And yet, psychiatrists must resist those who would hijack language in the service of their narrow political agenda—that of discrediting psychiatry and psychiatric treatment. We must begin by pushing back against the campaign to eliminate psychiatric “drugs,” by pointing out that there are substantial biochemical and clinical differences between many life-enhancing psychotropic medications and drugs of abuse, such as heroin and cocaine. For example, contrary to the notion that antidepressants produce only “cosmetic” changes that “cover up symptoms,” we now have compelling evidence from animal models that antidepressants are working at the deep, structural level of the gene. Thus, antidepressants are known to increase production of various nerve growth factors and to enhance the “connections” between neurons. Indeed, a 2007 review by Schmidt and Duman5 concluded that “hippocampal atrophy is observed in patients with depression, and this effect is blocked or reversed by antidepressant treatments.” A similar case for benign neurotrophic effects can also be made for lithium(Drug information on lithium) and possibly some of the atypical antipsychotics.
Let me be clear: as physicians and healers, psychiatrists have an ethical responsibility to see that medications are prescribed and administered in a compassionate and noncoercive way, consistent with the principles of informed consent and respect for personal autonomy. When informed consent from the patient is not possible—in certain emergency situations, or when the patient lacks the cognitive capacity to make informed medication decisions—we must ensure that medication decisions proceed from “due process of law.” This may require obtaining a legal guardianship, or seeking a judicial determination that involuntary medication is justified. And, beyond informed consent, our medication decisions should consider the patient’s personal, cultural, and spiritual needs, as articulated by my colleague, Cynthia M. A. Geppert, MD, PhD.6
Yes, one can argue that in today’s setting of “mis-managed care,” psychotropic medication is sometimes prescribed too readily when psychotherapy would be the preferred treatment. And, yes, we need more effective medications in psychiatry, used in more judicious ways—particularly in children, adolescents, and those with dementia, for whom our evidence-base is often shaky. We should be wary of attempts to expand both our disease categories and the labeled indica-tions for psychotropic medications. But to lump all psychotropic medications in with drugs of abuse is to embrace junk science and junk rhetoric. Psychiatrists need to find a gentle but persuasive language of resistance, in the face of this ploy.
FEEDBACK BY DR GREEN:
I was impressed by your editorial that countered some of the strident and angry accusations of antipsychiatry. However, I fear that you underestimated the responsibility of the profession. Motivational interviewing techniques help us minimize resistance through empathy, validation, curiosity, and flexibility. In this case, psychiatry needs to appreciate that some of the outrage and extremism of the antipsychiatry movement comes from our unwillingness to listen and take responsibility for the harm we have caused and continue to cause. People who feel mistreated form movements because they feel unheard and disempowered.
While you reference how those who control language can influence thought and behavior, you seem to be pointing at those who rail against psychiatry’s abuses. This is ironic, for Foucault and others taught us that the psychiatric profession defines madness, pathologizing and silencing difference, dissent, and the right to make mistakes. Your passionate defense of the profession and medications risks coming across like a “ In our era, the experience of madness remains silent in the composure of a knowledge which, knowing too much about madness, forgets it.”1
Mark D. Green, MD
WestBridge Community Services
1. Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason, trans. New York: Vintage Books/Random House, 1965, 1988.
DR PIES RESPONDS TO DR GREEN
I appreciate Dr Green’s comments on my editorial, and I most certainly agree that we need to listen carefully and empathically to our patients. In my experience, most psychiatrists do just that; of course, as with any profession, there are unfortunate exceptions. It is difficult to respond to Dr Green’s contention that psychiatrists have been unwilling to “take responsibility for the harm we have caused and continue to cause,” since Dr Green does not specify what “harm” he imputes to psychiatrists. Nor does he specify what “abuses” he associates with psychiatry.
Of course, I’m aware that some patients have been inappropriately medicated, or have been denied a process of fully informed consent. Such failures are notable, and we must indeed take responsibility for them. But these failings do not justify the nihilistic and hateful rhetoric that sees all psychiatrists as predatory jailors, intent on “drugging” their patients—this was the rhetoric I sought to challenge. I believe that the vast majority of psychiatrists are conscientiously doing their best to help their patients, often under very adverse circumstances.
As for Foucault: I’m afraid I find very little instruction in his book, Madness and Civilization, from which Dr Green quotes. It is true that Foucault’s concepts of “epistemes” and “discourses” shed some light on how language may become a vehicle of power—and this is certainly germane to my editorial. But Foucault’s claim that “…all disciplines—be they scientific, legal, political, or social—operate through a network of self-legitimizing power and knowledge…”1 becomes a self-refuting argument. That is, there is no reason for us to believe that Foucault’s own claims are anything other than a self-legitimizing grab for power—power over the field of psychiatry! This self-nullifying aspect of Foucault’s arguments is also true of most “post-modern” arguments against any objective truths. Furthermore, as Ian Hacking writes, “Despite all the fireworks, Madness & Civilization follows the romantic convention that sees the exercise of power as repression, which is wicked.”2
I think Dr Green and I would agree that we psychiatrists must exercise great care in how we wield our considerable power; some, alas, have not been so careful. And yet, I still believe that, for the most part, we have used our powers humanely and with our patients’ best interest in mind.
1. Critical Theory. http://www.smpcollege.com/litlinks/critical/foucault.htm.
2. Hacking I. The archaeology of Foucault. In: Hoy DC, ed. Foucault: A Critical Reader. Oxford: Blackwell Books; 1986.