Leaving Psychiatry Chap 12; Possibility.
The Final Chapter. What if it All Went Away?
"I suspect that our own faith in psychiatry will seem as touchingly quaint to the future as our grandparents’ belief in phrenology seems to us now"
Gore Vidal
“He who speaks of revolution without living it in their daily life speaks with a corpse in his mouth.”
Raoul Vaneigem
December 2019
We find ourselves in the final chapter. Notice I have not tackled the myth of the chemical imbalance theory of mental illness. Nor have we become lost in the weeds around the mischievous layers of assumptions behind fMRI and genetics studies. Nor have we wasted time in deconstructing the DSM project. Enough to take it at its Achilles heel in a previous chapter on multiple personality disorder (chap 5). We have approached psychiatry through deconstructing it down to its basic function in policing the social milieu and having the legal power to incarcerate and chemically modify (chap1). We have opened a window into the culture of the psychiatric apprenticeship (chap 2). Contra the view of other critics of psychiatry I see the core issues as neither rampant scientism nor as captured by big pharma. Though both are true to a point, rather the problem is philosophical pragmatism (chap 4) and other problems as well. This is not to deny psychiatry is wedded to mind brain reductionism (it is), though I am comforted in the confidence psychiatry will never prove the unprovable (chap 3). Within the pragmatic context of truth being whatever works, what works best for now is bending the knee to the trans juggernaut (chap 7), addiction as a brain disease (chap 8) and psychotherapy is whatever makes the customer “feel better” (chap 6). That the genealogy of psychiatry is as a replacement for the priest or shaman is self-evident. This would have left the clergy with authority only to attend to religious ministrations had Christendom not decided to abandon its faith and its nerve to claim authority over the psyche. Today the pastoral counsellor is happy castrated itself into a corner, leaving final pronouncements to those better “qualified”. That psychiatry flirted with completely divesting religion of relevance we also explored with the satanic panic (chap 5). We try and normalise the psychotic alien as an insoluble political problem (chap 9) and suggest property is not truly private unless the owner can destroy it (chap 10). In the penultimate chapter (11) I attempt to climb Mt Szasz.
If I have succeeded in tearing down psychiatry, the onus is probably upon me to offer an alternative. And fair enough. That having been said, some solutions are non-solutions. Or put another way, a problem erected on a fallacy requires no solution, only the removal of confusion. Logic would dictate that with the bad removed only the good can remain. And yet we live in a culture where it assumed clearing out the weeds is not good enough without adding fertiliser. Sometimes all that is required is to keep the weeds out and treat the plant with 24 hours of time every day.
Taking a leaf out of the book of Szasz, it is not as if we have abandoned medicalized mental illness as myth only to solidify it in another form. No, our project is more radical still. We must take a pause now to think. We best avoid falling into the “social justice” trap of looking for humane or more logically consistent alternatives to standard diagnosis and treatment in caring for the “mentally ill” and a different kind of expert. Were we to do so, our fallacious premises remain ensconced in our minds. We would be forever perched atop the patient, a looming shadow of the therapeutic state of which we are one of its organs. This is the problem of much of the movement critical of psychiatry today. Some Marxists want to liberate the mentally ill from the evils of capitalist big pharma and the stigma of the DSM and the psychiatric power structure. So far so good? Not quite for it recapitulates victimhood, first to mental illness (an underclass) and second to exploitation (by a pharma overclass and orthodox psychiatry). But the pharma critical psychiatrist usually wishes to liberate the patient from one locus of exploitation into their own. Any token pretences to toleration of the abnormal or liberation into freedom and responsibility are tepid at best. If the critical psychiatrist really wishes to liberate the patient, first undermine the psychiatric claim to legitimacy to do it and explain who the patient is. We reach a terminus of incoherent absurdity when the maverick psychiatrist takes aim at their profession, guild, pharma, theoretical schema and all and sundry only to justify authority to critique with….you guessed it…their MD and psychiatric credentials. The psychiatric tyrant would ask the critical psychiatrist what he/she would do instead if faced with the patient who must be fixed. Szasz answer would be that the psychiatrist probably should not even be in the room. The context and relationship is, a priori, exploitative.
