1. There are phenomena that people experience within their own mental life that are often life-denying at a minimum, life-destroying as a maximum. Please do not interpret anything else that I say here as in any way denying this first and most basic truth. My issue is all to do with a) how these phenomena are understood and b) how those who have to endure them are treated, both by ‘professionals’ and by wider society.
2. There is no such thing as ‘mental illness’. There are physical illnesses that have mental symptoms (eg Alzheimers). To describe the phenomena of thesis #1 as ‘mental illness’ is to wrongly apply a form of language (‘illness’ and ‘disease’) from one area of life to a different area of life. It is a category error, a philosophical mistake. That it is a mistake with a vast apparatus of the state and capitalist industry supporting it does not make it true.
3. The language of modern professional psychiatric care – as best summarised in the risible DSM (see this, which I think is brilliant) – is a perfect example of a Kuhnian paradigm which is overdue for being overthrown. In just the same way that the Copernican paradigm eventually couldn’t cope with all the epicycles that had to be introduced as a result of telescopic observations, we are not far from the time when contemporary psychiatric understandings will collapse under the weight of its own inadequacy and contradictions.
4. Pharmaceutical drugs do not work in terms of curing the phenomena of thesis #1. They do have benefit in terms of the placebo effect (which I do not see as trivial) and in terms of stabilising a volatile situation, ie they can suppress symptoms. Put simply they are a tool of social management. They do not heal people; at worst the side effects simply increase the phenomena of #1.
5. We cannot understand the phenomena of thesis #1 by looking at individuals in isolation but only as human beings embedded within a particular community and context. The phenomena of thesis #1 are inescapably social.
6. It is in the interests of the state that those who exhibit disorderly or otherwise unwelcome behaviour are pacified and controlled. Any full understanding of the phenomena of thesis #1 needs to have abandoned political naïvete.
7. It is in the interests of the pharmaceutical industry that there be new diagnoses of new forms of disorder, which thereby justify the creation of new drugs with new patents that form new income streams for those companies when old patents expire. Any full understanding of the phenomena of thesis #1 needs to have abandoned commercial naïvete.
8. The philosophical roots of contemporary psychiatric care lie in atheism and materialism – in other words, it proceeds on the assumption that there is no such thing as the soul.
to be with the freakshow
language of demons and angels
human centred care
taking the soul seriously
it is possible that the greatest failure of Western churches in the twentieth century is that they have capitulated to the psycho-complex. If we are unable to cure souls, then what on earth is the point of us?
Judging by some recent headlines it would seem that the controversy over antidepressants has been resolved. On February 21 2018 the medical journal The Lancet published on-line a study (Cipriani et al, 2018 – hereafter, ‘The Cipriani study’) containing a meta-analysis of antidepressants, with a view to “compare and rank antidepressants for the acute treatment of adults with unipolar major depressive disorder”.
The Cipriani study was a meta-analysis of other studies. That is, it was a statistical exercise at one remove from clinical experience, concerned to gather as much information as possible from a diverse range of studies (this is a well established and respected form of analysis for seeking more robust conclusions than can be gathered from any single study).
Nearly thirty thousand citations were identified and from these some 522 trials were considered in the meta-analysis, covering nearly 117,000 patients. These trials were those which covered antidepressant use, comparing antidepressant use with placebo or an alternative antidepressant, where there was “a primary diagnosis of major depressive disorder according to standard operationalised diagnostic criteria”.
The Cipriani study concluded: “the findings from this network meta-analysis represent the most comprehensive currently available evidence base to guide the initial choice about pharmacological treatment for acute major depressive disorder in adults” and that “All antidepressants were more efficacious than placebo in adults with major depressive disorder.”
This gave rise to some remarkable headlines and reporting in the national press. The Guardian newspaper, for example, headlined their discussion of the paper with the headline “The drugs do work: antidepressants are effective, study shows.”
