Controversies in psychiatric practice
The very nature of psychiatric practice lays it open to potential misuse and abuse. It involves a highly unequal power relationship with very dependent and vulnerable patients whose opinions and complaints can so easily be dismissed as ‘part of the illness’. Add to this the subjective nature of a diagnostic process which relies on psychiatrists’ assessments of the patient’s motives and mental state with no visible markers for diseases. The history of psychiatry doesn’t inspire that much confidence either. There have been shameful episodes of political abuse, some hare-brained theories, and treatments that appear to us both dangerous and barbaric. The very visibility of modern-day psychiatry (out from behind the institutions’ walls), plus a well informed public and a willingness to admit if things go wrong, is probably the greatest safeguard against such abuses. Psychiatry is also, thankfully, fully engaged in the worldwide movement of scientific, evidence-based medicine – facts and figures take precedence over authority and opinion. So while we focus in this chapter on what it can get wrong, let’s not forget that it more often gets it right and that progress has been substantial.
In the public imagination the greatest risk of psychiatric abuse comes from its immense power. The evil psychiatrist is portrayed in films manipulating the minds of his victim for his own ends, taking pleasure in subjugating the distressed and suggestible. Hannibal Lecter in Silence of the Lambs is one such – immensely skilled at reading his victim’s mind and using that power to trap and exploit them. In other films psychiatrists develop megalomaniacal delusions of using their power to rule the world.
There have been cases where this has happened on a small scale–where psychiatrists, convinced of their own infallibility, have wreaked havoc. Experiments with altering gender identity to confirm that it was socially determined is an extreme example, the mutilation of hundreds of individuals in a craze to remove sources of infection in teeth and bowels that were deemed the cause of mental illness and the wholesale use of lobotomy in the 1940s and early 1950s are others. However most of psychiatry’s excesses have stemmed from the very opposite, from psychiatrists’ sense of impotence and frustration turning to ever more desperate interventions to help tormented patients.
This dynamic is changing. Professions are no longer so powerful and independent. Deference and respect for authority are under global attack. The current risks in psychiatric practice may come less from professional isolation and arrogance than from social compliance. Monitoring psychiatrists may be only half of the job – we need to keep a wary eye on the other powerful players (multinational drug companies, governments, pressure groups) who can manipulate psychiatry. This is a diffuse and changing subject so what follows is just indicative.
Like all of medicine, psychiatry’s history includes what now appear dangerous and even barbaric treatments. Before being too critical think what it must have been to live at a time when early and sudden death was a constant threat and excruciating pain had to be endured, often for weeks and months on end. There were few certainties and even fewer effective treatments. What doctors were willing to do two centuries ago, and what patients were prepared to endure, have to be judged against quite different standards. Folk treatment of the mad was also far from gentle, despite our tendency to romanticize pre-industrial societies. Disabled individuals were often accepted and occasionally revered but the more disturbed were often excluded (which could mean death) or mistreated as witches or such like.
Early psychiatrists used the standard medical treatments of their time including bleeding, purging, and cupping (attaching hot cups to the back to ‘draw out’ toxins). The early asylums moved away from these, emphasizing moral treatments (Chapter 2), although various desperate measures were tried to calm ‘furiously’ agitated patients. These included cold baths (still used well into the 20th century) and a series of ingenious devices which worked by simply exhausting the patient, such as the notorious ‘whirling chair’. However, the major sins of the asylum era were those of neglect – restraint rather than attention, undignified and humiliating conditions rather than active abuse.
Long-term fluctuating illnesses are particularly prone to accumulate far-fetched theories and treatments. This is a mixture of desperation and pure chance (an illness may simply recover just when some irrelevant treatment is being used). There was a vogue for removing otherwise healthy organs in the mentally ill in the late 19th century because they were thought to be the site of ‘sepsis’ (low grade infection). Thousands of healthy teeth and tonsils were removed and even large parts of the bowel. In Trenton State Hospital, New Jersey, Dr Henry Cotton championed this approach right up until his death in 1933 (including taking out all the teeth from his own two sons and even subjecting one to an abdominal operation). These treatments were controversial but still supported by distinguished psychiatric figures.