Forcing me to offer alternatives is reminiscent of one of many similar conversations with senior colleagues when I was more junior in psychiatry. When I asserted that so called antipsychotics were entirely inappropriate for a number of reasons in a particular patient with an emotionally unstable and antisocial personality (tax payer funded medication mind you), the response was that it was then incumbent upon me to arrive at an alternative pharmacological solution as part of a “package of care”. What was I going to do with, and give to, the person labelled patient, that was the question. What I wanted to recognize in the person was her de-medicalized autonomy, responsibility and the rule of law hanging over her head as it is over my own. What I wanted to offer her were frequent empathic reminders to grow up and some advice on how this might be achieved. To this I could add all the appurtenances of psychotherapeutic psychobabble, though this jargon is empty and hollow. Anyone’s wise grandmother could identify the basic fault in her developmental history, her psyche and also recognise the necessary adult behaviour that would be a both a therapeutic exercise and a realization of recovery. Naturally such good sense falls on both the deaf ears of the patient who does not wish to grow up, and the psychiatrist whose affirmations to mental illness obstruct her from the same. The psychiatrist’s ego wants the patient to pass through a process of confession of being sinful (insight into mental illness), acts of contrition (medication etc) and only in passing through this ritual is absolution (recovery) and partial freedom to be found (partial, as freedom is always conditional in the therapeutic state). I imagine abolitionists of slavery free the captive from chains only to ask “but what do we do with them now?”. If the master slave relationship is broken, the answer is there is no “we”, no “them” and no “doing with”. When the one who sits across from me is a free autonomous citizen under the rule of law and assumption of adult personal responsibility, they are none of my business and I am none of theirs save for whatever free transactions we voluntarily choose to make amongst ourselves. After the twilight and just before the passing away of the slave/slave master dyad, “we” may go so far as to “give” our erstwhile slaves the plantation upon which they have laboured. Should free citizens choose to make it into a productive endeavour the profit is theirs. Should they choose to raise it to the ground they face the consequences of their own ruin and famine. In the latter eventuality, the slave master cannot a posteriori claim licence to re-enslave the free citizen and the citizen cannot blame their former masters for failing in “duty of care”. Same with imagining a death of psychiatry and any transitional alternative objects we may employ en route to its end. The point is not to argue whose “model/system of care” results in greater performance outcomes re suicide, “morbidity” from depression and anxiety, untreated psychosis etcetera using existing psychiatric metrics and observational studies. The people who would argue such things are, to quote Wilde, those who know the price or everything and the value of nothing. I could easily argue in favour of some monstrous Huxleyan brave new world where autonomy is effectively abolished altogether, everyone wrapped in proverbial bubble wrap, drugged into blissful oblivion and suicide as rare as a blue moon. But how would it profit the world if the psychiatrist engineers this utopia at the expense of the person’s soul? Freedom and responsibility are the only metrics worth measuring.
If psychiatry to vanish overnight the next day would not be smooth sailing. Every major change is a revolution of a kind. And every revolutionary or abolitionist, for lack of better terms, must be careful what they wish for. They must ask themselves what is to happen the day after they seize the barracks and the post office, or the psychiatric clinic. The immediate upheaval would be enormous and not without some quantum of tragedy, though not the catastrophe that the professions narcissism would want us to believe. Besides, tragedy is the stuff of life. Tragedy lived before psychiatry as it lives during the current era. The medicalization of tragedy is the greater sickness. Psychiatry’s narcissistic delusion is that a society without this class of expert manager is destined to failure and unnecessary suffering. Problems arising in the wake of psychiatry’s sudden death would be more the clash between the inertia of iatrogenic fostered expectation against the vacuum created in psychiatry’s absence, as opposed to revealing the indispensability of psychiatry in principle or in the mid to longer term. Such would be the birth pains of society growing up. If we are to reject utilitarianism, philosophical pragmatism, the myth of mental illness, the specialist class of the psychiatrist as the minister to souls, the involuntary therapeutic state, the whole menagerie of these hideous little creatures, the consequent inauguration of greater principles within which we may come to live is its own reward. Nonetheless and notwithstanding there is no excuse for failing to move swiftly towards a complete abolition of coercive and forced psychiatric practice and the market expansion of alternatives, one needn’t be rushed and reckless to do what is best.
Apart from a calling to a different principle, or principle as such (vs sophistic mischief from the pragmatic void), it occurs to me that the task is harder still. For even a salutary suggestion of what is possible might be seen as something of a fantasy, if not my own delusion. Just as many a youth today could not imagine a possible world without social media and smart phones, these being places within which their identity dwells and is diffused, many a psychiatrist is indoctrinated to believe it is impossible have a functioning world without SSRI’s, let alone involuntary hospitalization, civil commitment, ECT, lifetime administered neuroleptics and the psychiatrist themselves. They have swallowed the idea that without psychiatry there would be hordes of unwell people suffering, taking their own lives, or chained in the attic by the family or dying in the gutter. What I offer is a collage of suggestions, impressions, and proposals. I don’t offer solutions so much as an invitation to believe in possibility. Possibility must come first.
