Book Launch for Psychiatry Disrupted a Smashing Success

On Friday, September 12, the much anticipated book launch for Psychiatry Disrupted (Eds. Burstow, LeFrançois, and Diamond) happened.  The launch was nothing short of magnificent.  A wonderful community event, with the reality and the presence of community palpable. Approximately 120 people were in attendance--the editors, contributors, activists, artists, academics, radical professionals.  The air was filled with excitement. Indeed, you could feel a certain something in the room.  Something that uplifted and joined us to one another.  Also a sense that those of us who oppose psychiatry had inherited the moment and were unstoppable.

Tables included material from all participating activist organizations. All eight speakers were inspiring, thoughtful, and reflective.  While the entire event was uplifting, moments that particularly stand out for me were:  Ambrose Kirby as he told those assembled that the worst thing about psychiatry for the trans community is "not what you think", is not the diagnoses or the bias, but the invitation not to trust one's own body and mind.  Susan Schellenberg as she reasserted the significance of art to resistance. My keen awareness of people behind the scenes like Liam, who had risen early in the morning, and equipped with his cart, stopped in at shops around the city, making sure that there would be sufficient there for everyone to eat. Don Weitz, now his 80s, present and presiding over the CAPA table and Rebecca Ballen, going to the microphone and explaining CAPA. The card for ailing Carla MacKague that so many people signed. Brenda arriving all way from Newfoundland. A. J Withers as they carefully and brilliantly articulated a radical disability critique.

All and all, a rare event.  Thank you to the hosts--CWSE, CAPA, and McGill-Queen's University Press.  Thank you everyone who participated, and otherwise made it possible.  And thank you those who thoughtfully sent us good wishes (and yes of course, we felt you there with us in spirit)

Breaking News about Psychiatry and the Business of Madness

An important victory has just been achieved in my attempt--or more accurately, determination--to have my magnum opus--Psychiatry and the Business of Madness--make its debut to the reading public in the best way possible. What I wanted was a first rate international publisher, moreover a paperback release.  More generally,  I wanted something that would put antipsychiatry on the map in the way it has not been for years, such that it would engender a much needed societal wide conversation. And what goes along with this,  I needed it affordable (which it would not be if released in hardcover only). Given what I felt to be the importance of this book, how could I settle for less?

I turned to  Palgrave Macmillan--an excellent international publisher with outreach throughout the world.  Palgrave Macmillan was very enthusiastic, as were the researchers to whom they sent the book. The snag is, they have a policy about initially releasing scholarly books in hardcover only--a monetary issue. The long and the short is that while they offered me a contract, it was for hardcover only.  I imagined the book quickly buried.  And I was well aware that few people can afford a book such an expense--never mind the audience of psych survivors and students.  I took a deep breath. And albeit it was hard to do so, with my heart in my mouth, I  rejected the offer.   Months of negotiations followed, all of it in good faith. There were moments there where the suspense was almost unbearable. Today, the payoff came. Palgrave Macmillan wrote offering me a contract for a simultaneous paperback and hardcover release.

Within six months to a year, expect to see this book in your local bookstore, on Amazon, discussed in the press.  And do come to the book launch when it happens.

How do I understand what played out here? Let me say that to a degree I was just plain lucky for I had a highly receptive editor and in a way, the timing could not have been better.  Nonetheless, if there is a lesson to be learned here--and I suspect there is--it is to is to know the quality of your work, know the needs of your readers, and when push comes to shove, be willing to stand up for both.

A Not-to-be-Missed Conference, November 13 to November 15

Announcing the  ISEPP conference in California, November 13-November 15.  Whatever its limitations--and as is generally the case with such conferences, I would have liked to see more feminists and activists on the roster--this conference will be well worth attending. It has a number of vintage speakers who have long contributed to the critique of psychiatry.  For example, the first keynote and the opening welcome to the conference will be delivered by David Cohen, who himself needs no introduction. David has co-authored a large variety of leading books in the area, some with Breggin on the drugs, another with Kirk and Kutchins on the DSM. And then there is the wonderful researcher and ally John Read from Liverpool, who will be speaking about resistance to the paradigm shift, also, as as his norm, on evidence-based research. Read is always on top of his game and many of us have been enormously grateful to him throughout the years for the meticulous care with which he ferrets out the errors and the hoodwinking which is at the core of  psychiatric research. People will probably best know him best for the exemplary work that he has done critiquing the electroshock literature. Whitaker will be speaking on "The Guild Interest in the American Psychiatric Association", and one can always depend on him to slip in some new tidbits (incidentally, if you have not already done so, check out his multifaceted website Mad in America). Also there will be two presentations that are coming pointedly from an antipsychiatry and a left wing perspective, in the second case, a decidedly anarchist and feminist one. One is by Laura Delano, called "Reclaiming Humanity: Building a Post-Psychiatry World through Inner-Exploration, Mutual Support and Community Building". Laura is of the few mad activists that is a hundred per cent antipsychiatry--with no exceptions made. And her speech will be personal, political, and visionary. While I will not be there in person, for as many people know, my health does not permit, the other is mine. I am also one of the keynotes, and I have made a half hour video of a distinctly anarchist/feminist bent, which will debut at this conference. It is called, "Grounded Eutopianism"--Piece/Peacing Our Way Together: Toward a World with Commons and Without Psychiatry".  This will be the first time that I am presenting on my vision for the future, and it will give people a glimpse into some of the critical new directions that will emerge in my magnum opus "Psychiatry and the Business of Madness" (still in process), for it is based on the final chapter of this book. Want to find out why I spell "utopia" the way I do--as in "eutopia"?  All will be revealed in the video. For more details on the keynotes and on the conference itself, see
www.psychintegrity.org/2014_conference_info.php

Taking an Entry Point: On Investigating the Psychiatric-Psychopharmaceutical Complex

