conditions.
    I know that most Mad in America contributors don’t need to have an elaborate philosophical analysis of this position, but my blogs are aimed at those that are still convinced that madness is a medical disease, hence why I am setting out an elaborate and (sorry) rather slow argument. I completely agree with you that labelling someone’s distress as disease or illness is disenfranchising and disempowering.

  • Thanks for all the comments. I agree with Oldhead that doing away with the concept of mental illness exposes modern society’s inadequacies, but I also think that some of the problems it raises are difficult ones for any society, even a post-capitalist Utopia.
    I think the point Frank and Steve make about why we don’t forcefully treat physical illness is interesting. It shows that we (society) actually start not with disease at all, but with behaviour. The disease idea is brought into play post hoc when there is a problem with someone’s behaviour. The justification is that certain forms of disease- namely ones that affect the brain, impair rational judgement. Some brain diseases do do this, of course, and in later blogs I will discuss what distinguishes these situations from those we refer to as ‘mental disorders’.
    Nancy- I have just studied Heidegger who questions western, scientific epistemology for the study of human beings and stresses our intimate connection with the world around us. His work is similar, I think, to some Buddhist teachings.

  • In reply to Slaying the Dragon of Psychiatry, thank you for your comprehensive review of my book, The Bitterest Pills. I do not know how you got the idea that I susbcribe to the concept of mental illness, or the idea that mental disorders are biologically based brain diseases. In the preface to the book I explain why I use conventional langauge like ‘mental disorder’ and ‘schizophrenia’, but I never use the term ‘mental illness’. The current series of blogs represents my attempt to set out my objections to the idea that ‘mental disorders’ are brain diseases, or indeed diseases or illnesses in any other sense.
    In reply to Pat, my work on what psychiatric drugs do (the ‘drug-centred model of drug action’) attempts to explain how drugs can be helpful without treating a disease or sickness

  • Great response! By the way, the Leucht 2009 review is even worse than you suggest, because it includes all the studies of atypicals that you rightly criticised in Mad in America. Lots of these studies were done with chronically hospitalised patients who were already taking long-term antipsychotics, and were then randomised to take a second generation antipsychotic or discontinue altogether (most likely abruptly). Given this, the difference in ‘response’ rates between the drug and placebo (17%) is very disappointing!

  • Dear Frank,
    thank you for your comment. I understand your concerns, and how horrible it must be to have these drugs forced on you. I do see some people, however, who are really distressed and overwhelmed by psychotic experiences, tormented by paranoid feelings and voices and utterly engrossed in a bewildering and often frightening internal world. In this sort of state people are unable to connect with other people, so providing other sorts of help is difficult. Also, in a situation like this someone may not be able to make a proper choice. Sometimes antipsychotics can suppress the experiences enough to enable the individual to reconnect with reality and engage with people again, and then they have more chance of taking back control of their life, whether this ultimately involves taking medication or not.

  • Hi Matt,
    I completely agree about the naming of drugs. The term ‘antipsychotic’ is euphemistic at best, and downright misleading or dishonest at worst! I have taken to using it because when I asked my medical students what neuroleptics were they didn’t know what I was talking about! The term antipsychotic seems to be more widely recognised now. I agree this situation is lamentable, but we need to communicate with people who don’t necessarily know as much about it all as we do.
    On your other points, I guess I was aiming the piece partly at the authors of the Goff et al paper, and the sort of professionals who might be influenced by them. Hence I was trying to write in their terms, and to respond quite narrowly to the points they raise. I agree there is a much bigger battle to be fought about the nature of ‘mental disorder,’ how to help people and who should do this.

  • Thanks again to everyone for taking the time to comment. I really like Richard D. Lewis suggestion that what we call ‘mental disorders’ can start off as adaptive coping mechanisms that become self-defeating and self-destructive. In other words they can be made some sense of if we try to understand the individual’s reality (as Stephen Gilbert suggests).
    Frank Blankenship expresses the dehumanising effects of the medical/disease model very starkly with the idea that it ‘cancels you out as a human being’. I think this sums up what I was trying to say very powerfully.
    In reply to Misfitxxx, I certainly think there is something in the Eastern idea of silence and accepting uncertainty, and that it is likely we cannot pin down the experience of many states of mental disorder precisely in words.
    In response to Slaying the Dragon of Psychiatry, I agree that Szasz is the key thinker here. I was just starting off with some thoughts about what inclines me to accepting Szasz’ analysis. Where I probably disagree with you and maybe with Szasz (although he was always vague on the question of how else you deal with the ‘problems of living’ he identifies) is that I think there needs to be some system to take care of people whose capacity to function is compromised by an extreme state of mind. I want to think about what a system that is not based around a disease model would look like.
    In relation to this, and in response to some points raised by Matt Stevenson, Don and then by Oldhead, I think that at least some of the behaviour we refer to as mental disorder is behaviour that is not organised and motivated in quite the same way as more familiar forms of behaviour. I am not trying to say it is completely different (as I said, I think Richard Lewis makes a very sensible suggestion about how to understand it). But in states of psychosis or mania for example, people seem to lack the usual capacity to make judgements and understand the consequences of their actions. These states may be reactions to terrible circumstances or past events. I firmly believe that the real key to preventing mental health problems is to construct a fairer, more inclusive society in which all people have opportunities to flourish and develop their potential. Only then will conflict and mistreatment of some by others be reduced. However, states of extreme mental disturbance or distress still seem to me to require a response now.
    Thank you to everyone who shared their personal experiences of the current system, the dehumanising effects of the disease model and inspiring stories of how to help people in other ways. And thank you too for some very kind comments. I am posting this response a bit nervously, as I know there will be those who disagree, but as always I am so grateful that there is a space such as Mad in America in which to have these debates.