Trieste
Most in psychiatry and I’ll wager everyone under 50 years of age knows nothing of the Italian project. It is impossible to discuss the psychiatric history of 1960’s-1980’s Italy without running the risk of historiography. One can find whatever answer one wishes to find if to ignore the accounts and arguments one wishes to ignore. That is the prism which one is handed when looking back at Professor Franco Basaglia, the “Psichiatria Democrata” (democratic psychiatry) and the alleged secular miracle in Trieste at the San Giovanni hospital. Consequently, I shall restrict myself to what is undeniable in what mainstream psychiatry thought impossible before the fact of the miracle, this to be compared with the miracle itself.
Like Szasz and revolutionaries of many stripes, Franco Basaglia was born to a wealthy bourgeois family. With Szasz it was Budapest. With Basaglia it was Venice. Although driven and brilliant in his own way, he was a chain smoking iconoclastic who did not work well with authority figures. So he was banished from his chair at Padua. In a certain strictly limited sense, he shares the same character and fate of another University of Padua alma mater, Galileo Galilei. Province begat providence as outside Padua he could then work unseen and unfettered on his grand social project of reform and deinstitutionalization. Nonetheless he was not the first Italian “reformer”, and others had come before. He walked more than a century and a half after, though nonetheless partially in the footsteps of, a Florentine alienist Vincenzo Chiarugi. Chiarugi’s story is parenthetically of value, it being part of stepwise humanization of patients that began as early as the late 18th century, though several years after Grand Duke Leopoldo had already legislated to involuntarily detain the mentally ill and other social deviants and misfits. That is the state for you. First create the problem before seeking to disguise its tyranny under the language of care and reform from the very problems it has created. Under Leopoldo and, proximally, Chiarugi, the Ospedale di Bonifacio (Bonifacio hospital) expanded from what was essentially a place for the infirmed and elderly and those insane with syphilis to a larger insane asylum with some physically ill patients also. And so we go from a few in chains without a clear rule of law to many more bound with leather straps in legal perspicuity. Such is the victory of the enlightenment, to imprison more souls under cover of good intentions. Today psychiatry will consider themselves humanely victorious if the patient and millions of others place themselves in the ideological and chemical strappings of voluntary identification with illness and medication. Nonetheless Chiarugi ought to be given his due as the one who came before even the French reformer Pinel. And both did much good. Though before we heap too great a pile of laudation upon these children of the enlightenment, we ought to remind to ourselves also that Chiarugi was both alienist and dermatologist. Leather straps are friendlier to the skin than steel and iron, and a moral outcome need not be entirely the product of a moral intention in the way we might like. But when freedom is important, what causes less trauma to the skin isn’t the point is it?
Where Chiarugi would work with the state in reforming care of those imprisoned and alienated by the state, Basaglia’s Marxist goal was the state sanctioned destruction of the asylum altogether, and he was to inherit an asylum similar to that Chiarugi shepherded. These asylums were in every city of any appreciable size inside and outside of Italy. Every one of them would have had their own Chiarugi, their own superintendent psychiatrist as warden of the psychiatric jail. The reader’s imagination would not be off target if to envision some places with grey walls, shackles or straps, people left alone in the corner to rock and rot and sometimes be abused or exploited in “rehabilitative” work programs. In fairness to my older colleagues around who worked through the end of the 20th century asylums, the system was probably not necessarily as bad as imagined or portrayed. Not every older psychiatrist we can tar with the same brush as that we might use against the agents of Ceaușescu’s state hospitals for example. Such would be a grossly unfair caricature. Critique aside, we can extend the same grace to some individuals in previous centuries also, and even to the clerics who had original governance over the Ospedale di Bonifacio in the 14th century before the psychiatrists took over.