There are various ways to analyze an institution like psychiatry. One of the most common is by mining examples. You might, for example, talk to few survivors who seem to embody what befalls most folk subject to psychiatric rule (a common research sampling strategy called by the unfortunate name “typical cases”; see Patton, 2000). Or you might pen a stirring phenomenological account based on your own experiences. All, without question, highly worthwhile. A very different approach that I wish to demonstrate and would encourage other critics to consider employing now and then is choosing a single entry point—a moment where something feels wrong and which for reasons that you may not yet fathom, appears to hold the promise of helping you open up the institution—and then seeing where it can lead you. This is a part of a method known as institutional ethnography (see Smith, 2006 and Smith and Turner, 2014). For the purposes of this article, I will give a simplified version and will introduce you to the bare beginnings of an inquiry—one that I found myself falling into but a couple of weeks back. The entry point is the arrival of a letter. I choose it partly because it is helpful as a demonstration, albeit also because it indeed unlocks a direction and modus operandi that it behooves us to be aware of.

In short, I arrived at my office to find a letter from the Centre for Addiction and Mental Health (CAMH)—a huge psychiatric hospital/research institute in the centre of Toronto.   I was perplexed, for as a well known critic of CAMH and as someone who had recently forced an investigation into one of their research projects, I would have thought that I was the last person that they would want to interact with. I proceeded to open the letter. It was from the coordinator of a research project. The project was investigating the use of a “new treatment” for people ‘with anorexia” (for the letter in its entirely, see https://drive.google.com/file/d/0B39eB1GoDYuQM1RpUHFIX09NVHM/edit?usp=sharing). To quote some of the key passages, it states, “I am writing you on behave [their typo] of Dr. Allan Kaplan regarding a treatment study for anorexia nervosa. We hope that this study could be a great referral source for you and offer an important supplement to the therapy you provide.” It proceeds to say, “We offer (1) weekly visits with a psychiatrist/study physician for participants; (2) a commitment to find appropriate follow up care for participants at the completion of the study…(3) a commitment to follow up with referring clinicians to ensure continuity of care.” It ends with contact information.

Even as I started to read, I was perplexed. My immediate concern was: Why is a psychiatric research institute turning to me—a feminist therapist utterly unconnected with psychiatry, moreover, famous/infamous for organizing against it? A plausible explanation is that they had no idea who I was but had simply cobbled together a list of all therapists in the city known to work with people thought of as having “eating disorders”. As I continued reading, my perplex turned into a kind of alarm, for the words, “We hope that this study would be a great referral source for you” signals that they are hoping to use therapists as a means of recruiting people into their study. The point is, it is bad enough that studies that place people in jeopardy are being advertised on buses, on the internet, in the main media. Now they are hoping to hook people’s own counselors or therapists into “referring” them. In essence, my first discovery.

As I pondered this, as a feminist, I began to catch a whiff of a possibly formidable new assault on women (overwhelmingly, the gender diagnosed as “anorexic”). The pressing question now was: What “treatment” were they researching? My hunch was one of the psychopharmaceutical substances. I was likewise eager to know what they were actually telling people about the product being tested. In the interests of finding out more, I proceeded to call the coordinator. She confirmed that I had been contacted because I was on a list of therapists they had developed and clarified that this was a study on the use of olanzapine (better known by the brand name “Zyprexa”). “Would you like me to send you the study material?” she offered. Shortly thereafter she emailed me an article about the use of olanzapine for anorexia as well as some general advertisements for the study (not one of which mentioned olanzapine). What I did not receive, albeit I had explicitly asked for it, is the written information on olanzapine that they would be providing to prospective “participants”. I accordingly renewed my request. Her response was, “Generally [the doctor] discusses the details of the medication with the people in person if they are interested in finding out more.” (personal email, July 22, 2014) Which left me wondering if any written information is provided, if so: a) what it says and b) why they are reluctant to share it with the very people they are theorizing as a prospective referral source; and if not, why nothing is being put in writing. My own suspicion here? A couple of years ago, I forced an investigation into an ECT trial at CAMH, using as the basis for the complaint the very material that the principal investigator made public or handed to prospective participants. Now to be clear, the investigation in question, as expected, concluded that nothing wrong had happened. Given that the complaint caused the organization considerable consternation, however, one obvious possibility it is that it is now policy to put as little as possible in writing. Be that as it may, of course, this much is clear: If little or nothing is put in writing, it is very hard to prove what is being told participants—that is, whether risks are greatly minimized or indeed mentioned at all and whether the claims being made have any credibility. What goes along with this, even if judged by less critical standards, under such circumstances, the likelihood that what consent participants give will be “informed” is negligible.

Which brings us to the nature of olanzapine itself. For those unfamiliar with it, olanzapine is an atypical antipsychotic. It is approved for use with “schizophrenia” and has never been approved for use with “anorexia”. Unfortunately, nor need it be so approved, for off-label prescribing (prescribing for purposes other than those for which a drug has been approved) is legal. Now olanzapine is a particularly risky substance known to cause all the problems that typically attend antipsychotics, but in addition hypoglycemia, diabetes, and hormonal imbalance, the last of which, in turn, leads to pathological weight gain—likewise well documented (see Breggin, 2008; also postings at  http://www.lawyersandsettlements.com/lawsuit/zyprexa.html#.U90fukhPI4Y and

http://www.lawyersandsettlements.com/lawsuit/zyprexa.html#.U90fZ0hPI4Z).

The question that immediately presents itself is this: How many, if any, of these untoward effects do prospective participants hear about? And why do these researchers consider olanzapine effective for “anorexia” in the first place? And why in the larger scheme of things is this new “treatment approach” being pursued? 

The first question remains unanswered largely because the process is not transparent. I leave you to conjecture in whose interest that lack of transparency is. In an attempt to answer the last two, I proceeded to hunt for earlier studies. I also investigated what the principal investigator himself had written.