  • Thanks for all your comments. I think Stephen’s problems highlight the nature of modern medicine really well. For many chronic conditions the treatments are not very effective, or only temporarily effective, and sometimes the effects they produce are worse than the original problem.

  • This is such an interesting discussion. Thank you to everyone who has contributed. It has been very enlightening.

    In answer to the question about whether psychiatric drugs are responsible for rising benefit rates, I think the massive prescription of psychiatric drugs contributes by confirming to people that they are sick, and through the apathy-inducing effects of many drugs. I do not think that the drugs are the ultimate cause of this situation, however.

    I agree that a job is not the be all and end all of life, but I think that most people benefit from being able to contribute to society in some way, and by being rewarded and respected for their contribution. This does not need to be through paid work, I acknowledge, but it would be nice if there were more jobs out there that gave people a sense of satisfaction and pride.

  • Dear Saul and others,
    I think emotions, including depression, are almost always human responses to the environment around us. Other people are an important part of that environment, but it also includes physical and climatic elements. Long hours of dark and cold are depressing, just as losing a job or a loved one is depressing. Of course some people are more susceptible than others to these various factors. And I wholeheartedly agree that ‘depression’ is many different things. It has to be understood as a property of each individual subject, in their own particular context, and not as an abstract entity that can be studied independently as if it had a life of its own.

  • Thanks for all your comments and suggestions. In response to Sandy, I think that sometimes medication is necessary for a severe manic episode, but ideally people should be gradually weaned off over a few months once they have recovered. I have also wondered if just using benzodiazepines rather than antipsychotics might be adequate, and less distressing for the individual concerned. Benzos cause other problems, of course, and the rapid tolerance to their effects that often occurs may limit their usefulness. I really think this should be tested in an RCT though. I know Guy Chuoinard from Canada started one in the 1980s with clonezepam, but I don’t think the full results were ever published.

    However, picking up what Chrys and others have said here, I have also found that people can sometimes learn to manage their mania with little and sometimes no additional medication. Often this comes with time and experience, and being able to make lifestyle adjustments to help them identify early warning signs, take time out etc.

  • In response to John Doe, of course there is much more to say about Christianity and society, and many ways of viewing their relationship. I was only selecting one aspect of the Christian religion to make a point about the way the ancient world contrasts with our modern values.

    Despite what you say, there is a consensus that aspects of Christian philosophy facilitated the rise of modernity, and despite the pitfalls that have come with our modern civilisation, I for one am grateful to Christianity for the emergence of a society that is no longer based on static and rigid hierarchical structures, that values freedom of thought and has enabled the rise of science and democracy.

    Nevertheless, I think modern society has inherited a moral burden, which can be traced back to conceptions of original sin, but has also been an influential current in modern secular philosophy, such as Kant’s idea of the conflict between duty and appetites. It seems likely that this idea makes it more difficult for people to be at peace with themselves, hence I think it is worth reflecting that it is not universal- that other societies have had different perceptions of the nature of human nature.

    Finally, the view of Hegel as an apologist for authoritarianism, although once popular, is no longer credible, and is especially curious given that for Hegel the highest aspiration was freedom.

  • Thanks for all your comments. I completely agree that one of the principal problems of this and other similar research is that ‘schizophrenia’ is a label imposed by society on a wide variety of situations and behaviours, which have nothing fundamental in common. However, in order to critique the details of the research, it is sometimes necessary to accept the labels used, and I wanted to focus on problems inherent in the analysis of the genetic data.

    On the question of drug-induced (or withdrawal-induced) mental disturbance, some psychiatrists did quite a lot of work on this, including Guy Chouniard from Canada and Ross Baldessarini from the States. Unfortunately it seems to have been largely forgotten, and the massive clinical and research implications have never been properly addressed.

  • To respond to Frank, I agree that Szasz’s views, and the whole antipsychiatry movement, have been influential in many areas, including law and humanities. In my experience their influence is fading, however, as the population has been so deluged with the idea that mental disorder is a chemical imbalance. A group of humanities lecturers I spoke to recently were amazed to hear that this is a figment of marketing, and has never been demonstrated. They thought it was scientifically proven. But to say that Szasz’s critique of psychiatry is not currently influential is not to say that it is unimportant. I think his critique was right and that it will be influential in the long-run.

    On the issue of Hippocratic medicine, I expect that it was both proto-modern and traditional. It survived, up until the 19th century, as the humoural approach to medicine, which represented a curious blend of the empirical and the mystical.

    In response to Steve, the history of psychology is also fascinating and thanks for this brief summary.

  • Excellent letter, thank you to all involved for composing it. I gave a lecture to some University academics the other day (from arts and humanities faculty), and they were shocked to hear that the chemical imbalance theory of depression has no scientific grounding. I just mention this just to illustrate how successful the marketing of the chemical imbalance has been. The general public just have no access to information debunking it, and as you point out, the media continue to propagate it. Leading psychiatrists know that the chemical imbalance theory of depression and justification for antidepressant use is unproven and ‘metaphorical.’ They do not want to challenge it publicly though because it helps to support disease-based theories of depression, which psychiatry is so fearful of losing.