Excerpts from Psychiatry and the Business of Madness

Introduction to the Study: Unveiling the Problematic


Mrs. Packard's Resistance


Psychiatric Drugs and the Approval Process


"Treatment," "Consent," and "Informed Consent"

 

Introduction to the Study: Unveiling the Problematic

Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive….The robber baron’s cupidity may sometimes sleep…but those who torment us for our own good torment us without end for they do so with the approval of their own conscience….To be ‘cured’ against one’s will and cured of states that we may not regard as disease is to be put on a level with those who have never reached the age of reason and those who never will. (C.S. Lewis, 1970, p. 292)

This is a study of psychiatry. It is a study of an area officially a branch of medicine and overwhelmingly seen as legitimate, benign, progressive, and effective. That psychiatry is typically so viewed is readily apparent and may seem a “no-brainer”. Doctors specialize in it. It is covered by our health insurance, overseen by ministries of health. A high percentage of the population uses its treatments. People encourage their loved ones to consult a psychiatrist when encountering “personal problems”. And the media routinely report its “discoveries” and “improvements”, much as they report “breakthroughs” in the treatment of cancer. But what if society had it wrong? What if this were not legitimate medicine? What if psychiatry’s fundamental tenets and conceptualizations were inherently faulty? Indeed, what if—despite some helpful practitioners—it does far more harm than good? Such is the position of this book. While on the face of it, that position may sound bizarre, it is important to note that for decades now scholars have indeed demonstrated fundamental and overwhelming problems both with the treatments and with the underlying conceptualizations (see, for example, Szasz, 2001, Breggin, 1991a, and Woolfolk, 2001). Correspondingly, unlike with any other branch of medicine, there is a long standing international movement (largely comprised of folk which it has allegedly served) protesting most everything about it. 

While I no way dispute the very real abyss of agony and confusion into which human beings sink, nor the enormous importance of support, what makes this book a challenge is that it invites the reader to take an about-turn, or minimally, to hold in abeyance the seemingly indisputable truths about psychiatry that they may have taken for granted all their lives—that whatever its shortcomings, for instance, it is benign and scientifically valid. I ask you more fundamentally to be open to questioning the very concept of mental illness on which psychiatry rests—a counterintuitive thing to do given that mental illness appears to be all around us—in the rambling of the street person, on billboards, in hospitals, and as such, seems as real as the air we breathe. What is involved here, to be clear, is revisiting what seems to be cut-and-dry, stepping outside the circle of certainty that has bit by bit been built up around this institution, and daring to rethink.

This is a foundational study, a critical archeology, as it were.  The ultimate purpose of the study is to awaken and to disturb. Not an easy task for in part psychiatry has the power that it does precisely because it is reassuring, in other words, precisely because we do not wish to be “disturbed”. We want to know that the people whose being-in-the-world particularly trouble us are elsewhere or are someone else’s problem. At the same time, we want to know that there are creditable people with answers—and on the surface minimally, who could be more credible than the people entrusted with the health of society? We want to know that our ways of life are reasonable. We want to know that both those who strike us insane and those who just need a “tune-up” can be helped, that there are concrete and discrete diseases at the root of the misery that people face, that we as a civilization have progressed tremendously, that there are now expert, enlightened, and indeed humane solutions to human unhappiness, misery, and confusion.

Fear, of course, underlies much of this need for comforting answers. While we may have trouble accessing this level, on a deep level, to varying degrees, it is ourselves that we fear; and it is reassuring that there are experts at hand that can keep us from losing our grip. We may also be authentically frightened and wanting to protect people dear to us who are in obvious distress. The medical paradigm in this regard acts like a metaphoric tranquilizer in its own right. Behind the medical language and commitment lies a deep-seated angst. We fear the subterranean parts of ourselves—the part that thinks or acts in ways that appear out of step; we fear for those close to us, all the more so if they strike us as vulnerable. In the process, we essentially “other” what does not strike us as rational, as “okay,” as “normal”. Correspondingly, we fear the “other”, the person who is not like us, or who we fervently pray is not like us. If the person is uttering words that we cannot wrap our minds around, if they are muttering to themselves, if their appearance is decisively outside our comfort zone, we are especially likely to surmise that they present a danger to the community and “need” to be under control. Except where they are our loved ones—and often not even here, for note, it is kin who most commonly turn to psychiatry—the compassion that we often feel in the process generally does not alter this judgment, for we are convinced, indeed are continually primed to be convinced, that such measures are for their own good.