12. Whirling chair: one of the many devices developed to ‘calm’ overexcited patients by exhausting them
13. William Norris chained in Bedlam, in 1814
The Hawthorn effect
A complicating factor is that the fuss and attention surrounding treatments can make a real difference even if the treatment itself is ineffective. This was shown with insulin coma treatment. Insulin had been long used in psychiatry to stimulate appetite and calm agitated patients (who could otherwise literally starve to death). A course of insulin comas was believed to be effective in schizophrenia and this became a common treatment from the 1930s through to the 1960s. It was a potentially dangerous treatment requiring skilled and attentive nursing – if the coma went too deep the patient could die. It was the first psychiatric treatment subject to a controlled trial to establish its effect. Half the patients were put into a light sleep using tranquillizers and half into an insulin coma, without the staff knowing which was which. The results were the same for both groups, forcing the conclusion that it was the nursing attention and hope inspired by the treatment that made the difference, not the insulin. The treatment was abandoned. This effect is known as the ‘Hawthorn’ effect and psychiatric research always has to account for enthusiasm.
Enthusiasm shouldn’t be written off in psychiatry. Much of medicine may be best conducted in a dispassionate, scientific frame of mind but psychiatry requires hope and optimism from its staff. Patients have so often lost hope and need help regaining it. Hope is therapeutic in its own right as the insulin coma study indicated. Many studies have confirmed that optimism makes a difference to outcome (even in cancer patients). It can, however, lead to over-enthusiasm and treatments, including effective treatments, being given well beyond their indications.
Electro convulsive therapy and brain surgery
ECT was certainly overused after it was introduced in the 1930s right through to the 1960s. It continued to be used in schizophrenia and for disturbed behaviour although it had become clear that its main effect is in depression. The original treatments were given without anaesthetic. Ostensibly to ‘treat’ disturbed behaviour, its application, and the threat of it, was undoubtedly sometimes misused as punishment. Sensationalist and misleading portrayals, such as the unmodified ECT given to Jack Nicholson in One Flew Over the Cuckoo’s Nest, continued to fan the controversy.
In many countries ECT is almost impossible to obtain in public psychiatry – in Italy and Greece and Spain for instance and in California in the US. In England and several US states a ban has been proposed several times but not legislated. Some of this is undoubtedly because of its earlier overuse – many of its fiercest critics are people who received it inappropriately without benefit. However, even for those who support it, there is something very offputting about it. It seems such a ‘crude’ assault on that most delicate and important of our organs, the brain. ECT is experienced as an affront to our nature as creative and sentient beings – particularly so as we really do not know how it works. It is vigorously opposed by groups such as the Church of Scientology.
Even more shocking than the overuse of ECT was the crusade of brain surgery conducted by Watts and Freeman in the early 1950s in the US. Brain surgery in psychiatry followed the observation of a freak accident in a Pittsburgh steel mill where a foreman, Phineas Gage, survived a bar passing through his head. The only damage noted was some change in personality – he became more easy-going (but also a bit more disinhibited and foul-mouthed). Severing the connections to the front part of the brain (where the bar had passed) was tried as a last-ditch attempt to reduce intolerable chronic anxiety or disturbed behaviour. It is called leucotomy in Europe and lobotomy in the US and was introduced by a Portuguese psychiatrist Egon Moniz in 1935. He received the Nobel Prize for it in 1949 and, in an ironic twist of fate, was shot dead by a disgruntled patient in 1955.
Psychosurgery probably can help a very limited group of individuals absolutely disabled with severe obsessive compulsive disorder or chronic depression. It appears to work by making the patient uninterested in their symptoms, rather than abolishing them. The patient experiences the obsessional thoughts but doesn’t ruminate on them and is able to ignore them. There are changes in personality with the operation – the patient is said to become somewhat ‘blunted’.