I believe that we need to be a great deal more cautious than those journalists. To begin with, it is worth making note of the claims actually made in the Cipriani study itself. The authors of the Cipriani study claim that they provide information for the initial (not the long-term) choice of medication (as opposed to non-drug treatments) for those with acute major depressive disorder (not all depressed patients) in adults (not children). Furthermore, the authors acknowledge that the short-term benefits of antidepressants “are, on average, modest”; that the long-term effects of antidepressant use are “understudied”; that there is “paucity of knowledge about how antidepressants work”; and that “the certainty of evidence was moderate to very low” in the studies that they were assessing. These are commendably cautious comments.
However, even with those caveats, the Cipriani study is open to a more rigorous critique. As mentioned above, the Cipriani study is a meta-analysis. It gathers the most comprehensive survey of relevant research on antidepressants and subjects that research to a statistical analysis, with the aim of extracting a more general truth. The worth of any meta-analysis is entirely dependent on the quality of the research that is thereby aggregated. If there is a systematic flaw in the original research, then that flaw will be reinforced by the meta-analysis – in other words, if the original research is garbage then all that a meta-analysis will provide is highly processed garbage.
The first major problem is that 78% of the papers assessed in the Cipriani study were funded by the pharmaceutical industry. The authors contend that this made no difference to their conclusions, stating “In our analyses, funding by industry was not associated with substantial differences in terms of response or dropout rates. However, non-industry funded trials were few and many trials did not report or disclose any funding.” This conclusion is open to some question, as other research demonstrates that studies funded by the pharmaceutical industry are five times more likely to report a positive effect of a drug.
The second major problem is that the research assessed remains predicated on the ‘disease centred model’ of depression. On this understanding of depression there is an underlying problem with the brain, understood as a physical construct, which a particular drug therapy can rectify. One analogy commonly used is that of insulin for diabetics: the normal functioning of a pancreas is impaired in those suffering from diabetes, giving rise to various unpleasant symptoms up to and including death. The administration of insulin makes up for the lack of insulin normally provided by the pancreas, thus enabling the diabetic to resume a normal life. Thus, a disease centred model for antidepressant drug use views the drug as addressing a specific problem within the human body which gives rise to the symptoms of depression. The drug treats that underlying problem – the ‘disease’ – and as a result the patient is cured, ie returned towards a more normal biological state.
The trouble with this ‘disease centred model’ when it comes to depression is that there is almost no evidence in its favour, and a very large amount of evidence against it. Whilst it has been a dominant way of understanding depression for the last few decades, it is now becoming discredited. According to the British Psychological Society, “it is timely and appropriate to affirm publicly that the current classification system … in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system which is no longer based on a ‘disease’ model.”
My sympathies are with a group of psychiatrists, medical practitioners and researchers who align themselves with the Critical Psychiatry Network. According to their chair, Dr Joanna Moncrieff of University College London, “…the disease-centred model of drug action has been adopted, and recently widely publicised, not because the evidence for it is compelling, but because it helped promote the interests of certain powerful social groups, namely the psychiatric profession, the pharmaceutical industry and the modern state.”
Caveat: nothing in what I say here should be taken as underestimating the immense amount of suffering endured by those struggling with depression. My concern is about seeking the most effective way to alleviate that suffering – in other words, about what can help people be healed.
In recent years many of the insititutional pillars of society have fallen into disrespect. Politicians, obviously, but also journalism, the priesthood, the police, many others. Groups that were trusted who have now fallen from grace. Are doctors going to be next?
This is a question raised by Ben Goldacre in his extremely stimulating book ‘Bad Pharma’, which I read on holiday. Goldacre is a qualified medical doctor and psychiatrist, and presently a lecturer at Oxford. In his book, published in 2012, Goldacre sets out to show, in his words, that “Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques which are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects.”
Goldacre supports these contentions throughout his book building up a detailed critique of the pharmaceutical industry and the way in which it systematically distorts the medical process at every stage. The motivations for the pharmaceutical industry to do this are quite straightforward, given that it is a multi-billion pound industry and a successful new drug can mean the difference between a company flourishing and failing. However, in pursuit of that economic end, Goldacre documents the ways in which the industry undermines the scientific process in order to make more profit. The material that Goldacre presents is utterly shocking, and if I had any residual faith in the science lying behind much modern medical and psychiatric treatment, it has certainly vanished now.