This depiction, of course, over-generalizes for the purpose of making a point. Without question, there are many people—kin, fellow survivors, even relative strangers—who struggle authentically to help distressed or distressing others irrespective of their own position on psychiatry. More to the point, there are some—myself included—who view psychiatry differently. Throughout the world, nonetheless, though most especially in the west, there has been a huge acceptance of psychiatry. Country after country has mental health laws, has places of detention called “mental hospitals”. Correspondingly, the general populace speaks readily of “mental illness”, of “schizophrenia”. The buy-in, in other words, is enormous. From the vantage point of this book, that is the bad news.

The good news is, however profound the buy-in, there are fissures in most people’s acceptance of psychiatry, and these can be seen in the everyday world. Take those moments that come upon us unaware. Occasionally when watching a television program, we witness a fictional judge responding to the testimony of a fictional “mental health expert” with a degree of ridicule, maybe a touch of irony, and without necessarily intending to do so, we begin to nod in acknowledgment. We may be concerned by how cloudy our next door neighbour’s thoughts have become since starting Prozac and find ourselves expressing the thought that some people are “overmedicated”. Even some medical model psychiatrists (psychiatrists who believe that biological abnormities underlie what they call “mental disorders”) exhibit such doubt. That is, while regarding old standbys like “schizophrenia” as unquestionable—for it seems impossible to question the legitimacy of this category—there are medical model psychiatrists themselves who are uncomfortable with several of the “disorders”, moreover who express dismay over how readily “distress” is conflated with “disorder” (see, for example, Horowitz, 2002). Herein lies the beginning of critique. That we all have such glimpses, or to put it another way, that we all experience such moments of disjuncture, I would add, are important for they are a base from which to proceed. Moreover, it is urgent that they be attended to, for as researchers such as Whitaker (2010) have amply demonstrated, we are facing a virtual epidemic of iatrogenic diseases (diseases caused by medicine, in this case, by psychiatry); the alleged progress in which society takes comfort is dubious; indeed, we have allowed something which is arguably highly problematic even on a small scale to mushroom out of control; and as members of society, we have reason to be concerned.

The Focus of this Book

The business/institution of psychiatry is the focus of this book. By this I mean not only psychiatry as a discipline and profession per se, albeit that is most focal. I mean all that surrounds it, make it possible. Insofar as they facilitate the work of psychiatry, I include here the various apparatuses of the state—courts, mental health laws, ministries which provide funding, mechanisms of enforcement, mechanisms of oversight. I include industries which feed it and which are in turn fed by it, such as the pharmaceutical industry, the medical research industry. I include the army of professionals that contribute to the work of psychiatry—nurses, doctors, social workers, psychologists, caseworkers, academic researchers, occupational therapists, policemen. While it most assuredly is not focal, for the work involved is typically contractual and largely of a different order, naturally I include as well the branch of psychiatry known as psychoanalysis, but only peripherally—that is, only to the extent which it is part of, buys into, depends on, or contributes to the work of the larger institution. The question is, how are we to understand this institution? How does it work? What is it genus? Its nature?