Returning to Basaglia, his first forays into deinstitutionalisation were in the far north in Gorizia near the Slovene border in the 1960’s, though it was in the San Giovanni hospital in Trieste commencing 1971 that the project really flowered. Basaglia was his own man of course, though influenced by the works of Goffman and Foucault, and to a lesser extent Szasz also. All three authors were publishing seminal works, a perfect storm of opprobrium against the asylum system of the early 1960’s, and psychiatry more generally. Equally influential was Basaglia’s politics. Both he and his wife Franca were active communist party members and the latter at one stage a member of the senate. It would not be too simplistic to formulate Basaglia to have decided that the liberation of the proletariat was to be a drama played out symbolically in the liberation of the psychiatric patient and he was to be their Lenin. In Gorizia he managed to publish two books; “Che Cos’è la Psichiatria?” (What is psychiatry?) and “L’istituzione Negata” (The institution denied). Curiously neither were translated into English. Though I do not suggest any conspiracy by the Anglo psychiatric establishment, others have. Naturally Basaglia had a great many establishment enemies in Italian psychiatry, the public and the local fourth estate. It did not help that his project fell victim to a tragic anomaly early in on in 1972 when an ex-patient murdered his parents. The incident does not make the insane more dangerous than the sane. It was a “one off” event not clearly even related to “insanity”. To counterbalance against his opposition, Basaglia was able to mobilize certain powerful demigods in Italian politics and the media to his cause. Soon Trieste became a mecca for counterculture revolutionaries, bohemians, and fellow travellers of many stripes from inside and outside Italy also. These were (paradoxically) the makings of a criticism if the project were it to succeed. It could always be argued success was only on account of turning the isolated little city into a heavily staffed de facto commune with a charismatic leader that it could go as far as it did. Some would say such Herculean efforts it could not be up-scaled to a Milan or Rome or the mega asylums of France or England. In any case, life at San Giovanni was to change from locked doors and involuntary patients to open wards and voluntary “guests”. The guests were given greater free reign to roam about and choose their own destiny. In this “Psichiatria Democrata” guests were involved in frequent discussions as to the running of the institution. Like other socialist utopias, certain sexual proscriptions of the Latin Church were seen as oppressive and the genders no longer segregated, though gender segregation was also practiced for secular pragmatic reasons back in time and place with Chiarugi in Florence. Despite reservations and horror at the notion of sexual beings doing what sexual beings do, San Giovanni neither turned into a Sodom and Gomorrah or a nursery of little babies with mythical schizophrenic genes. Work programs were replaced with more egalitarian co-ops where the patient workers had more managerial clout. San Giovanni also became a place of regular street theatre and art. Communist graffiti and politically charged slogans were painted on the walls and architraves. Some were more Szaszian libertarian than Basaglia communist
‘la libertà e terapeutica’ (‘freedom is therapeutic’).
By the end of 1977, by some accounts he had reduced the involuntary patient number from over 1000 to about 50. He announced that the hospital would be closed, this later officially effected in 1980, the year of his death from a brain tumour. Basaglia’s law, or law 180, was put in place in 1978. Over the largely posthumous decade to follow its implementation scores of thousands of institutionalized patients were liberated from the asylums across Italy. This was at a time when many other nations would not believe it to be possible.
One interesting analysis of Basaglia movement was that of a study tour completed by psychologists Kathleen Jones and Alison Poletti. They embarked on the first tour in 1984, strangely omitting Trieste and Rome from the itinerary yet finding in other centres outcomes from which the conclusions were resoundingly negative of the deinstitutionalisation that swept across Italy. The cities they did visit included Como, Milan, Pavia, Pisa, Lucca, Florence, Salerno and Reggio di Calabria. This work was met with the understandable critique of not having visited Trieste itself, in addition to other criticisms as to the authors bias. Consequently, they embarked on a second glorified vacation (sorry study tour) the following year to Trieste, Ferrara, Rome and Bologna. The second revised conclusion was, to their credit, more balanced and positive of law 180. Of Trieste, they praised the informal atmosphere and the spirit of carnival. Nonetheless the dominant critique was that the hospital did not, ipso facto, close. A relatively tiny number of patients still resided there, as if this somehow negated the whole project and the fact of their freedom. Many of these were patients rebranded into residents of what effectively became lodge accommodation. But we cannot possibly see the four walls in the same light when the door is unlocked and the one who dwells therein is granted liberty. Just as a deconsecrated church is a gentrified little restaurant with quaint stained glass, an asylum converted to housing is no longer part of the same therapeutic state. Nonetheless some persons were admittedly still held as involuntarily patients. Given these were the senile dementias and younger patients with intellectual disabilities and acquired brain injuries, we would hardly be surprised. The closest equivalent to the psychiatric ward proper, the optimistically named “diagnosis and cure unit”, was reduced to a mere 8 beds. These beds were empty when Jones and Poletti visited. It must be added that home based care and integration of care back into the family unit (if available) was a focus. Another critique of the authors was that less therapeutic activities were available in this quasi-commune, missing the point that to liberate the patient from the locked door is also to liberate them from the medicalized language of the relationship. Only patients need therapy. People need community. Patients need rehabilitation. People have jobs. Finally, in the very nation of Cerletti and Bini, the founding fathers of electroconvulsive therapy, Trieste saw no need for what many a psychiatric service thinks an indispensable therapeutic modality. To this day Italy is a country which exported ECT only to largely abandon it.
The contemporary psychiatric shoulder shrug to the Trieste miracle would be to say that this was the righteous end of the asylum era, something echoed all over the developed world. And so what? How can this inform any critique of the humane psychiatry of the twenty first century when we, in our wisdom, only involuntarily incarcerate and medicate persons when necessity forces our hand? Such a dismissal would miss the point. The lesson to be learned is in what people assumed was impossible and what was readily achieved when the will was placed upon the gears of the problem. When people were freed or forced from ideological commitments that deprived another of freedom under the rule of law, the impossible became real. From this we might ask what evidence do we have that Trieste is the terminal horizon of what is possible? We might further ask why psychiatry needs to be dragged kicking and screaming to each and every reform with which it feels uncomfortable, a Kuhnian break with each paradigm. Why the resistance to winding back its influence even further, even onto Basaglia’s dream to do away with the system altogether?