Brain surgery evokes the same disquiet as ECT. It seems altogether too invasive and brutal. The explanation of how it works is superficial and unconvincing. Freeman and Watts developed a very simple version of the operation that only required a local anaesthetic. Playing down the risks, they travelled across the US carrying out thousands of these operations in large mental hospitals. Between 1939 and 1951 over 50,000 such operations were performed in the US, 3,439 by Freeman alone. Modern techniques are very different (usually involving the destruction of a couple of cubic millimetres of brain tissue) and highly regulated. Only a couple of dozen operations a year are conducted in the UK and the same number in the US. Nevertheless it remains a highly charged issue and one where people rarely change their opinions.
Political abuse in psychiatry
Psychiatry has always had twin obligations – care for the individual patient and protection of society. This ‘social control’ aspect has to be weighed carefully against individual rights, especially in compulsory treatment. The balance remains a hotly debated issue in most countries. The vastly differing psychiatric care offered to blacks in South Africa under apartheid and in the US Southern States during segregation has often been characterized as political abuse. Similarly the high rate of compulsory detention of ethnic minority patients (particularly blacks of African and Caribbean origin) in England has been cited as an intolerance of different cultures that borders on the repressive. This is probably ‘politics with a small p’. Inequitable access to care is a characteristic of many health care systems. It may be inexcusable but it is hardly a deliberate policy aimed at persecuting a specific group.
The use of psychiatry explicitly to repress or silence dissident political opinions in the former Soviet Union was, however, conscious persecution. The Soviets used a diagnosis of ‘sluggish schizophrenia’; meaning withdrawal and strangeness which developed slowly without positive symptoms (hallucinations, thought disorder, etc.). Sluggish schizophrenia was used to detain people with dissident political views who opposed the state but demonstrated no clear signs of mental illness. Of course some mentally ill individuals do oppose the state which they believe is persecuting them. The Soviets incarcerated vast numbers of clearly healthy individuals in their forensic psychiatric clinics. This was a scandal that has seriously damaged psychiatry’s credibility (particularly in Central and Eastern Europe).
One positive outcome of the Soviet psychiatric abuses was the development of an international movement within psychiatry to challenge such practices. United Nations and Red Cross organizations regularly visit and monitor prisons and detention centres throughout the world and now routinely include mental hospitals in their work. China has recently had to submit to international scrutiny over its dealings with the Falun Gong sect. International awareness provides the strongest protection against political abuse.
Psychiatry unlimited: a diagnosis for everything
Psychiatry has moved centre stage in public health. Four mental illnesses rank in the World Health Organization’s top ten global causes of lifelong disability. Depression is currently number two and predicted to be the number one by 2020. Forty-four million Americans have been treated for depression. Is this good news or bad news? It could be a long-overdue recognition of the burden of mental illness as reduced stigma improves detection and recording (and presumably treatment and recovery). Alternatively, it could be that modern living and an ageing population is associated with greater stresses and more mental illnesses. However, rates for established severe mental illnesses such as schizophrenia and bipolar disorder appear static.
Could the rise in mental illness be illusory? Are there other factors at play and could psychiatry go astray if we don’t keep an eye on them? Psychiatry operates now in vastly different circumstances from those in which it originated. Medicine enters the 21st century well equipped to detect and control the failings of the early 20th century (professional arrogance and ignorance). Current risks may, however, stem more from psychiatrists unwittingly acting out the agendas of others (as Foucault has insisted they always have). Who else has an agenda?
Psychiatric diagnoses arise in a dialogue between patient and doctor. The patient offers his concerns and the psychiatrist tests these against the range of illnesses he or she knows. Both parties in this exchange can influence the threshold for what is ‘psychiatric’. How do we as individuals interpret our experiences? What do we just accept (even if unpleasant and difficult) and what do we consider unacceptable, worthy of reporting and needing help? We seek help much more readily now and seek it from professionals where previously we might have put up with it or turned to friends and relatives. Anxieties over child-rearing, disappointments in relationships, bereavement, and distress after trauma – all are now considered legitimate territory for psychiatric assessment and possible intervention.
Society has rejected the stiff upper lip and embraced psychology and psychotherapy. It has become immeasurably more tolerant and decent as a result. Our emotions and inner life are taken seriously, we are expected to share them and ‘understand our feelings’. Consequently we seek help with understanding them and relief from them if they become unbearable.