Mrs. Packard's Resistance

Mrs. Packard was confined for years in Jacksonville State Mental Hospital at the behest of her husband Reverend Packard as a consequence of religious differences. She herself astutely notes that the most modern control mechanism was simply being used against her, that had this drama played out a couple of centuries earlier, she would have been turned over to the Inquisition (see Packard, 1865/1974). Correspondingly, after being confined a second time (this time in her own home), she initiates a writ of habeas corpus—a landmark act often cited as the beginning of the patients’ rights movement. I leave you with examples of the two competing discourses involved in the skirmish—that of the psychiatrist who testified against Mrs. Packard and her own reflection.
At the trial which ensues the psychiatrist Dr. J. W. Brown testifies as follows:

I have written down in order, the reasons I had, to found my opinion on, that she was insane…. 1) that she claimed to be in advance of the age of 30 or 40 years; 2) that she disliked being called insane; 3) that she pronounced me a copperhead….4) an incoherence of thought….5) her aversion to the doctrine of the total depravity of man; 6) her claim to perfection or near perfection in action and conduct; 7) her aversion to be called insane; 8) her feeling toward her husband; 9) her belief that to call her insane and abuse her was blasphemy against the Holy Ghost; 10) her explanation of this idea; 11) incoherence of thought and idea; 12) her extreme aversion to the doctrine of the total depravity of mankind. (see Packard 1865/1974, p. 130 ff.)

Ignore the muddled repetition, and the main thrust of the argument is that Mrs. Packard is crazy because she finds Dr. Brown stupid; because he himself is unable to follow her logic; because she dares to disagree with her husband; because she respects herself and insists on respect; because she does not accept the doctrine of the total depravity of man. While I am in no way claiming that most people in Mrs. Packard’s situation are as reasonable and articulate as her or that all psychiatrists are so obvious in their deficiencies, I ask the reader to contrast these confused utterances with the clarity and good sense evident in this statement by the soon to be victorious Mrs. Packard:

It has always been my fortune…to be a pioneer…therefore I am called crazy….I freely accord to…my enemies the right of opinion in believing me to be an insane person and so long as these opinions do not lead them to trespass against my inalienable rights, I have no right or desire to interfere with them….But since my opinion is as dear to me as those of my enemies are to them and since we have no right to do wrong, therefore, when the opinions of my enemies lead them to kidnap my accountability, by placing me on a level with beasts for opinion’s sake merely, the law of self-defense compels me to resist. (Packard, p. 17)

Telling, I would add, that it took a travesty this obvious for the woman to prevail.

Psychiatric Drugs and the Approval Process

Insofar as the drug in question is a new product and the pharmaceutical company wishes to bring it to market, typically, the process begins with tests on animals (see top of Figure 7.1). The human studies that follow form the start of the approval part of the process. They are randomized trials (subjects are randomly assigned to either the treatment group or the control group); they are double blind (neither subject nor researcher knows to which group a subject has been assigned; and they include use of placebo (more or less sugar pills) and often contrast drugs (drugs for the “condition” already on the market).  The aim is to establish that the product being tested is more effective than placebo and than products already on the market, to demonstrate this, moreover, at the level of statistical significance—the accepted gold standard in scientific research. Correspondingly, it is to satisfy the regulators that there are no significant adverse effects (commonly known as “side effects”).

An abbreviated walk through the process: As you can see if you glance at the top of the diagram, the trials per se are conducted by the third parties. And initially, many such trials are conducted. The trials generally last 4-6 weeks. The data thereby generated is submitted to the drug company. The drug company proceeds to analyze it. It typically picks two or three studies to present to the regulatory body (bottom part of diagram). “Presenting to the regulatory body” means: creating and submitting a summary report (bottom of diagram); releasing other data as required; and providing a provisional draft of the label (the information insert, which includes such items as side effects and warnings).

On first blush, this may seem like a credible process. After all, third parties—not the pharmaceutical companies directly—are conducting the trials. And a government oversight body is empowered to accept or refuse. Even before we delve further, however, worrisome factors are evident. Note, in this regard, the drug company gets to choose which trials to present—a setup, as it were, for “cherry-picking”. Correspondingly, the trials are designed by the pharmaceuticals themselves. Moreover, analysis happens in the office of the pharmaceutical companies. What further contaminates the process, the putative third parties are in the hire of the drug companies and are likely to do the bidding of the drug company if they want to keep receiving lucrative contracts (for details on these dynamics, see Healy, 2012, Moncrieff, 2009, and Breggin, 2008a and 2008b). As you can see from the diagram, moreover, when it comes to the trials per se, the drug companies are hardly at arm’s length. Information is at all times traveling back and forth, which means that strategic new instructions can be delivered at any point. Additionally, findings that prove problematic for the drug company can be reworked at any time—and routinely are. Lilly’s instructions to its investigators on how to deal with adverse effects serves as an indicator of how deep this control goes and how it can skewer results. In a Prozac trial, Eli Lilly, note, instructed its investigators to code all evidence of drug-related adverse effects as symptoms of the original depression (for verification and details, see Breggin, 2008b, p. 389 ff.). If such blatant tinkering “crosses the line”, what “crosses the line”, as shall become progressively evident, is nothing more or less than the standard process edged one stage further.

