Open to abuse
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 illnesses. 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, 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.
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 off-putting 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 obsession 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 millimeters 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.