I have learned my own little lessons in my own little career. There have been times when wards have been forced to substantially downsize, this despite bed availability being ordinarily strained and in perpetual crisis. But boost community resources and the sky did not fall, patients were not left languishing in the emergency department awaiting a bed or dead in a ditch somewhere when less beds were available. When I suggested that this was evidence to take seriously the notion of closing the wards altogether the response was as if I suggested we could turn water into wine. Government services, like hot air, have a habit of expanding to fill the available space and budget whilst the government worker, like a gas, seeks the lowest available energy state.
This might give a clue as what Basaglia really accomplished. I once heard it said from a source I cannot recall
“if suicide is a cry for help, schizophrenia is a cry for housing”.
Any honest psychiatrist will see the ring of truth in this, i.e. that many a schizophrenic is not a person who necessarily cannot live in the world, so much as someone who cannot flourish in a world of people distressed by them, or exploitative of them. The hospital is a periodic place of sanctuary for the patient and a respite for the others who are embarrassed and exhausted by them. They are people who lost their way somewhere along the path of life and could not find their way back. Schizophrenia is a name we give such a wayward soul, and medication is to domesticate their many and varied disjunctive eccentricities. Unfortunately, many patients still cycle in and out of hospitals, where hospital stay costs the tax payer far more than placing the patient in a five star hotel. The miracle of San Giovani and the Szaszian philosophy opens the way to imagining public housing blocks staffed by a nurse or two and frequently patrolled by police on the beat. Residents would have the option to stay there and the obligation to act civilly and soberly. There would be no coercive psychiatry, only autonomy and responsibility of free citizens under the rule of law. Ideally also would be the social inculcation of the value of connectedness and community. Give this a generation of adaptation and we could take the further step to do away with the label of schizophrenia altogether.
Soteria; from Berne to San Francisco
If the measure of success is symptomatic control, a patient not being a nuisance to self or others and metrics based on these outcomes, the asylum has no peer in managing the variable of public nuisance and embarrassment. Simply lock up the patient and throw away the key. Only conscience and imagination remain to bother the populace walking past the high fences and dark grey walls. Have no fear. A good dose of egocentric self-centred psychotherapy and an SSRI will cure most people of a social conscience. Second best to the asylum in a post Basaglia world, assertive coercive medication centred psychiatric treatment with threat of hospitalization has no peer. Should I be asked to speculate on the best treatment to bring about public safety and symptomatic control in 95% of patients (of all diagnoses, not simply schizophrenia), it would be to medicate the person with x diagnosis with clozapine (an oral medication), with repeated cycling of involuntary hospitalization should they be non-compliant until they learn their lesson. The patient will then be fat docile and and domesticated. The mood would be neither too high or too low, the voices but a murmur and the beliefs in the strange and fantastic still held, but they don’t care as much about them anymore, and not much else besides. Dramatic behaviour of the dramatic personality would be domesticated also. Should they not tolerate the clozapine I’d simply forcibly administer a different neuroleptic available in injectable form, once again with periodic coercive admissions as required.
All this is to concede the obvious; i.e. persons un-medicated will likely be more “psychotic” or “manic” or “neurotic” than drug free patients, though this approach is not value free. A radical Szazian will reject this on principle and reject Basaglia also as he rejected Laing and Frankl. Even Italy never dissolved the threat of the therapeutic state entirely. Those 8 remaining involuntary beds were the stain on Basaglia’s cassock that would not go away, or so Szasz would say. The next step along the spectrum of liberty and responsibility is Soteria.
Soteria, a name charged with an almost religious calling, is derived from the Greek for salvation. The use of the name speaks of the optimistic counterculture within certain marginal (and marginalized) sectors of psychiatry in the 1960’s and 1970’s, Basaglia, Szasz et al being but two aforementioned others.