To put a marker here—and we will return to the issue of process shortly—hypothetically, a flawed process can be “cleaned up”. What cannot be cleaned up are faulty foundations. And ipso facto, faulty foundations means untrustworthy results. Moreover, they will likely interact in manifold ways with whatever conflicts of interest exist. This brings us to the methodological foundation of the research itself.

Evidence-based Research

These trials claim to credibility is they constitute “evidence-based research”. Evidence-based research is precisely empirical research involving randomized double-blind trials and use of control group (there are two general kinds of control groups here, ones given a placebo and ones given a contrast psychopharmacological substance). Correspondingly, results are established at level of statistical significance. The attempt is to show that the substance being tested is effective—indeed, more effective than other substances on the market—and to rule out placebo effects (translation: benign effects which happen independently of the chemistry).

On the face of it, the “evidence-based research” protocol would appear to offer an appreciable measure of protection against manipulation as well as error. Randomization of subjects is an established safeguard against skewed results. The epitome of what is seen as constituting sound science—use of placebos—gives us reason to believe that it is actually the product or process being investigated that produces the changes in question. Correspondingly, having statistical significance as the standard appears to guarantee that the findings are “rock solid”, are beyond anecdote, are generalizable. By the same token, having the research double-blind” ostensibly safeguards against not only deliberate manipulation but such unintended skewing as happens with the placebo effect. As such, the foundations would appear to be sound.

An initial caveat: As Healy (2012) documents, the drug companies themselves are among the major proponents of “evidence-based research”. This, of course, hardly invalidates the use of such concepts and standards. At the same time, given what we already know about the pharmaceutical industry, the fact that the industry has come to uniformly embrace and tout them is a development that should give us pause. While I would not wish to overstate the significance of this, the reader is likewise reminded that these concepts were employed by the psychiatric residents (interviewees) referenced in Chapter Six, and in those instances, the allusion to evidence-based research served as a means of sidestepping analysis entirely. That noted, the question arises: What are we to make of the discourse, of the measures, of the use to which it is being put?

To start with what looks unassailable, the use of placebo groups and of double blind studies seems utterly unproblematic—that is, if the situation were truly double blind. Herein lies our first disjuncture. The reality is, given that the drugs have recognizable effects (pronounced sedation, for example) and given that the placebo used has none, both subject and investigator are likely to know within hours to which of these groups she has been assigned. As such, we appear to be dealing with appearance only—not carefully constructed research as normally understood. Other elements of the standard design likewise minimally raise questions: What is achieved by large randomized trials that last four to six weeks only? What exactly does the achieving of statistical significance demonstrate? And why are drug effects being divided up between two categories—the effect being measured (inherent in the concept “effectiveness”) and “adverse reactions”? As we probe these questions, the credibility of the process begins to evaporate while at the same time, the institutional manufacture of findings comes into view.

Significantly, effects which take time to develop, such as tardive dyskinesia, would never appear in four-to-six week trials (for a detailed discussion of “tardive dyskinesia”, see Breggin, 2008b, pp. 55-68). Nor indeed would most other dire effects. Short trials in this regard serve to invisibilize inconvenient facts. Creation of randomized short trials and the concomitant valorizing of the process as the “gold standard”, correspondingly, avoids the unfortunate discoveries that might be made by tracking individuals over an extended period. In this regard, I would invite the reader to compare short placebo-involved trials based on statistical significance to the once common physician practice “challenge, dechallenge, and rechallenge”. The latter works as follows: A physician who wishes to ascertain what effect a drug has on a patient administers said drug to the patient, observes what happens, (challenge) takes the patient off it, notes what now transpires (dechallenge); places the patient back on the substance to see if the “effects” return (rechallenge). Real observation, the real work of  “figuring out” is happening here. Which method is superior, as Healy (2012, p. 72) suggests, depends on what you are looking for. Be that as it may, the downgrading of such procedures as something less than “evidence-based research” and the concomitant sidestepping of direct observation and retests creates a space for arbitrary, mechanically produced, and manipulated numbers to replace the evidence of the senses, common sense, and genuine analysis.