Some salient findings? In 2007, there was a pilot study on the use of olanzapine for “anorexia”. It was funded in part by Eli Lilly—the manufacturer of Zyprexa. There were also a few other small studies. This larger study itself (the topic of the letter) is predicated on those earlier studies and it is taking place at CAMH in collaboration with Columbia University and three other U.S. sites; correspondingly, what is being testing is precisely the proposition that olanzapine is efficacious with “anorexia.” Question: What makes the earlier studies sufficiently promising to warrant such a study? It is here where what is essentially fancy footwork takes place. While anxiety relief is being hypothesized, the main and only convincing finding, as seen in Attia et al. (2011, p. 5), is that “in a small group of outpatients with AN, olanzapine was associated with greater increase in BMI [Body Mass Index] than was placebo.” To put this in layman’s terms, the participants on olanzapine gained more weight than the participants on placebo. 

What is going on here? Quite simply, pathological weight gain caused by hormonal imbalance which in turn is caused by olanzapine is being repositioned as indicator of effectiveness for “anorexia”. In other words, not “normal”, note, but pathological weight gain itself is being re-packaged as successful treatment. Something not hard to do, given the worry that people naturally have about the weight loss of women diagnosed with “anorexia”.  Put aside our understandable worry about women in these circumstances—and I am in no way denying that women deemed anorexic are often in very serious trouble with themselves (see Burstow, 1992)—what we have here in effect is the patriarchal control and harming of women made to look palatable.

Exactly how far this new direction will go remains to be seen. That depends on what happens with other research studies on anorexia (note, there is more than one new “approach to anorexia” being researched at CAMH and around the world). It likewise  depends on how coopted therapists become, what propaganda is churned out with what “before and after pictures”, how much money is pumped into the marketing, and what distraught family members can be brought onside. However, it is not hard to imagine a substantial chemical onslaught on young women with eating problems ensuing.

As for the participants themselves, what is the likely fate of the women once the trial  ends? The answer is latent in the letter. The investigators promise to find “appropriate follow-up care at the completion of the study” and commit to ensuring “the continuity of care.” Translation? They will refer the women to doctors likely to keep them on the olanzapine, using among other things, the pathological weight gain (repackaged as benign) as the reason why the women should continue on the “med’.

If it is now fairly clear what is going on, also why it is a win-win for the pharmaceutical industry. Further clarity arose as I unearthed and scrutinized one other publication. In an article called “Drug Rescue and Repurposing”, Kaplan, the principal investigator of the CAMH research in question states that olanzapine is being studied for “its repurposing potential”. He goes on to explain:

Many pharmaceutical companies are moving away from developing new central nervous system drugs and psychiatric drugs in particular, due to the high costs of drug development, the absence of good animal models for psychiatric disorders, and low success rates in phase 3 clinical trials. As a result the CNS line is drying up and drug repurposing ends up an important and valuable research approach to able to develop new drugs in a cost-effective manner. (Kaplan, 2013).

Despite the use of the term “develop new drugs”, the companies, in point of fact are not in these instances “developing new drugs”, but as Kaplan puts it, “repurposing”. The very words inserted into the title of his article “Drug Rescue”, correspondingly, is an answer to my final question. The pharmaceutical companies are experiencing what they see as a challenge to their bottom line— that is, purportedly, they are in need of “rescue”. Stringent “repurposing” for drugs, whatever the type and whatever population can be theorized in relation to it, is the solution. The sacrifice of people for the greater good of the drug companies, I would add, is astonishingly close to being acknowledged.

To return to the beginning of this article and retrace our steps, we began with a letter offering what sounded like a benefit to the therapist. However, besides that as an antipsychiatry activist, I have no connection with psychiatry and so such communication is minimally an annoyance, in this instance something in particular did not “sit right”. And so instead of throwing away the letter or commenting on its “errors” or using it as an example of the type of letter that I receive from time to time, I approached it as a possibly useful entry point that could be employed to shed light on psychiatric processes. That is, I followed the different institutional threads that presented themselves. What I found initially is a lack of transparency, combined with the use of a highly dangerous drug--olanzapine. Probing further, I discovered that what recommended this off-label use of the drug was nothing less injurious than the pathological weight gain arising from hormonal disturbance. And in process, I found what may well be the beginning of a new frontal pharmaceutical assault on women diagnosed with anorexia. Finally, while of course the prevalence of “off-label” prescribing and that its purpose is to increase industry profit is well known, one related finding surfaced that is minimally less theorized: The immediate reason for “repurposing” note, is to get around not only the problem that stage 3 trials (the huge trials mandatory when attempting to bring a new drug to market) are expensive, but the at least as serious problem that they typically yield dismal results. Hence the need for what is euphemistically being termed “repurposing” and hence studies that use whatever evidence can be mustered (including ones that can reasonably be put down to harm pure and simple) to declare effectiveness. In essence, not only is this cost effective, it has the added advantage of sidestepping the entire approval process, while creating the appearance of acting responsibly. A further direction that appears to have been uncovered is the use of people’s own therapists—including private feminist therapists—to secure research participants and the practice of guaranteeing repeat customers by guaranteeing “continuity of care”.

All findings that it is important to make known. Moreover—and this takes us back to the beginning of this article—a modest demonstration of the value of employing an “entry point” approach.

A final methodological comment in ending: I stated at the outset that there was a relationship between what I was doing and institutional ethnography (IE) So was this an institutional ethnography study? No. What I did is take a few IE elements and fashion an easily accessible method available to anyone. Should this intrigue you about IE itself and should you want to know what could be done if one were actually using real IE in all its dimensions and complexity, keep reading BizOMadness (bizomadness.blogspot.ca) and Mad in America. I am in the process of training a veritable army of antipsychiatry critics in IE and so you will be hearing more about this serviceable methodology in the months and years to come. 