Psychiatrist Loren Mosher and social worker Alma Menn began the Soteria project in 1971. Not surprisingly this was in San Francisco, ground zero for some of the American avant-garde movements then and since, though Mosher wasn’t as fringe as one might expect, as he initially moved within the higher echelons of the National Institute of Mental Health before being pushed out for his heresy. Like all but Szasz, Mosher bought into the myth of mental illness. But rather than writing it off as a neurochemical imbalance requiring a neurochemical solution, Mosher largely though not entirely eschewed the use of antipsychotic medication and drew upon his German Jewish phenomenological background positing that psychosis in large part is a psychological lesion of “Affektlogik”. Affektlogik is a mereological re-conceiving of the component parts of the mental state along with the persons experience in the world. It sees affect (qua emotion or feeling about in this case) and cognition (thinking about) and perceiving (hearing and seeing about) not as separate modalities yet rather fused into a conceptual whole different to the component parts. Thus, there is a mode of being (feeling/thinking) that is context dependent and further contextualized by the wider life and individual narrative of the person. Specific context dependent mental states may include rage logic, infatuation logic, fear or anxiety logic and so on. The psychotic state is another logic of its own kind, even paradoxically logical in the sense that the phenomena can be objectively understood, explained, explored and rectified. Soteria and affektlogik would have it that schizophrenia arises from certain disturbing experiences and emotions triggering a reflection of amplified disturbance within thought and feeling leading eventually to the psychotic state. So, for example, the person may experience a sense of loss of agency charged with emotion, this leading to excessive self-reflection, a worry and existential doubt that viciously feeds on itself. The resultant is perhaps disconnection altogether with one’s own ego, or even one’s own inner dialogue and sensory experiences as being “mine”. Then have the hearing of voices, the wildly strange misinterpretations, “otherness” and persecutory delusions and so on. The remedy, so says Mosher et al, is a comprehensive restorative therapy that even includes the architecture and furnishings lending towards harmony and healing. The patient ought to be in a place where the rules and appearances of things are less alien. Hospitals are as alien to persons daily life as the person has become an alien to the world.
Parenthetically, you may be interested to know that originally the keeper of the asylum might have been called the alienist, this being synonymous with psychiatrist. Ergo Freud was the neurologist was technically never a psychiatrist as he never worked in or managed an asylum. Indeed, he could not have been as a jew could not elevate to the authority of superintendent of large state owned mental institutions. Similarly, Szasz was a psychiatrist in qualification only and a professor of psychiatry by academic title, and not classically speaking a psychiatrist at all. He carefully avoided the context within which he could exercise authority over the adult human. He was the last pure distillation of what began with Freud.
Returning to Soteria, our phenomenological alien (i.e. psychotic patient) is encultured back into humanity by living as a human, in a harmoniously furnished and welcoming home. Attachment theorists, cybernetic theorists and occupational therapists alike will also appreciate the heavy reliance on, and ubiquitous presence of, volunteers and professionals to give the patient an experience of “being with” and “doing with” normality. The patient has access to sane human beings with whom they share their mental experience and daily chores. In the process the patient recalibrates themselves to reality and normal human praxis by a process of introjecting the sane other (taking within and becoming the sanity surrounding them). The distinction between thinking and doing is always arbitrary, as there is conversation and cognition even in the doing. What do I think about what we are doing? What do you think and why? From this comes the synthesis of a dish sanely cooked, a house sanely cleaned, a conversation sanely shared and also a sane mind. The language of “being with” and “doing with”, of the psychotic person made sane by practice, reflection and becoming, is evocative for me of the Heideggerian language of “unready to unhand” to “ready at hand”, of clumsily learning only to later reflexively expertly do. Naturally as per affektlogik, it is critical that the emotional tone be soothing and supportive, the makings of a sane and calm logic. Calm logic requires extremely intensive and motivated staffing and support. It would not be possible within a culture of the disinterested workplace periodically assessing safety and mental state with pro forma questions, dishing out medications and generally providing no substantial psychotherapy. This is the prevailing ethos of the contemporary inpatient ward (especially those wards who would deny my description fits).
Empirical evidence in favour of Soteria is equivocal, studies being methodologically poor and largely restricted to young psychotic patients who might well remit regardless the treatment or lack of it. Notwithstanding this critique, the results at least point to Mosher’s relatively radical approach having outcomes not inferior to standard care (i.e. not worse than coercive medication and hospitalization) in similar patients, and, primum non nocere, without the harms. Todays crop of psychiatrists would not believe Soteria possible and probably would not want to believe it to be possible. They would be divided on the basis of how to coercively treat the young psychotic patient for it is reflexively assumed standard psychotic care is necessary and withholding coercion to constitute medical malpractice. Such are explicitly the guidelines of all guilds, who have purchased the nonsense that time off so called antipsychotic medications (the “duration of untreated psychosis” or DUP) is a time at which the un-medicated brain is literally being damaged by the disease of psychosis. Consequently it is thought that coercion and powerful tranquilisation are literally therapeutic and neuroprotective. From the perspective of personal liberty, the medicated patient might only be fortunate enough to choose from a list of similar drugs they will be forced to take. No, rather the debate today is whether the psychiatrist can diagnose and treat the adolescent or young person at risk of psychosis, that is to say one can look across at the troubled teen (adolescence often being a para-psychotic state), look down into the crystal ball, reliably then predict the future onset of schizophrenia and prevent the thought crime before it arrives without serious adverse effects of neuroleptic medication or the diagnosis of “at risk of psychosis” being reified, the label in and of itself qua label placing the patient at risk of one day being declared schizophrenic.