An equally formidable problem emerges with the practice of dividing the impact of the drugs between the “effectiveness” category (which relates only to the effects sought) and “adverse reactions” (essentially, “side effects”). Albeit this is fairly standard in medicine—so much so that we do not blink an eye at it—it begs the question. Quite simply, “side effect” is not a property in nature, not a quality of the drug per se, but a social construct. What the artificial division accomplishes is to define some effects as inherently primary, others inherently secondary, in the process, privileging one side of the equation—not coincidentally, the side that culminates in increased pharmaceutical profits. Now there may at times be a legitimate reason to use such a conception in medicine proper where, for instance, the “effect” being sought demonstrably addresses an underlying imbalance. By contrast, with psychoactive drugs (and with these, note, there is no proven condition, no imbalance), use of such distinctions is misleading. It functions to create the appearance of a disease, while illegitimately downplaying both the reality and the importance of the “undesirable” effects. In the process, there is an equivocation on the concept of the drug “working”— itself a discursive product. Question: Exactly what does “work” mean? If a substance only minimally produces benign effects while producing lamentable effects in abundance, additionally, if those minor benign effects have nothing to do with a presumptive therapeutic action of the drug, by what standards can one claim that the drug “works”? Add the fetishization of statistical significance to the mix and the scene is set for making certain effects appear and others disappear. Herein we see the trickiness of the statistical significance measures.

The point is, include enough people in a study and use advantageous measuring criteria, generally, you can easily construct some minor degree of “effectiveness”. Note, if you have hundreds or thousands of subjects—and as Moncreiff (2009) reminds us, huge multisite trials are now the norm—a trivial degree of effectiveness over placebo suffices to reach the level of “statistical significance”. It does not even matter if in your combined trials, placebo outperforms the drug, for you need only present two trials to the oversight agency, and naturally, you present the ones in which “statistical significance” are “established”. The drug thereby becomes officially effective and acceptable. This is so even if all of the following pertain: the difference in effectiveness is so small as to be inconsequential; for all intents and purposes, the placebo results in substantially less “adverse reactions”; and what counts as effective has nothing to do with the putative “therapeutic action” of the drug. Conversely, by the power of numbers, you can make highly worrisome “adverse reactions” disappear.

"Treatment," "Consent," and "Informed Consent"

Most everyone on the inside is administered treatment—a frightening reality given the truth about the treatments already in evidence. Technically, protection is provided by virtue of the consent criteria in the HCCA (see beginning of this chapter). Note, the “incapable” person or their substitute decision-maker may refuse the treatment. Moreover, consent must be informed—that is, states the Act, the person must be told:

1.    The nature of the treatment
2.    The expected benefits of the treatment
3.    The material risks of the treatment
4.    The material side effect of the treatment
5.    Alternative courses of action
6.    The consequences of not having the action. (HCCA. s. 12, 3)

Given what is on the face of it good criteria, the question arises: how is that most everyone on the inside is on such demonstrably harmful “treatments”? There are several answers to this question.

The first relates to the problematic conceptualization of capacity. As already noted, it is defined in such a way that the person who sees a treatment as unacceptable is at the bare minimum in enormous jeopardy of being “found” incapable (more on this issue later). A related problem is the current conflation between involuntary admission and incapacity. More fundamental still—and it is time to tackle this—is the proverbial “elephant in the room”—the quality and quantity of the “information” provided.