References

Attia, Ec. et al. (2011). Olanzapine versus placebo for anorexia nervosa. Pathological Medicine, p. 1.

Breggin, P. (2008). Brain-disabling treatments in psychiatry. New York: Springer.

Burstow, B. (1992). Radical feminist therapy: Working in the context of violence. Newbury Park: Sage.

Kaplan, A. (2013). Drug rescue and repurposing. IMS Magazine. Downloaded July 30 2014 from http://www.imsmagazine.com/drug-rescue-and-repurposing-allan-s-kaplan/.

Patton, M. (2000). Qualitative evaluation and research methods (2^nd ed.). Newbury Park: Sage.

Smith, D. (Ed.) (2006). Institutional ethnography as practice. New York: Rowan and Littlefield,

Smith, D. and Turner, S. (Eds.) (2014). Incorporating texts into institutional ethnography. Toronto: University of Toronto Press.

Breaking News: Release of Anthology Psychiatry Disrupted

Breaking News:  I have just received my editor’s/author’s copy of Psychiatry Disrupted (one of the two dates used as official release dates). Accordingly, it is my pleasure to announce the much anticipated release of the international anthology Psychiatry Disrupted: Theorizing Resistance and Crafting the (R)evolution. (Eds. Bonnie Burstow, Brenda LeFrançois, and Shaindl Diamond).  McGill/Queen’s University Press. Preface by Kate Millet, Forward by Paula Caplan.

A wonderful new addition to the fields of antipsychiatry, critical psychiatry, and mad studies. Perspectives include antipsychiatry, critical disability, anti-colonialism, feminism, queer and trans theory, anti-racism, mad theory, Marxism, and anarchism.  While previous studies have critiqued psychiatry, Psychiatry Disrupted goes beyond theorizing what is wrong with psychiatry to concretely theorizing how we might stop it.

Scholars, activists, psychiatric survivors, and artists from across Canada, the U.K., and the U.S. have come together to make this unique book possible. Contributors include Simon Adam (University of Toronto), Rosemary Barnes (University of Toronto), Peter Beresford (Brunel University), Bonnie Burstow (University of Toronto), Chris Chapman (York University), Mark Cresswell (Durham University), Shaindl Diamond (York University), Chava Finkler (Memorial University), Ambrose Kirby (therapist in private practice), Brenda A. LeFrançois (Memorial University of Newfoundland), Mick McKeown (University of Central Lancashire), Robert Menzies (Simon Fraser University), China Mills (Oxford University), Tina Minkowitz (World Network of Users and Survivors of Psychiatry), Ian Parker (University of Leicester), Susan Schellenberg (artist), Helen Spandler (University of Central Lancashire), and AJ Withers (York University).

This is a timely and courageous book that asks compelling questions that no other book in the field touches.

Stay tuned for news about the book launch, to be happening in Toronto on Friday September 12.

Consent and Psychiatry: Problematizing the Problematic

It is rare to get involved in a dialogue over psychiatry without sooner or later someone defending the use of such “treatments” as ECT “as long as they are consented to”, with the term “informed consent” periodically employed. Herein lies the context for this piece. The issue that I want to probe, to be clear, is not whether force should be used—for of course it shouldn’t—but the thorny issue of consent itself—what exactly constitutes consent and what other issues besides consent are critical to factor in when considering what it is and is not legitimate for a “medical” professional to offer.

Let me begin by suggesting that the standard framing of such issues is conceptually impoverished. Nor is the problem limited to the psychiatric arena. It is part and parcel of the dominant liberal, rationalist, individualistic notion of choice generally—which has little do with how “choice” concretely plays out in the world. The point is, despite the image that we all have of an independent person scrupulously sifting through information and carefully coming to the best position, even calmly made choices are seldom arrived at this way. Our choices and our thoughts about what is possible and best are increasingly managed by institutions, prepackaged by forces and processes outside of our view. While of course it is important to keep others in mind, we can be under considerable pressure from family or friends. And others beyond our ken have a frightening degree of “interest” in what we “decide”. Moreover, oftentimes we find ourselves forced to jump in one direction or another at moments so charged that we can barely breathe. Nowhere is this more obvious than with psychiatry.

We are at a strange moment in history. On one hand psychiatry places little value on the rights of others and is only too willing to run roughshod over them. Reinforcing this infringement way more than actually constraining it, we have a rights apparatus managed by the state which creates but the illusion of safeguarding rights—consent primarily (see Burstow, 2014). In the process of defending rights—in itself absolutely vital—meanwhile, so many of psychiatry’s critics themselves slip into acting as if consent were the only value of significance, and in the process invest themselves in this liberal conceptualization. 

The issue “in a nutshell”? It is commonplace for otherwise critical thinkers to take the position that as long as an individual “consents” to something called “a treatment”, then by definition, it is more or less unproblematic for a separate individual called “a doctor” to administer that treatment or an institution called “medical” to include it in its repertoire. Nor is it deemed relevant that the procedure being offered has no medical validity, exists only because it is in the interests of an industry, and beyond that, that it does profound damage—electroshock, for example (for literature demonstrating the lack of validity and the harm caused by ECT, see for instance, Breggin, 2007 and 1991). In some formulations (and admittedly not others), nor is it deemed significant who said what to a person just before she consented or what is likely to befall her afterward. What such a position does in essence is to at once hollow out and fetishize consent. It is as if we had substituted law for ethics and the technical for the meaningful. We have likewise conflated two very separate issues. While no one should be subjected to a “treatment” without consent, the giving of consent does not in and of itself make a “treatment” acceptable.