These changes have led to an enormous rise in demand for counselling and psychotherapy and also for antidepressants and medications to reduce anxiety. Of the antidepressants prescribed in the UK 96 per cent are prescribed by family doctors. Most of these are for individuals who will never see a psychiatrist and many who would hardly have been considered unwell a generation earlier. This is not all a bad thing – many patients benefit from these treatments. But there are risks. As treatment thresholds get lower there is less risk that patients who need treatment will be neglected but an increased risk that others who won’t benefit do get treatments. Relying on medicines for relief may also inhibit us exploring alternative strategies. Persisting with an unhappy marriage and hoping that the pills will make it better is not a sensible long-term strategy. Similarly our expectations change imperceptibly and personal resilience may be eroded.
Treatments we seek from psychiatrists may even make us worse. Excessive prescription of valium and other sedatives led to an epidemic of dependence which proved enormously difficult to reverse. Some studies indicate that routine counselling after severe road traffic accidents or after stillbirths may slow down recovery, not just not help. Perhaps some experiences are best simply put behind one and forgotten. In natural disasters, providing counselling may distract energy and resources from the promotion of self-help and social cohesion.
There is a growing unease about the relationship of the medical profession with the companies which research, manufacture and sell the drugs we use. The cost of developing a prescription drug in the US is estimated at $800,000,000. So the pharmaceutical industry is increasingly concentrated in a small group of immensely powerful multinational businesses. The statistics are staggering. It takes on average up to 10 years from isolating and patenting a molecule, through tests and trials to its first routine prescriptions to patients. Only 1 per cent of new molecules make it from test tube to prescription. The research and development budget is consequently enormous. That of Pfizer (the largest pharmaceutical company in 2005) is greater than the whole national research budget of some European states.
Not surprising then that the marketing of these drugs is ruthless. The financial relationships between doctors and these companies are murky. Over half of all educational meetings for psychiatrists in the US are funded by pharmaceutical companies and luxurious hospitality and travel are routinely offered to doctors as barely concealed inducement for them to prescribe. Until recently psychiatry was immune from this as our drugs cost so little. However the new generation antipsychotics and antidepressants are vastly more expensive (newer ‘atypical’ antipsychotics cost $2000–$3,000 a year per patient in the US compared to $100–$200 or less for the older drugs; newer antidepressants also cost several hundred dollars a year as opposed to ‘pennies’ for the old antidepressants such as tofranil and amitryptiline). The patent on a new drug is strictly time limited and the companies have to recoup all their development costs usually within 10–15 years from launch. With the financial muscle of the pharmaceutical companies brought to bear on the profession it is hardly surprising that social and psychological interventions (which have no such financial backing) have a lower profile.
‘Big Pharma’ has been accused of stretching the boundaries of what are treatable psychiatric disorders to increase the sales of its drugs. It has been accused of creating a need for its drugs rather than developing drugs for existing needs. The enormous success of prozac has lead to an expansion of the concept of clinical depression. Milder and milder cases get treated. Prozac’s iconic status has helped reduce stigma against depression but has made it a ‘lifestyle’ drug. Most university students will know class-mates on antidepressants – inconceivable only a generation ago. Diagnostic patterns have changed in response to the marketing of these drugs. There has been a striking increase in the diagnosis of disorders such as PTSD (post-traumatic stress disorder) and social phobia (a disorder which some would consider just extreme shyness) since drugs have been licensed to treat them.
Even more worrying is the massive growth in psychiatric prescribing for children. Once a rarity, child psychiatrists now regularly prescribe psychotropic drugs for children. The most dramatic increase has been in the diagnosis and treatment of ADHD (attention deficit hyperactivity disorder): 7 per cent of US schoolchildren are diagnosed with ADHD (one in ten boys as they are three times more likely to be diagnosed), with half of these on stimulant drugs.