From San Francisco, Soteria spread across the oceans to Berne, certain other European cities and Jerusalem where it remains to this day. It largely fell into stasis in the USA due to lack of funding and being ignored, critique being not unexpectedly bias in its the ideology (see Carpenter and Buchanans piece in 2002 in Schizophrenia Bulletin for example). Today it remains as fragmented and fringe as it was when it was founded almost a half century ago. A pity.
Open Dialogue
Just as the relative isolation from scrutiny in remote Gorizia afforded Basaglia the chance to experiment with what would become realized in Trieste, the necessities of economic contraction and lack of hospital beds in remote Lapland in 1990’s recession Finland drove the beginnings of open dialogue by psychologist Jaakko Seikkula and colleagues at Keropudas Hospital in Tornio, Finland.
An adaptation of psychiatrist Yrjo Alanen’s Need Adapted Treatment model and other Finnish initiatives and conceptually feeding on the ideas of the Russian anarchistic philosopher Mikhail Bakhtin and English Anthropologist Gregory Bateson, Open Dialogue was preceded in particular by an enormous regional upskilling of mental health professionals in the psychotherapies, most especially a full three years training in systemic family therapy. In many ways open dialogue simply is a kind of assertive narrative family therapy where multiple authors co-create the language and the shared narrative. This is central to the treatment model. Patients in a state of crisis or first episode psychosis are triaged as quickly as possible and assessed in home by a team that forms a dialogue around the patient as nucleus. The component parts specifically include the patient, significant others (family is always invited), a moderator and treating psychiatrist and other clinicians (plural). Each hears the perspectives of all others, with a deep exploration of the shared experiences and meanings of what is considered the psychosis. I say “considered the psychosis”, as open dialogue is philosophically grounded in social constructivism and the meaning of the symptoms are not taken for granted as connoting anything alien to normality. Rather the patient’s experiences and their impact are seen to have their meaning only in terms of how this is perceived by the social milieu and what can be negotiated as mutually understood at the close of the dialogue/s. As Seikkula et al write and I wholeheartedly agree
“many psychotic states can be interpreted as reactions to difficult life situations and/or traumatic events rather than as symptoms of biological disorders” and “Psychotic reactions should be seen as attempts to make sense of one’s experience and to cope with experiences so difficult that it has not been possible to construct a rational spoken narrative about them. In subsequent stress situation, these experiences may be actualized and a way is found to utter them in the form of a metaphor”.
In this sense paranoid psychosis can be a displacement metaphor for many things, for power dynamics, for dilemma of personal agency and so on. Eating disorders may similarly be about relationships, about expectations and the dilemma of an ambivalence to maturation, and so on.
Psychosis can even be conceptualized as an isolation in self conversation and isolation from effective conversation with the others in one’s life. Open dialogue itself is the aide to restore what is lacking, and additionally borrows on the ideas of attachment theory and of Lev Vygotsky’s “zone of proximal development in the child.” As Seikkula continues
“This means the space between adult and child, wherein the adult’s more developed functioning provides scaffolding for the child to reach beyond the current limits of his/her abilities. This idea can be used to describe the psychotherapeutic situation as well”.
The sense of what is said cannot be known to the speaking patient until it is reflected off the listener, who in turn cannot know the speaker until they themselves become the speaker and the original speaker the listener. This the flow of a dialogue which is, a Bakhtin realised, inherently unpredictable. Yet it is not chaotic. A certain faith is implied in the shared understanding finding its way towards the kind of sanity that is neither the sole imposition of the family or mental health practitioner, nor the sane becoming as insane as the patient. Together the knots are untied, the dilemmas resolved and the affect responded to in ways less vulgar than certain other therapies such as the grotesque torture porn that is ISTDP (see chapter 6). The therapist reader acquainted with the concept of active listening may see in open dialogue something assumed to be their regular practice, though this is not so. The usual psychiatric conversation and the phenomenology of the participants involves an exchange of monologue and no shared space. I hear what you are saying in response to my own questions and construct meaning within the space of my own analysis. You the patient do the same. Clarification as active listening is a polishing of one own personal monologue even whilst the other is speaking. Open dialogue is about the meaning residing in the centre of the circle, then the participants take it all in together.
Other components of the treatment include the building of rapport whilst all acknowledge the uncertainty of how the crisis or episode will unfold, this being an honest humble admission to the limitations of what mental health professionals can know and predict, along with a deliberate cultivation of an attitude to speak in plain language as opposed to psychiatric jargon. This ethic extends even to the remarkably deliberate practice of the therapists and psychiatrist asking permission to talk about the patient and family, not behind their back as something necessarily isolative and even conspiratorial, yet right there in front of them as part of the therapy. The practitioners can themselves feel invited and open in talking about their feelings, thoughts, concerns about family dynamics, risks, patient beliefs and behaviours and what the treatment plan may involve. In so doing the non-professional characters have reflected back upon themselves an understanding from another perspective in the dialogical shared understanding of the group, the family therapy session being a microcosm also of the world of plural views and uncertain outcomes.