Goldacre describes one example from when he was working in General Practice, which relates to the drug Reboxetine (Edronax), which is used as an anti-depressant. He had a patient who was not improving on other drugs, and was considering using Reboxetine to see if it had a beneficial effect. He looked at the available literature which seemed positive, and agreed with his patient that it was worth trying, and duly wrote out a prescription. However, shortly after this, a review of all the research on Reboxetine was published, which for the first time included data from medical trials that had not been published (one of the main ways in which the pharmaceutical industry manipulates things is by only publishing information about trials that show their drug in a favourable light, whilst suppressing information that is critical). Goldacre writes, “I did everything a doctor is supposed to do. I read all the papers, I critically appraised them, I understood them, I discussed them with the patient and we made a decision together, based on the evidence. In the published data, reboxetine was a safe and effective drug. In reality, it was no better than a sugar pill and, worse, it does more harm than good. As a doctor, I did something that, on the balance of all the evidence, harmed my patient, simply because unflattering data was left unpublished.”
The problems that Goldacre are describing are recognised as serious problems by some influential voices. The British Medical Journal, for example, recently published an editorial written by Goldacre entitled “How medicine is broken, and how we can fix it” so there are some grounds for hope. However, very little of substance is changing, and the pharmaceutical industry continues to operate with a great deal of freedom in how it manipulates the scientific process.
What really needs to happen is that the light of public attention needs to shine on this area in a sustained and intensive way. We need to become as worked up about what is happening in pharmaceuticals as we are about all the other scandals of our time. All institutions run the risk of becoming cocooned in their own ways of thinking and patterns of life, and sometimes it takes an outsider to come along and say ‘this is simply not right’. MPs doubtless thought that claiming expenses for the draining of their moats was simply how things were done; journalists doubtless cynically accepted that phone-tapping was the way in which the truth was discovered; church hierarchies were doubtless concerned that priests accused of child abuse had to be given a chance for redemption. In the same way I believe, following Goldacre, that the medical profession needs to be told that the present practice of relying on the pharmaceutical industry as the principal guide for the benefits or otherwise that come from any particular medicine is not acceptable.
I suspect that this will be a very difficult process because there is something different about the medical profession at the moment that doesn’t apply to the other examples. In our current society, as I have said many times, “science” operates in the role that theology used to, in that it is the overarching and dominant form of knowledge, which incorporates all others. Those who are learned in this form of knowledge are the priests of our contemporary age and, in particular, those who provide forms of healing on the basis of that form of knowledge function in the modern world in a very similar fashion to ancient shamans. Sometimes the healing can be entirely ritualistic, as is most apparent when considering the difference in effectiveness between anti-depressants and placebos (sugar pills) – both have the same healing effect, which rather suggests that such healing as takes place is a product of the ritual visit to the tribal medicine man. In other words, what we are dealing with here is not a simple, practical, technical problem that can be solved by the application of sufficient determination and good will. No, here we are seeking to topple the gods of our society, and Goldacre is a blasphemer and heretic.
There are, obviously, many ways in which the pharmaceutical industry has helped the common good, and Goldacre gives credit where it is due. However, it is equally clear that the present system is broken. I would thoroughly recommend Goldacre’s book to anyone who is interested in this subject. I shall be following the ongoing conversations with great interest.
The story of Andreas Lubitz and the doomed Germanwings flight is a terrifying one. There are many details of the story yet to emerge, most especially around what may have been Lubitz’s motivation in enacting such carnage. I have been struck by the way in which steps taken to make us safer have sometimes made us more vulnerable, in that making the cockpit impregnable from the outside makes the passengers on a plane even more dependent upon the good intentions of the pilot. A good example of where good intentions can go awry and make things worse.
What seems to occupy the headline writers on the shelves of shame opposite the tobacco counter in the Co-op is the question around his ‘depression’. I do not wish in any way to question the reality of the experience that is presently given the label ‘depression’. There are phenomena that people experience within their own mental life that are often life-denying at a minimum, life-destroying as a maximum. Please do not interpret anything else that I say here as in any way denying this first and most basic truth. My issue is all to do with how these phenomena are understood and how those who have to endure them are treated, both by medical professionals and by wider society.