That noted, some questions to reflect on: If a way of being is not a “medical issue”, what happens when we call it medical? Irrespective of whether or not a “patient” consents, does a doctor have a right to offer an intervention as if it were medical when it is not? Or is it enough that his/her fellow doctors keep talking as if it were medical? Is it acceptable for what is not medical to be taken up as such, promoted, and popularized by a putative branch of  medicine? Does a doctor have a right to offer what substantially harms—and does little else? When a figure as esteemed in our society as a doctor offers a “bogus” product, is that the moral equivalent of a businessman offering it? Who benefits and who loses from that happening? Has anyone the inherent right to brain-damage another? If brain-damaging is not okay on the face of it, does “the recipient” signing on the dotted line make it okay? Is informed consent sufficient? When is “informed consent” not “informed”? Should the reason why one consents have a bearing? Or are reasons irrelevant? Should the context in which one consents have a bearing? Or are contexts irrelevant? Are we responsible only for what we force on others? Or are we also responsible for what we introduce, make available, recommend, offer?

As help in pondering such questions, correspondingly, I would introduce the following testimony by an ECT survivor (now deceased) named Chris:

I would like to speak briefly about electroshock and informed consent. Although they are inextricably linked, I will address them separately….I was hospitalized twice. I received ECT in both hospitalizations. The first hospitalization…was two courses of treatment….The second time I received one course of treatment….I was never given any information about potential risks, let alone any reliable information about the potential risks….What I was exposed to was the usual psychiatric propaganda. The sort of stuff you…hear in the media frequently. The idea that ECT saves lives. [That] ECT is now safe and effective. Is not damaging…is now safe and modern. It is as though beating someone with a plastic stick is much an improvement [over] the old wooden stick. I was shown a short video in the hospital. The video actually showed the person going through a course of being shocked....The video did not show the person awakening in the recovery room alone and disoriented….The very obvious and important thing is that blunt force trauma to the brain is not healing. Blunt force trauma to the brain is damaging….Finally on the topic of consent, I would like to say very clearly that when you are in a state of complete terror, absolute despair, and utter isolation…when you are in such great pain that suicide seems the only reasonable way to escape that pain, you cannot be said to give consent. (http://coalitionagainstpsychiatricassault.wordpress.com/articles/personal-narratives)

Implicit in this testimony is the position that giving “informed” consent to ECT is close to impossible for the “information” given is a “party-line” generated by the industry. More particularly, not only are key elements characteristically missing (e.g., that it damages the brain) but it is factually inaccurate and egregiously misleading. The same generalization, I would suggest, can be made about consent in psychiatry generally. I would quote in this regard from a comment by Mead (2014):

I for one consented to take the drugs because I was told all sorts of “facts” about biological illnesses, correction of chemical imbalance, “unmasking” etc. I was told that the drugs were “safe” and “effective” “medicine” and was rarely told about risks, particularly of permanent damage….The fact remains that I willingly embraced psychiatry because I believed it was the only rational choice — in essence, not a choice at all.

Of course one answer to the dilemma of “inadequate information” and egregious “misinformation” is that those of us with the knowledge and “fire in the belly” create and disseminate accurate information—and many are doing just that. As long as the current system prevails, it is mistake, however, to think what information we provide will be afforded the same credibility as the misinformation churned out by the system, or indeed will even be seen by the average person confronted with such a “choice”. 

What implication ought these and related conundrums hold for critics? The evolution of Dr. Peter Breggin’s position is significant in this regard. When I first started organizing against ECT, already his medical position was that there is a one-to-one ratio between the “therapeutic effect” of ECT and the damage done (see Breggin, 1979). Nonetheless, he did not take an abolitionist position. What he advocated instead is pushing psychiatry to provide better information, just as so many critics do today. This notwithstanding, he eventually shifted to an abolitionist stance on ECT. Why? The degree of damage done and his growing sense that there is little to to be gained by arguing for better information for psychiatrists are in the business of circulating misinformation among themselves (see Breggin, 1983). By the same token, with misinformation continuing and with ever more proof of the damaging effects of the various “treatments” having materialized, minimally, critics today should stop taking refuge in the concept of consent.

To be clear, I am not denying the possibility of official information materializing that is less egregiously wanting than what is provided now. Indeed, some hospitals’ consent forms are “less inadequate” than others. But the point is that no matter how improved the information became—and let’s be clear, it is going in the opposite direction—it is predictable that neither a consent form nor the verbal information provided would ever go far enough for anything resembling meaningful consent to be enacted. The point is the misinformation is being produced en masse, and it is hardly in the industry’s interest to substantially change.

I am reminded here of the article “A Model Consent Form for Psychiatric Drugs”, by Cohen and Jacobs (Cohen and Jacobs, 2000). Cohen and Jacobs did an admirable job designing a form for psychiatric drug consent, including such information as there is no proof of any mental illness, that if problems arose, the doctor would probably deny that they stemmed from the drug; moreover, they clarified the enormous likelihood of permanent impairment arising and specified the precise nature of the risk for each major class of drug. The “kicker” is, however, almost no “patient” would take a drug were it accompanied with this information, and accordingly, no such consent forms would ever figure in the official repertoire. The point is that psychiatry is built on lies and cover-ups and it has a huge vested interest in continuing both. Nor does the problem of “consent” stop here. 