The prescribing of ritalin (methylphenidate) increased sixfold in the 1990s in the US and accounts for 85 per cent of world prescriptions but Europe is rapidly catching up (150,000 prescriptions in the UK in 2002). Child psychiatrists insist that the diagnosis is made carefully and that drugs are used only after psychological treatments have been tried but the figures simply don’t stack up. Irrespective of the controversy about the legitimacy of the diagnosis, there can be little doubt that this is an example of psychiatric practice being rushed by commercial agendas.
Before leaving the pharmaceutical industry we need to acknowledge its very positive contribution to human health and welfare. It would be naïve to ignore the financial imperatives that flow from such staggering R&D costs and to profess surprise at the marketing practices. The dramatic increase in both its scale and power, however, raises ethical problems which are not restricted to psychiatry. They include the exploitation of poorer countries for research where ethical standards may be less strict and where the patients in their trials may never have the resources to benefit from the drugs developed. The temptation to create spurious health needs to sell products is particularly potent in the psychological sphere as almost everyone would like to ‘feel a bit better’. Honest debate and tighter guidelines are needed.
Reliability versus validity
Diagnosis in psychiatry has moved towards a criterion-based system (see the diagnostic criteria for depression in Chapter 1). The traditional approach of pattern recognition and reflective empathy informed by extensive familiarity with normal and abnormal behaviours has been replaced by a process of carefully listing features of the disorder that are present. The change was a response to unacceptable variations in diagnostic practice. The new diagnostic system (laid out in the Diagnostic and Statistical Manual – DSM III, now DSM IV) also strove to avoid relying on the psychiatric theories which had caused such conflicts in the past. Whether one really can have an entirely ‘atheoretical’ diagnostic system is, of course, open to debate.
The new system emphasizes reliability (i.e. ensuring that different psychiatrists faced with the same symptoms will always come to the same diagnosis) more than it does validity (i.e. ensuring that patients with a particular diagnosis will have similar outcomes and responses to treatment). The goal would be, of course, maximal reliability and maximal validity. Good reliability does not, however, necessarily guarantee good validity. The fact that we all agree on the defining characteristics doesn’t mean it really is ‘something’. For example, 17th-century witch-finders were very reliable – they all agreed on the tell-tale signs and so consistently agreed on who was a witch before they burnt her. We would not now say that they had really ‘identified’ a witch, because we don’t believe in them, but their methods were certainly very reliable.
Reliability can mistakenly imply validity so that a condition gets accorded the status of a diagnosis essentially because psychiatrists can agree on how to define and recognize it. I have already mentioned a couple of these controversial diagnoses – social phobia and ADHD – but there are several more which really stretch credibility. Nicotine and caffeine ‘use disorders’ are now both official psychiatric disorders, but few of us would consider these mental illnesses. Similarly there is a range of behavioural patterns which have acquired the highly questionable status of a diagnosis (and therefore may receive ‘treatment’). An example is adolescent ‘oppositional defiant disorder’, which is suspiciously close to the description of a difficult teenager who simply refuses to do what his parents want.
Psychiatrists on the whole are trusting souls. They tend to take their patients’ stories at face value. This was vividly demonstrated by the psychologist David L. Rosenham’s famous study, ‘Being Sane in Insane Places’. In 1973 he got eight volunteers to go to emergency rooms in America complaining of a voice in their head which said ‘empty’, ‘hollow’, or ‘thud’. All eight were admitted to psychiatric units where they then behaved absolutely normally. The most amazing thing was that they stayed in hospital for an average of just under three weeks each before they were discharged. Even worse, most of them got a diagnosis on discharge of ‘schizophrenia in remission’. Not surprising then that there is such a call for reliability.
So there are several forces acting on psychiatry (including the natural curiosity of researchers) which threaten continued expansion. Whether this is a desirable development is one that should not be left to the profession alone to decide but requires debate within the broader society (i.e. you).