Firstly, I would want to ask questions about the convenience to a society that has available to it a form of language that isolates the problem within a single person. If it is established that Lubitz was ‘mentally ill’ then it substantially relieves the wider society of any responsibility for what has happened. Any questions about the social context within which a person is living, and which may contribute to their mental suffering, are side-stepped. It is simply bad luck, the misfortune of a particular genetic inheritance. Nothing to see here, move along.
In contrast I would want to insist that ‘no man is an island’ and that we cannot understand mental suffering without paying close attention both to the social context in which that suffering takes place, and to the particular life-story of the person concerned. Is the person diagnosed with a ‘mental illness’ a victim of discrimination or bullying or social isolation? Are there people in their lives who love them? Has something happened recently, such as a bereavement or divorce, that might trigger severe sadness? It is, after all, perfectly understandable that someone in such a situation would experience all the symptoms of what are presently labelled ‘depression’. Such a person is not mentally ill, they are grieving, and this is a perfectly normal and human response to a particular situation. It says a lot about our culture that the dominant psychiatric guide for dealing with such a situation has recently changed its policy so that, if someone is deeply sad for more than two weeks after a major bereavement, they can now be classed as ‘depressed’ (the ‘Diagnostic and Statistical Manual of Mental Disorders, 5th Edition’ or DSM5).
This leads directly to my second area of questions, which is to highlight the relationship between the pharmaceutical industry and the forms of diagnosis that are offered. In American Law – and the DSM5 is an American publication – it is only possible for drug companies to sell medicines for named disorders. Where those medicines are being provided by commercial enterprises, as with the American health care system, there is a strong financial incentive to increase the number of named disorders so that there are more opportunities to sell medication. This is why there has been an explosion of ‘disorders’ that can justify the sale of new pharmaceuticals. I find it significant that almost all the major pharmaceutical companies spend vastly more on the sale and marketing of their drugs than they do on researching their effects. (For more on this, read ‘Big Pharma’ by Ben Goldacre.)
My final area of questioning is about the efficacy of anti-depressants, that is, do they actually enable a person to be cured of ‘depression’? The evidence rather suggests not. I recently read an excellent book by Irving Kirsch entitled “The Emperor’s New Drugs”, which I heartily recommend for anyone with an interest in this topic (Kirsch is a lecturer in medicine at Harvard Medical School). Kirsch’s main target is what he calls the ‘chemical imbalance theory’ of depression, and his main area of research is the comparison of anti-depressant drugs with placebos. Kirsch does not dispute that people who are given anti-depressants experience a benefit from having done so; what he disputes is that there is anything medically effective going on. That is, his case – a case that I find thoroughly persuasive – is that anti-depressants work because people expect them to work, no more and no less. Kirsch writes: “Depression is not caused by a chemical imbalance in the brain, and it is not cured by medication. Depression may not even be an illness at all. Often, it can be a normal reaction to abnormal situations. Poverty, unemployment, and the loss of loved ones can make people depressed, and these social and situational causes of depression cannot be changed by drugs.”
What concerns me about the language being used with respect to Lubitz is that it can confuse our understanding of all that led up to the crash. It is too convenient to argue that it was the result of one person who was mad or bad or both. I believe that we need to have a much more thorough conversation about what is presently called mental illness, starting from the areas of questioning that I have outlined above, to ensure that, as with locked cockpit doors, we are not simply making a bad situation worse as a result of misguided good intentions. It is also true, of course, that what is presently considered to be the preserve of psychiatrists used to be well understood as the cure of souls. I will return to exactly what that phrase means at a later date.
Christmas is approaching. We remember the story of a pregnant woman travelling far from home being turned away from shelter. We give thanks for the miracle of the safe arrival of the Christ-child, and all the wonderful things that have followed from that.
I can’t help but ponder the differences between that story and the one that has recently come to public attention involving Alessandra Pacchieri. Ms Pacchieri was also a pregnant woman travelling far from home – in her case, she came from her home in Italy to Stansted Airport, to attend a training course. She was heavily pregnant, and through an unfortunate sequence of events, fell foul of the local constabulary and social services. Because she had been diagnosed with bipolar disorder, and was not maintaining her medication, she was ‘sectioned’ – meaning that she was detained in a psychiatric hospital. Her baby girl was removed by caesarean section and, after the first few days, she was forbidden to continue breast-feeding and the child was placed in foster-care. Some fifteen months on, her child is now being put up for adoption, and Ms Pacchieri is pursuing her case through the courts – quite simply, she seeks for her child to be returned to her. In this she is being supported by a number of people and institutions who share my horror at what Essex Social Services have done.