Note, consent must not only be “informed”, it must be freely given. “Free and informed consent” is the precise discourse used. What we are assuming when we say that “free and informed consent” has been given is that the person has not been manipulated in any way and was able to say “no”, with no repercussion arising from this refusal other than those inherent in not taking the procedure in question. We hear these concepts in medicine proper so often that we tend not to question that they are being applied. While such an assumption misses the point in general, when this assumption is extended to psychiatry, what is left out is precisely the nature of the context. The point is that these are inherently coercive institutions, and so even if you got beyond the propaganda, and even if you are technically allowed to refuse, subtle and oftentimes not-so-subtle pressures are almost invariably and inevitably brought to bear. Take the many many women who over the years have been told that they never get well if they did not comply. Take being chided that you are being something less than a good wife to your husband if you reject “the treatment” (see Wendy’s story in Burstow, 2009). Take the change in tone, the condescending looks with which people are faced. And beyond pressure of this ilk is pressure by family and loved ones who themselves have been socialized to believe in the medical model. Such pressure may be imagined as existing on a continuum, with withdrawal of empathy and support on one end and further along, such phenomena as those experienced by Connie Neil, who accepted ECT out of a well-reasoned fear that if she did not, she might never get her baby back from her mother-in-law (see Burstow, 2006 and Phoenix Rising Collective, 1984). And then there is the pressure that comes from within, from having being told so often that you are mentally ill that you have internalized the message and in the process become your own enforcer.

The point is that consent in this arena is neither “free” nor “informed”. Nor would amassing an even larger army to oversee the consent process make it so. Ironically, indeed, in the long run all that expanding this sphere of operations would succeed in accomplishing would be augmenting the size and credibility of the institution. While it beyond the scope of this article to cover this dimension, I would add, nor do the prepackaged alternatives with which people are presented even roughly equate with what, in our deeper moments, we actually intend by the word “choice”.

Moreover, putting all this aside—which we can do only hypothetically—even were consent free and informed, and even were we convinced that real choice was involved, the question remains: Is what is happening ethical? In this regard, Chris points out quite correctly that “blunt force trauma to the brain” (inherent in ECT) is not healing and is always damaging. That said, bracket off for a moment the lack of real consent and ask yourself this: Is it ever acceptable for a medical institution to unleash such unmitigated damage on a person? Violence, however cosmeticized? To be clear, I am not suggesting that individuals do not have the right to harm themselves. Indeed we all of us do. However, doctors per se have no right to do harm—never mind to advocate for it or to call it “medicine”.  

The issue at hand, I would add, becomes still more confused when people contend that we would be interfering with someone’s right to choose by eliminating a treatment. Treatments in “real medicine” are discarded all the time as a result of an assessment of the harm caused. If it is valid as opposed to an interference with personal liberty to stop offering a  treatment because of the enormity of the harm caused when the treatment is actually medical, how much clearer this issue should be when “the treatment” is not medical. Nor is okay to pass off the non-medical as medical, regardless. Bottom line: doctors should not be in the business of introducing bogus treatments and passing them off as medical. It is likewise confused, I would add, to defend such abuse on the grounds that people need choices.

Still other dimensions come to light in Chris’s testimony—some transparently present, some lurking just beneath the surface. He states, “I would like to say very clearly that when you are in a state of complete terror, absolute despair, and utter isolation…when you are in such great pain that suicide seems the only reasonable way to escape that pain, you cannot be said to give consent.” In essence, what Chris is telling us is that he was so terrified and so alone he would have agreed to anything. Comments like this, minimally, should give us pause. As we are all painfully aware, being in such a horrible state that one would hazard anything is hardly uncommon for people in “psychiatric institutions” and/or in crisis. But does that mean that “anything” is fair game for a psychiatrist or anyone else to “offer”? Or rather, as Chris suggests, should this very vulnerability put a greater onus on others to take care in what they offer?

Chris himself states very clearly that agreement under conditions such as this cannot be called “consent”. Finally, he hints at something that I will only briefly allude to here for it is not central to my argument, albeit it is a dimension that we forget to our peril —that accepting such a treatment may be part of a suicidal wish, born precisely out of agony and despair. Again something to bear in mind.

At the very end of his testimony, Chris makes one final point. To whit:

Support and compassion do not cause brain damage. And as far as I know, no one has ever died from oversleeping.

If Chris’s main point is that consent to psychiatric “treatment” is inherently compromised, his secondary point is that it unacceptable for a doctor to perpetrate harm. This is so, I would suggest, irrespective of consent. I would remind readers here of the ancient Greek medical principle “primum non necere”—first do not harm. Also, the Hippocratic Oath, which obliges the physician to use medicine to approach disease and in the process “to do no harm” (see http://en.wikipedia.org/wiki/Primum_non_nocere). How is it that we have so strayed from the basis of the profession that we are defending the right of doctors to approach non-disease as if it were disease and to do so in a way that harms? How is it that we are conflating individual choice with what “medical practitioners” should or should not be providing?

Which brings us back to where we began.

To sum up, our prevailing conceptualizations of choice are out of keeping with our experiences as human beings. With regard to psychiatry more particularly, we have fetishized consent to such an extent that we have lost sight of ethics in a more expansive sense and the nature of consent per se. Moreover, we have trivialized hegemony and the fact of institutional rule. The point is, a liberal and individualistic notion of consent is wanting at the best of times. Beyond that, it is seriously at odds with the truth about psychiatry. When it comes to psychiatry, typically, consent is not even close to informed, is not even close to “free”. Additionally, what is far more basic, “doctors” should not be offering bogus medical “treatments, nor interventions that essentially harm—and yet such is the nature of psychiatric “choice”.

(for research, articles, and interview excerpts on these and related topics, see  other posting on http://bizomadness.blogspot.ca or follow author on twitter @BizOMadness)

References

Breggin, P. (1979). Electroshock: Its brain-disabling effects. New York: Springer.

Breggin, P. (1983). ECT ban controversy (www.breggin.com/ECT/ECTBanControversy.pdf).

Breggin, P. (1991). Electroshock: Scientific, ethical, and political issues. International Journal of Risk and Safety in Medicine, 11, 5-40.

Breggin, P. (2007). ECT damages the brain. Ethical Human Psychology and Psychiatry, 9, 83 ff.

Burstow, B. (2006). Electroshock as a form of violence against women. Violence Against Women, 12, 372-392.

Burstow, B. (2009). Electroshock: The gentleman’s way to batter women. Domestic Violence Report, 1 ff.