Personality problems and addictions
Psychiatrists have always dealt with the consequences of drug and alcohol addictions. They have also always recognized that there are groups of individuals whose personalities are markedly abnormal and can cause endless problems. The degree of human misery associated with these problems is beyond dispute, and such
DSM IV Diagnostic criteria for Oppositional Defiant Disorder
A. A pattern of negativistic, hostile, and defiant behaviour lasting at least 6 months, during which four (or more) of the following are present:
often loses temper
often argues with adults
often actively defies or refuses to comply with adults’ requests or rules
often deliberately annoys people
often blames others for his or her mistakes or misbehaviour
is often touchy or easily annoyed by others
is often angry and resentful
is often spiteful or vindictive
Note: consider a criterion met only if the behaviour occurs more frequently than is typically observed in individuals of comparable age and developmental level.
B. The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning.
C. The behaviours do not occur exclusively during the course of a Psychotic or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
individuals are found in large numbers in mental health services. There are, however, strong arguments for and against whether these are primarily psychiatric disorders and whether psychiatrists should be responsible for treating them. This is no simple academic argument that could allow both sides to just make individual decisions that suit them. People with these problems may be, and are, treated against their wishes.
Coercion in psychiatry
Compulsory treatment is permitted in psychiatry in every society – including Western societies whose very founding principles are respect for individual liberty before the law. This very striking exception stems from the observation that during periods of illness an individual’s judgement is impaired and they are not able to make rational decisions; mental illnesses often involve a ‘break’ with normal functioning and a change that estranges the patient from their normal self. Unlike, for instance, a learning disability where the individual may also not be able to make informed and rational decisions because they have never developed the capacity, the striking characteristic of mental illnesses is the change. Most societies have sanctioned a paternalistic provision for coercive treatment from a humane desire to protect an individual who is clearly ‘not themselves’. This resolve is strengthened by the repeated observation that patients recover and express the same concerns as the rest of us about their behaviour when unwell. Many are even grateful that they were forcibly treated.
Lawyers find these areas difficult. The standard assessment of ‘capacity’ to make treatment decisions (the ability to understand the information, the ability to trust the individual giving the information, and the ability to retain and make a decision based on that information) works well for children, the learning disabled, and those with dementia. However, it doesn’t work well where the problem is one of judgement and mood rather than intellectual ability. Imposing treatment against a patient’s will rests ultimately on the psychiatrist’s conclusion that the patient is suffering from a mental illness such that their current decisions are not those they would usually express. Note that this involves the psychiatrist making a judgement on what he believes that the patient would usually do or want when well. Compulsion is also sometimes used as a brief safety measure with people who are ‘temporarily unbalanced’ – a terrified individual in a strange place or young people attempting to kill or harm themselves in despair after a relationship break-up.
Severe personality disorders
Psychiatry’s attitude to psychopathic and antisocial personality disorder usually in men, and borderline personality disorder, usually in women, presents ethical and conceptual concerns. Psychopaths are cold, callous individuals who lack empathy for others and consequently can commit awful crimes. They give no thought to the consequences for others and show no remorse afterwards. They are often recognizable early on (death of pets, arson, etc.). Being self-centred and not caring about others’ feelings they can be extremely successful; it is jokingly proposed that mild psychopathy is an essential for being a successful politician. Psychopaths are often lumped together with explosive and violent individuals as antisocial personality disorder. This group is a massive problem for the prisons and criminal justice system.
In some countries psychiatrists detain these individuals under the same conditions as the mentally ill and this has been criticized as an abuse of power. Compulsory treatment is justified mainly by the belief that the patient is not making the decisions that they would normally make and which they will make again after recovery. To warrant coercion the condition is usually time-limited and it is believed with some confidence that the treatment will speed recovery. None of these conditions are met for severe personality disorders. Their behaviour reflects their personality – their real identity; they are not aberrant or temporary, and to date there is no convincing evidence that forced treatments will significantly change them.
Such people pose profound challenges for society. They have often committed serious sexual and violent crimes and it is obvious to prison staff that, as little has changed, they will offend again. In England they are labelled as having a dangerous severe personality disorder (DSPD) and highly staffed new units have been built to treat them. But is their potentially indefinite detention by psychiatrists (as opposed to a prison sentence when they break the law) any less an abuse than the detention of political prisoners in the Soviet system was? The humanitarian sentiments of those involved do not remove the ethical dilemma.