Now I am quite certain that a rational case can be developed to demonstrate that the actions of our Social Services were in line with the proper procedures and guidance that they have to follow. At each point someone with proper authority gave their advice or consent for the next step to be taken. It may be the case that there are details of this case that have not been made public, and that would shed a very different light upon what seems to be a frightening injustice. Yet, I also can’t help but believe that such information would itself have to be pretty staggering to do justice to what has happened. To enforce a caesarean section upon a woman without consent, and then to deny further contact between mother and child, and then to put the child up for adoption against the wishes of the wider family – clearly, this mother must be seen by our social services as one of the most evil mothers ever to walk the earth. For what else might justify their actions? If Ms Pacchieri is simply an averagely competent mother, the welfare of her daughter is greatly advanced by being kept with her mother. This basic truism is even enshrined in European Law, which in this case at least manages to coincide with common sense.
I shall be following the details of this case with great interest, and I pray for an outcome which minimises the trauma for the families involved. What I would like to tease out here, however, is the way in which Ms Pacchieri became subject to the choices of bureaucrats. Wittgenstein once remarked to a friend (who went on to become an eminent psychiatrist) that nothing would frighten him more than being misdiagnosed as mentally ill. Surely it is a fate similar to that of Ms Pacchieri that concerned him. After all, once the diagnosis had been made – once the system had taken control of her life – once ‘the Matrix has her’ – all of Ms Pacchieri’s rights were taken away. She was no longer a person, she was simply a unit, moved around and manipulated, operated on and directed by bureaucratic imperatives. Can there be a more fundamental breach of human rights than this?
We have inherited, in our justice system, a good number of checks and balances; things like trial by jury, habeas corpus, rights to do with free speech and free assembly and so on. These have evolved because of a recognition that the centralisation of power will inevitably lead to abuse. It is through a dispersal of power and, especially, an insistence upon bounds to the arbitrary exercise of power, that have enabled this country to enjoy a wealth of freedom through recent centuries. What the Pacchieri case says to me is that this historic settlement has been abandoned.
What, after all, did it mean to be diagnosed as ‘schizophrenic’ – which is the diagnosis given about Ms Pacchieri to justify her incarceration. There is no recognised aetiology for schizophrenia; the word is simply an umbrella term used to gather together a bundle of disparate symptoms – and those symptoms themselves essentially boil down to ‘behaviour which makes the wider society uncomfortable’. (For a thorough debunking of ‘schizophrenia’ as a concept – in other words, for the definitive argument as to why the word has no inherent meaning whatsoever – I would heartily recommend Mary Boyle’s ‘Schizophrenia: A Scientific Delusion’.)
What has happened is that a small group of people, following recognised ‘good practice’ and deploying all the powers available to the state – including those given to the recently developed ‘Courts of Protection’ (oh Kafka, if only you had lived to see this) – decided that Ms Pacchieri didn’t conform to their desired patterns of behaviour. As a consequence Ms Pacchieri has had her life turn into a real-life version of Rosemary’s Baby. She has been deprived of all agency and dignity and still the bureaucrats want to rend mother and child apart.
I feel ashamed to belong to a society that can allow such a thing to happen. We are ruled by barbarians and bullies. Two thousand years ago, a vulnerable young woman found shelter amongst the animals. Grace allowed amazing things to happen in consequence – in a place apart from polite society, apart from the realms of social acceptability. That is where God is – at the margins, with those who are broken, with the mad and maladjusted, the sinners and fools, those whom the system breaks and crucifies. Ms Pacchieri stands amongst them, and I pray that this Christmas time she might gain some small measure of comfort and support from knowing that.
As well as excellent acting from leads and support I was particularly pleased by two things: the treatment of “mental illness”, and the way in which the individual story was used to exemplify the much broader issue of homelessness. 5/5