Burstow, B. (2014). The Consent and Capacity Board: Justice enacted (http://www.bizomadness.blogspot.ca/2014/07/as-researcher-investigating-psychiatry.html).

Cohen, D. and Jacobs, D. (2000). A model consent form for psychiatric drugs (http://laingsociety.org/colloquia/polofdiagnosis/modelconsent.htm).

Mead, E. (2014). Comment. http://www.madinamerica.com/2014/07/attrition-model-psychiatry-abolition/#comment-46145.

Phoenix Rising Collective (Ed.) (1984). Testimony on electroshock. Phoenix Rising 4 (3&4), 16A-22A.

On the Attrition Model of Psychiatry Abolition

In a recently released article I provided an overview of antipsychiatry, teasing out its features and both its overlaps with and differences from related movements and constituencies (Burstow, 2014; see http://bizomadness.blogspot.ca/2014/07/on-antipsychiatry.html). Necessarily, the commitment to psychiatry abolition emerged as definitional as well as pivotal. In this article, I will be attempting to shed further light by clarifying and probing a particular model of psychiatry abolition. The question being addressed here is: Okay, so you know what you want—but just how do you go about figuring out what to do? A question that has been plaguing the movement for some time.

A brief history: For the longest time, while antipsychiatry activists were clear about the abolitionist goal, virtually nothing was written on how to achieve it. No articulation, no models, not even, for that matter, debates—exactly. This much, nonetheless, was obvious to most: So powerful and so firmly entrenched in the state is institutional psychiatry, that it was not about to disappear any time soon, no matter how valid the reasons for discarding it, how many scandals come to light, or how astutely those who oppose it proceed. Here is a reality that left all abolitionists shaking their heads. What at once arose from and further contributed to the conundrum, antipsychiatry activists had difficulty prioritizing actions, also choosing when to actively support and when to “pass” on initiatives developed by other constituencies. It is not that there were not rationales given, sometimes cogent ones, for pursuing some paths and avoided others, but there was a lack of consistency and oftentimes choices were made on the sole basis that the action in question was one in which everyone had always engaged. As such, it gradually became clear that a decision-making model specifically geared to antipsychiatry was needed. It was in this context and with this understanding that in 2010, as a keynote at the international PsychOut Conference in Toronto, I introduced a model for prison abolition—what I call the “attrition model” (see Burstow, 2010--http://individual.utoronto.ca/psychout/papers/burstow_keynote.html). This model was subsequently adopted by Coalition Against Psychiatric Assault (CAPA). I articulate it in this article so that people can get a sense of it and assess its possible usefulness.

The model was inspired by and is loosely based on an attrition model developed in the 1970s for a neighbouring social justice movement—prison abolition. Significantly, that model to varying degrees underpins “penal abolition” to this day. The attrition model for prison abolition is predicated on two key premises: 1) that an entrenched institution like prison will not quickly disappear and so working at gradually wearing it away is the most judicious way to proceed; the issue then is to assess each potential move carefully to see if it is likely to advance things “in the right direction”; 2) one can easily be deceived over what constitutes “progress”; a change which looks like “a move in the right direction” may in fact only be further entrenching or indeed actually expanding the prison system (see Mathiesen, 1974 and Knopp, 1976). Substitute “institutional psychiatry” for “prisons”—and you can see the fit here—and an attrition model for psychiatry abolition begins to take shape.  

The attrition model for psychiatry abolition, as I have articulated it, centres on three “definitional” or “touchstone” questions which antipsychiatry activists are asked to keep firmly in mind when considering an action or direction:

1)    If successful, will the actions or campaigns that we are considering move us closer to the long-range goal of psychiatry abolition?

2)    Are they likely to avoid improving or giving added legitimacy to the current system?

3)    Do they avoid widening psychiatry’s net (creating conditions that allow psychiatry to scoop up, as it were, ever more people; see http://coalitionagainstpsychiatricassault.wordpress.com/attrition-model)?

Question one is the most fundamental of the questions asked. The purpose of asking it directly is to help activists stop themselves from getting sidetracked into focusing on otherwise benign actions and missions which in no way contribute to attrition (an example might be measures aimed at securing pocket money for people “on the inside”—a good thing in itself, but a questionable preoccupation for an abolitionist per se, given it brings us no closer to the ultimate goal.

With question two (are they likely to avoid improving or giving added legitimacy to the system?), psychiatry abolitionists more clearly part company with psychiatry reformers. The point underlying the question is that all sorts of actions, including many actively spearheaded by concerned people in related constituencies, serve to lend psychiatry legitimacy or in some way “improve psychiatry”. As such, however good the intention and whatever benefit certain people may derive (reasons why others might support them) they function to protect, support, and possibly expand psychiatry, and as such, should not be taken up by abolitionists. An example of the type of action that lends legitimacy to psychiatry is co-creating and mounting community/cultural events in concert with psychiatric institutions—festivals, theatre, celebrations. For examples of “improving psychiatry”, we need look no further than the long standing historic attempts of different players to exert a corrective influence on the DSM, arguing for the tweaking of some “diagnostic categories” or the removal of others. To be clear, I fully sympathize with people’s desire to intercede here, especially when it comes to groups uniquely oppressed by these categories. This notwithstanding, on a very basic level, even engaging in such advocacy has an unintended but unavoidable consequence: By the very act of everyone privileging the psychiatric text this way, such advocacy further ensconces the DSM as the go-to book—and as such, reinforces the centrality of psychiatry’s most formidable boss text (an institutional ethnography term; see Smith, 2005). Nor does the service to psychiatry stop here. Take the gutsy and very understandable fight to remove “homosexuality” from the DSM, which unfolded in the early 70s. While of course no one committed to social justice wants these highly oppressive definitions and categories, what in fact did this campaign succeed in doing? Making it look as if being lesbian or gay was no longer covered by “diagnoses”, when in fact new diagnoses which pathologized lesbians and gays such as “ego-dystonic homosexuality” were quickly and quietly introduced in place of the diagnosis removed (for a discussion of these diagnoses and this strategy, see Burstow, 1990); creating/recreating the classical “us-them” division, with activists involved in the campaign distinguishing between people who allegedly really were “mentally ill” and “gays” (see Teal, 1971). Moreover, it helped institutional psychiatry appear progressive—something to support. Ironically and sadly, it even proved to be a formidable factor in the ascendancy of biological psychiatry (for a discussion of how this happened, see Kirk and Kutchins, 1992 and 1997). In other words,, the consequences for the most part were decidedly negative. While it might not have been possible to predict the enormous boost this would give to biological psychiatry, the rest indeed could have been figured out—not something one can exactly expect of others, but herein lies the hard work of evaluating which abolitionists avoid at the cost of undermining their own goal. Hence the importance of taking care in assessing the likely long run impact of any action on psychiatric rule. And hence the significance of the second question.