The Western world has experienced an upsurge in chaotic selfdamaging behaviour in young women. Overdosing and cutting have become common features of female inmates of mental hospitals and prisons. Patients seem out of control, are clearly distressed, and damage themselves in what often seems like a mixture of anger and a desperate plea for help. Psychiatrists feel responsible but impotent and often try to ‘contain’ the situation by keeping the patient compulsorily on a ward offering supervision and support. Unfortunately things may go from bad to worse – the patient selfharms more and the psychiatrist increases the restrictions to control the situation. A vociferous pressure group argues that what these women do to their bodies is their own affair and psychiatry is overstepping the mark in treating them against their will. They point to the cultural precedents for self-mutilation (religious and ritual scarring are common in many societies) and underline how medicine, and psychiatry in particular, has consistently denied women’s self-determination over their own bodies.
Drug and alcohol abuse
A similar set of arguments holds for drug and alcohol abuse. Both can be associated with mental illness and both can also cause mental illnesses. Fine for psychiatry to be involved then. But are drug or alcohol abuse mental illnesses in themselves? The rebranding of addictions as illnesses was a humanitarian impulse in the 1940s after the founding of Alcoholics Anonymous in 1939, to provide help to detoxify addicted individuals and support sobriety. The world’s largest self-help groups (Alcoholics Anonymous, AA, and Narcotics Anonymous, NA) both consider addiction a lifelong illness, although they rely on personal and spiritual support rather than medical treatment.
AA and NA view the addict as fundamentally different from other individuals, never able to use drugs or alcohol sensibly. Within psychiatry, however, there are divided views. Many view addiction as an illness to be treated like any other mental disorder. Others see drug and alcohol abuse as dangerous habits that can lead to mental illnesses but are not themselves illnesses, and ultimately are the responsibility of the individuals themselves. The medicalization of substance abuse is criticized as a distraction from effective public health measures such as raising the price and restricting access. Both of the latter have been shown to reduce drinking and drink-related illnesses and deaths.
Offering help such as prescribing medicines to cope with withdrawal and support to build up a sober lifestyle are uncontroversial. Concerns arise from the use of compulsion which is common to a limited degree in most countries. In much of Scandinavia, Eastern Europe, and Russia, however, there has been extensive use of specialized mental hospitals for longer term detention and treatment of alcoholics and drug addicts. Can this be justified? The consequences of heavy drinking or drug abuse can undoubtedly be disastrous, even fatal. But many of us make foolish decisions and suffer the consequences – smoking is probably more dangerous than drinking but we don’t compulsorily treat smokers. The confused thinking and poor judgement when intoxicated is also a questionable justification for psychiatric intervention as the express purpose of becoming intoxicated is to alter judgements by blurring an unattractive reality.
Increasing sophistication in genetics and epidemiology has helped identify those who are at greater risk of alcoholism and drug abuse. There are well recognized ethnic variations in the ability to tolerate and metabolize alcohol. These findings strengthen the contention that these are not simply personal choices but disorders, much in the same way that schizophrenia is a disorder – we just don’t yet know as much about it as we do about schizophrenia. Some even propose that self-destructive drinking and drug use must be the result of a mental illness. Clearly the issue is still open and psychiatric engagement with drug and alcohol abusing patients will continue to attract some controversy.
The insanity defence
The coercion controversies in psychiatry are about unfairly depriving individuals of their rights. An important motive in early mental health legislation, however, was to protect patients from being punished for crimes they committed when unwell. Society has always felt uncomfortable about such punishments. The crime of infanticide was distinguished from murder because 19th-century juries refused to convict and send to the hangman mothers who killed their babies while suffering post-partum psychoses.
The importance of establishing criminal intent (‘mens rea’ or ‘guilty mind’) has guaranteed a long and tortured relationship between psychiatrists and the courts. Agreeing whether or not someone was insane at the time of the crime (i.e. unable to judge the significance of their acts and realize that they were wrong) has in principle been fairly straightforward. However it is often far from easy in the individual case. Similarly floridly ill patients, unable fully to understand what is going on in court, may be judged unfit to plead and admitted to hospital for treatment. Most countries will accept the decision of unfit to plead on the basis of a psychiatric assessment or will return a not-guilty verdict on the grounds of insanity.
