Brooke at Bittershack linked to this essay by mental health attorney Nils Riis with admiration. Now, do I just have a blindspot as a defensive psychiatrist, or is it the kind of overblown us-vs.-them diatribe someone writes just to be politically correct and pitifully self-righteous? Sentiment like this was important, true, necessary and moving to all of us in 1962 when Kesey wrote One Flew Over the Cuckoo’s Nest. But especially if Riis is a mental health advocate attorney it would be fitting forty years later for him to show some recognition that, although the legal process is adversarial, the psychiatrists and other mental health personnel caring for the psychiatrically distressed are by and large not the enemy but concerned helping professionals. Except as a literary conceit.

The ‘eagle’ character in this piece is in fact a dangerous caricature of the mentally-ill-as-romantic-hero right out of R.D. Laing and the antipsychiatry movement of the ’60’s. I know, I was there, as an ‘antipsychiatric’ psychiatric ward attendant long before I went to medical school and became a psychiatrist, clutching my volume of Laing and doing my best to convince the patients that their peer-to-peer work with me was much more important than cooperating with their psychiatrist. Both phases of my career have been equally passionate commitments to the rights and welfare of the psychiatrically ill; my thinking has just gotten abit more sophisticated and realistic and less misguided along the way. (Isn’t it usually true that there’s no scorn like that of a religious convert for the doctrine from which s/he has converted?)

Laing was a genius in phenomenological description of the inner world of the schizophrenic and humanizing him or her as a distressed-One-of-Us (rather than the Other we often make our mentally ill to be in this society); I still use Laing’s 1959 The Divided Self as an unsurpassed depiction of the disease in my teaching of medical students and residents. Fine to champion resistance to stigmatization and dehumanization… but he lost me when he started to proclaim that the process of the breakdown, the psychotic episode, should not be interrupted by treatment because it represented some sort of heroic struggle to remake oneself by breaking free of the mold of the oppressive socialization paradigm of modern society. He forgot his own phenomenological insights about the unbearable suffering psychotic patients undergo, a torment that caregivers have an obligation to relieve and need considerable specialized training and technique — both psychological and psychopharmacological — to address effectively. Laing descended into irrelevancy and, ultimately, it appears, madness himself.

Riis tries to sound like Laing, or his similarly overboard American counterpart Thomas Szasz, as he goes on,

Outside the hospital, my clients face troubles far more challenging than the ones inside their heads. There is stigma, of course, often compounded by the crippling effects of poverty. There is the growing sense that the public needs protection from people with mental health problems. There are economic policies that brush aside the people who struggle hardest in day-to-day life. There is environmental degradation, the postmodern religion of unsustainable growth, consumption, and production.

Hey buddy, work for peace, social justice, human dignity, basic economic equity, environmental protection all you like. Subvert the dominant paradigm that generation by generation perfects its relentless ability to empty lives of meaning. But do a different kind of good work inside the mental hospital, one that is collaborative rather than polarizing against all those good mental health professionals working for the same ideals. Most of us in the mental health field are passionately committed to the civil rights and human dignity of our patients — unfeeling people primarily motivated in career choice to amass power, glory or riches don’t go into the psychiatric field, believe it or not — and have welcomed the advances in mental health and involuntary commitment statutes that make your diatribe little more than an unreal caricature. The troubles your clients face outside the hospital are emphatically not “far more challenging than the ones inside their heads”, except maybe the challenge of being made figureheads for the ignorant (even if, as I’ll grant you is possible, well-intentioned), misguided and self-serving agendas of people like you, Riis. Among the patient rights for which you should be advocating is their right to relief from the unimaginably tormenting and not at all romantic suffering of their psychiatric conditions.Your patients are not simply people who chose to crow in imitation of a bird of prey in a public place, no matter how loudly. There are all sorts of arbitrary social oppression and intolerance of deviance in modern society, but the mental health field in western society is not a tool of social oppression or even conformity. (There is, by the way, a less histrionic, considerable body of scholarly work within sociology and social psychology which attempts to see ‘madness’ as a result of social labelling or attribution. But, at the risk of making a blanket dismissal, I’ll make a blanket dismissal. It doesn’t work.)