We have already seen how flawed the official claims about the treatments are, beginning with the research underpinning them. Insofar as people are given “information”, predictably, it is precisely the misinformation that we have seen manufactured (see Chapter Three)—for that is official. Moreover, as interviewee after interviewee observed, generally, but slim “information” is provided. To whit:

Bonnie: What did the psychiatrist tell you about the ECT?
Mel: Just that it is good for me.
Bonnie: Were they any more specific?  Did they go through any benefits and risks?
Mel: No. Just take the electroshock, he said, and you’ll feel better. (interview data)

Correspondingly, being offered no alternative (violation of criterion 5) is not unusual.  A case in point:

Bonnie: You are saying that was the only treatment offered?
Steve: That’s right.
Becca: So daddy, no one suggested any form of talk therapy?
Steve: No.
Bonnie: Or psychiatric drugs?
Steve: Absolutely nothing but ECT was offered.

By the same token, in the extensive four-day-long public hearings into psychiatric treatments held in Toronto City Hall in 2005, overwhelmingly, recipients testified that they were told virtually nothing. They were simply advised that their prognosis would be poor otherwise, in some cases, with information about the diagnosis similarly withheld (for the testimony in question, see Inquiry into Psychiatry, 2005). Note Tim’s story:

Tim’s father was killed by a drunk driver. Overwhelmed, Tim was admitted to a psychiatric facility. There he was diagnosed with PTSD and placed on a medley of psychiatric drugs. At the time, he was totally compliant. Upon getting out, he remained compliant. He proceeded about his life, slipping in and out of hospitals. With significant complications later arising, he subsequently laid charges and demanded and received a copy of what proved to be a very telling report. “Then and only then,” observes Tim:

did I realize that I was actually diagnosed with schizophrenia. Now I disagreed with the diagnosis. Nonetheless at no time was I told of this second diagnosis. The doctor who diagnosed me with that told me that I was being medicated for posttraumatic stress disorder. He didn’t inform me at any time that those drugs had a “withdrawal”….Because he chose not to inform me, at no time was my treatment consensual….There’s no one to watch the doctors. There is no one to force them to inform anything and because they hold the level of credibility they do, there is no one to challenge them. 

Tim’s words shed further light on how people “choose” to take the “treatment” proffered. Factor in an inherently coercive environment where people are scared to appear non-compliant, where additionally, they cannot keep up what is being thrown at them (or are too exhausted or confused by the psychiatric drugs currently on to make sense of anything presented to them), and you begin to get a picture of how consent comes about. 

Finally, I would factor in the allusive but formidable institutional ethnography dimension. Consider in this regard the following clause in CAMH’s ECT Consent Form (which a prospective recipient is asked to sign):

The nature of the procedure, its risks and benefits and those of alternative available treatments have been explained to be by Dr.________________ and I understand them. All of my questions regarding this procedure have been answered. (Centre for Addictions and Mental Health, no date).

On the face of it, such clauses are exactly what we might hope for—something that reassures us that all necessary care is being taken. That, however, is to confuse “avowed intention” with “institutional function”. The point is, by mirroring, even exceeding the HCCA requirement, this form effectively turns the giving of the mandated information into a legal fact. Whatever your intention, successfully induce a “patient” to sign this form and by definition, she has been “adequately informed”. Sign this form, additionally, and a sequence of institutional events begin to unfold: The nurse slips it into the chart, the doctor orders an assistant to schedule the procedure, and the treatment date is set.
Question: Has the patient truly received the extensive information mandated?

Significantly, asking such a question is not part of protocol. That understood, were one concerned, one obvious safeguard would be replicating the information on the form itself. Significantly, not only is the information as a whole not replicated therein, nowhere on this form does one find any concrete information—not even a single instance of a “risk”.  In IE terms, the words are empty shells. The fact that the “patient” signs such statements is itself an indicator of how institutionalized patients become. Not surprisingly, several interviewees who spoke of the dearth of information had signed forms precisely like this.

While some jurisdictions are a bit better, some worse, essentially, such is consent as it plays out institutionally—demonstrably, a manufactured product. Everyone does their job, and in the process, what is typically a hollow “informed consent” is “accomplished”.