The real problems in court concern diminished responsibility on the grounds of mental illness – particularly where the criminal behaviour itself is the clearest manifestation of the disorder. It is less a problem with a grossly disturbed individual whose crime is just one among many signs of the illness (such as a manic patient in court for reckless driving but who also at that time is not sleeping, dressing in outrageous clothes, and spending all his money). Proposing personality disorders as a defence (i.e. because a psychopath does not notice or care about the distress caused) strikes at the concept of free will and personal responsibility that is the very foundation of criminal justice systems. Most criminals have had dreadful childhoods. Many have been abused. Few have skilled jobs or stable families to fall back upon. So it is not surprising that we may temper justice with mercy. But is there not a circularity in citing the very qualities that give rise to the crime as an excuse for a reduced punishment? This ethical dilemma is particularly sharp in individuals with Asperger’s syndrome (a mild form of autism) who cannot see the world from the other’s perspective and cannot interpret others’ motives even though they may desperately want to.
In practice the more serious the crime and the greater the risk, the easier the decision. Where the alternative to a guilty verdict and prison is hospital care (and sometimes secure hospital care) courts and juries feel more comfortable to make the allowance. In lesser cases, where punishment is not so severe, and might just deter a repetition, it is argued that a psychiatric defence is unjustified and probably does the individual no favours in the long term. Thomas Szasz (Chapter 5) insists that the psychiatric defence is a denial of the fundamental rights and obligations of the individual. A psychiatric defence is generally accepted for individuals where the disorder is plainly there for all to see.
Sometimes the only evidence of a disorder is the crime. There have been several high-profile cases of murder where the perpetrator denies any memory, claiming it occurred during an ‘automatism’ (a dream-like or dissociated state). In even more extreme cases ‘multiple personalities’ have been proposed where a single individual has several fully developed identities, each completely independent of each other. This is a very attractive concept which captures the popular imagination (e.g. Robert Louis Stevenson’s 1885 novel Dr Jekyll and Mr Hyde, and the 1957 film The Three Faces of Eve).
The postulated mechanism is that some mental functioning is so successfully repressed that it is only accessible through deep psychotherapy or ‘triggered’ in highly specific situations. This is of enormous psychiatric/legal significance in cases of alleged childhood sexual abuse. The extent to which children are exposed to sexual abuse by family members has long been controversial in psychiatry. The pendulum has swung back and forth between considering it a common trauma that causes neuroses to the alternative belief that it is rare and most reports are ‘false memories’ arising from current distress and confusion. Currently the presumption is in favour of believing the adult who complains of child sexual abuse. This has resulted in high-profile cases splitting families when ‘recovered memories’ have been unearthed. Psychiatrists appear on both sides of the case, stressing either the damaging impact of abuse, repressed over many years, or, conversely, the patient’s suggestibility in over-enthusiastic therapy.
Psychiatry: a controversial practice
Psychiatric practice will probably always be risky and controversial. Many psychiatrists argue for a more limited approach, restricting it to clearly identifiable and agreed mental illnesses: ‘We should stick to treating diagnosed illnesses, schizophrenia, anorexia nervosa, depression and accept that there are many other causes of human distress beyond mental illness.’ ‘We should leave the social policy and ethics to the politicians and philosophers.’ This is an attractive argument. The history of psychiatry is full of examples of overstepping the mark. But as we have seen in this chapter it is not simply up to the psychiatrists – there are other stakeholders and powerful forces at play with broad ethical issues and significant potential benefits in the balance.
Scientific developments are expanding what we can do; families and patients have steadily rising expectations from us; governments and the pharmaceutical industry challenge us with new demands, inducements, and opportunities. We could only possibly avoid controversy and the risk of potential mistakes if we turned our back on progress and innovation. But that means not fulfilling either psychiatry’s promise or its obligations. Straddling hard science and the field of human behaviour and ambitions, it is simply impossible for psychiatry to be uncontroversial. It comes with the territory and, as we are about to explore in Chapter 7, may be getting worse.