Likewise crucial and likewise complicated is the third question: Do they [the actions being considered] avoid widening psychiatry’s net? What this guideline is inviting activists to do is avoid any action, which if successful, is likely to increase the number of people subjected to psychiatric rule. Again this is irrespective of whether or not the action is otherwise benign. Examples of initiatives, however seemingly benign, which would in point of fact “widen the net” are new services which are either performed by psychiatry or have a demonstrable tie-in with psychiatry. Think about how direly certain services are needed—services for battered women in isolated northern Canadian communities, say, or services for trans youth who have become homeless—and you can see how easy it would be to overlook or rationalize the hook-in with psychiatry which accompanies them. What this model is inviting us to look at and take seriously is this: If we make such a deal and we accept the expansion of psychiatry into some area as a necessary tradeoff in order to get “services”, whatever may or may not happen in the short run, our primary long term achievement is precisely the expansion of psychiatry, that, paradoxically, together with eventual endangerment of the very population that we were endeavouring to assist. While the expansion of psychiatry may seem like a minor hiccup or “side effect”, the point is, as with the psychiatric drugs, the “side effect” is the major effect.

Tricky though it may be at times—and you can see that it is—the long term benefits of such a model are obvious. As is evident from the examples, it would help abolitionists avoid seemingly benign actions that would preserve the status quo—or worse—that might otherwise be very easy to slip into. Moreover, the model would readily facilitate prioritization. While it is beyond the scope of this piece to spell out the various prioritizing that might emerge, for example, it could be argued that the disappearance of various noxious “treatments” has the potential to erode psychiatry, and as such, use of the model would lead to the prioritization of campaigns such as those against ECT. Other priorities that I can see emerging are the rescinding of key pieces of legislation (e.g., out-patient committal laws and involuntary “hospitalization”); the launching of law suits against “hospitals”, individual doctors, the pharmaceutical companies, moreover, the state; the curtailing of psychiatry’s “right” to “treat” without consent; and the creation of “befriending” networks independent of government and professionals (for a fuller articulation, see Burstow, 2010 and Burstow, “Psychiatry and the Business of Madness”). 

Here then is the model as I have developed it and its possible usefulness. I leave it to antipsychiatry organizations to determine for themselves if and how it might serve them. An observation: The Coalition Against Psychiatric Assault adopted this model at its 2005 retreat. It was contentious at the time and so was taken up on a trial basis only, to be reassessed in one year’s time. Come the 2006 retreat, every member to a person endorsed making its adoption permanent—so helpful had it proved in establishing direction, settling disagreements, and getting our bearings. Not that it was consulted as a matter of course, but now and again in the midst of a heated disagreement or a decision that initially seemed simple, a light would go on in someone’s eye and the person would ask, “But what about our model?”—and a unique space for thinking and planning materialized.

That noted, a few questions in ending: While the attrition model has obvious relevance to antipsychiatry activists, would this model or a modified version thereof be of any use to other constituencies who organize against psychiatry? Has it the potential, for instance, to illuminate the path of mad theorists or critical psychiatry theorists who are not abolitionists per se? Possibly, yes, though not in any easy or straight forward way. The point is that it is likely to “complexify” decisions or directions that now seem simple or obvious—in itself, a good thing—but people would need to want to take that on.  

Finally: Is attrition per se the only major factor that an abolitionist need consider? At the risk of further complicating an already complicated issue, my answer would be no. Besides that the future, while crucial to keep sight of, can never be our only concern, it is not enough to rid ourselves of psychiatry. If that is all we accomplished, psychiatry could easily be replaced by a new form of ruling that is just as powerful, that is just as all-encompassing, also—dare we imagine it?—that is every bit as damaging. Moreover, if we as a society want something better, we need to sow the seeds now.

But that is a topic for a different article.

References

Burstow, B. (1990). A history of psychiatric homophobia. Phoenix Rising, 8, S38-S39.

Burstow (2010).  The withering away of psychiatry: An attrition model for antipsychiatry (http://individual.utoronto.ca/psychout/papers/burstow_keynote.html).

Burstow, B. (2014). On antipsychiatry. http://bizomadness.blogspot.ca/2014/07/on-antipsychiatry.html).

Kirk, S. and Kutchins, H. (1992). The selling of the DSM. New Brunswick, New Jersey: Transaction Publishers.

Kirk, S. and Kutchins, H. (1997). Making us crazy. New York: The Free Press.

Knopp, F. (1976). Instead of prisons: A handbook for prison abolitionists. New York: Prison Research Educational Project.

Mathiesen, T. (1974).The politics of abolition. New York: Halstead Press.

Smith, D. (2005). Institutional ethnography: A sociology for people. Toronto: University of Toronto Press.

Tiel, D. (1971). The gay militants. New York: Stein and Day.