As the superintendent of my psychiatric hospital and a treater of patients with the most severe mental illnesses of psychotic extent, I frequently testify at commitment hearings to keep people in the hospital when they present an imminent risk (to themselves or others around them or are so substantially impaired by their illness as to be incapable of caring for themselves in a less restrictive setting) and no recognition of their need to seek help to avert such harm. Ethically, I buy into this degree of paternalism when it is strictly based on substantial imminent risk; barring potential to harm someone, people have a right to be mentally ill, to refuse treatment, and live their lives unimpeded, and in such cases I facilitate their rapid release from the hospital in accordance with their wishes. Those that need to be committed, however, are represented or assisted at such a hearing by an attorney, usually court-appointed. The best of these attorneys know that their obligation to do what is best for their patients means being a thoughtful, supportive facilitator of their clients’ collaboration with their hospital caregivers. The worst, like Riis would probably be if I ever faced him in a courtroom, would be cutting off their clients’ noses to spite their faces, insisting on their clients’ release at all cost.

This AdBusters “Prozac spotlight” goes on, if you click the arrow down at the bottom and continue to surf, with a disclaimer. The author, he says, is not being critical of the people who work in mental health, who ‘take care of the rejects,’ ‘after all, somebody’s got to’. He boldly proclaims himself to be ‘attacking the theories of psychiatry’ instead. This is either naive or somewhat disingenuous or both, since there is perhaps less separation in psychiatry than any other healthcare discipline between theory and practice. They configure each other in a dialectical relationship shaped by the empirical experiences of thoughtful and responsible practitioners.

Moving along, we come to a long, yellow-journalism rewarming of the old stories about antidepressant-induced suicide and violence and the wrongful death lawsuits against the pharmaceutical manufacturers which have ensued. It is full of the same half-truths, poorly designed research, and irresponsible unwarranted conclusions about which I have written before. Modern antipsychiatrists have reacted with glee to the discovery of akathisia, the syndrome of agitation and restlessness various psychiatric medications can cause. Not the root of all evil, but a side effect for prescribers to be aware of and manage conscientiously. There are very few free lunches; most therpeutically useful medications, throughout medicine, have costs as well as benefits.

Finally, AdBusters assembles a useful collection of ‘mad movement’ resources that empower, dignify and support ‘survivors’, refuseniks, outsiders… and prideful lunatics.’

Note to Brooke: Whatever the depths of your clearly ambivalent feelings about your own treatment (about which you are quite candid), I fear they color your reading of Riis’ piece, which really has very little if anything to say about antidepressants or the ‘walking wounded’ depressed patients, who are even less victims of psychiatric oppression than hospital-level patients with psychotic illnesses. I agree when you write —

“The truth is, we need the drugs to be available, and they often do work temporary miracles, and that is not a minor truth. But they are not the end, only the means. They are the life-preserver in the moment of near-drowning. They are not a substitute for swimming lessons.”

In fact, I think I said much the same down below in reacting at length to last week’s New York Times piece on new antidepressant developments. And I write often here in disgust about the industrialization of psychiatry and the commodification of prescribing. But Riis, Laing, Szasz, and the otherwise perspicacious AdBusters (to which I’m a subscriber and longtime contributor, admiring and joining in their fight against ‘mental pollution’) should not be your champions on this issue…

Thanks to mark wood, here’s a more realistic view of what you get when you fight to release the patients from the psychiatric hospital — Fighting the Demons on $930 a Month by Ted Schrecker:

Imagine A psychiatric hospital in which accommodation is often unclean and sometimes unsafe; violence against patients by people just passing through is common; patients are left largely on their own to feed (or not feed) themselves; and some cannot afford the medications that enable them to function.

Even in these hardened times, the existence of such a hospital would be considered a scandal. Nevertheless, many Canadians must fight the demons of serious mental illness under precisely such conditions — no longer in hospital, but now in that abstraction called “the community.”… Toronto Star