Of medication, Seikkula et al write that
“neuroleptic medication should not be introduced at the initial meeting, and should only be started if other efforts prove insufficient”.
Open dialogue even takes seriously the heresy that…
“neuroleptic medication could block biological and mental functions that are essential for remission. In OD, the more selective use, and possible postponement of neuroleptic medication may give opportunities for the psychotic crises to progress along a more natural trajectory with an adequate sense of mutual trust and security, and this might have a favourable impact on the outcome. Our results are in line with other follow-ups, in which it was found that long-term treatment outcomes for the schizophrenia spectrum population were more favourable with samples receiving less medication”.
Evaluating the results of open dialogue have been made somewhat problematic by the methodology being suboptimal, though the idiosyncratic features of Finlands comprehensive national health system are a methodologists dream and render the results of sufficient quality not to be dismissed out of hand. And these results are quite impressive, with open dialogue patients at 19 year follow up requiring less medication, less hospitalization and less reliance on disability benefits. Notably, proponents write that failure to maintain all patients care under the open dialogue “paradigm” often resulted from “more threatening behaviour”, though it is not elaborated whether this was informed by psychosis or simply medicalized criminality and antisocial personality. This is an important observation by the Szaszian, that implies the gravitational role of psychiatry in social control as an adjunct to the police. Insomuch as open dialogue always contains within it the fall-back option of involuntary hospitalization and treatment, it does fall short of the Szazian categorical imperative, but then does all of psychiatry outside Szasz.
Naturally the American National Institute of Mental Health is reluctant to finance research into Open Dialogue, as recent as 2013 declining to do so as “its paradigm is too different”. In time this brazenly ideological dismissal could come back to bite them. But then they would do what psychiatry is long in the practice of doing, playing lip service to the value of family, psychotherapy, recovery models and other fluffy notions whilst being faithless in praxis to anything but the drugs. And then if ever open dialogue becomes mainstream, mainstream psychiatry can simply say it knew it all along.
Open dialogue is to be commended for its ardent attempts to place the so called medical model into a place more subordinate to notions of the person within the community, and is a damning indictment of the crude medication focused management and medicalization of the youth in Anglo psychiatry.
What To Do With the “Psychotic” Other
Soteria and Open Dialogue are predicated on there being staff adequately trained and adequately motivated. Naturally these models of treatment also depend upon the patient and other “stakeholders” (note the sterility and corporatisation of newspeak) meeting a certain threshold of personal investment, all this collectively being easier imagined than realized. Nonetheless the open dialogue situation, as almost the only game in the town of Lapland, proves that such an approach can be the default first port of call and a refutation that more coercive approaches are absolutely required from the outset. Nonetheless I understand how difficult it may be for the standard Anglo hospital based psychiatrist to imagine this as realistic, a model of care coming literally from the home of Santa Claus. Much of my own career I too have managed more severe psychotic patients highly resistant to intervention, where successful intervention is code for a shift to conformity. Accordingly, the question might be asked what we might do with such persons if psychiatry (which I have established is coercive by definition) were to vanish? Taking the lead from Szasz and to revise the thrust of the previous chapter, if these persons retain sufficient architectural integrity of thought to understand the proposed treatment and yet still decline the "help" offered, the refusal ought to be respected. That is to say that regardless of their beliefs being however so strange, and regardless of what disembodied voices may or may not be counselling them, the vast majority will have the capacity to understand how their own world conflicts with that of others. Regardless the motivations they interpret upon the psychiatrist, they understand what the psychiatrist is wanting achieve in dulling their deviant thoughts and the volume or frequency of the voices. And from this fact they may make their choice to enter into a voluntary psychotherapeutic process, take medication, see a doctor or wise elder or whomever. This is the basic transaction between persons if freedom is to exist at all. Our sentiment to save cannot be permitted to trump the others dignity in facing the consequences of their own self-determination. Such an adjudication of this most basic understanding of mental state in no way requires a specialist of any stripe, let alone a doctor trained in bewitching psychobabble. The recognition of interpersonal disagreement is the stuff of ordinary human life and language. When society dumps the person in the lap of the psychiatrist, society cannot be permitted to divest itself of good sense without at least being reminded of its inhumanity in turning its back on the other. We may not be our brother’s keeper, though there is no excuse in not being their friend or being brave enough to admit we are, in our indifference, their enemy. Nor can “lack of insight” be allowed to be reified and smuggled in, a medicalized substitute to wash away what is essentially someone’s stubbornness to hold a contrary view. At base, we all hold radically different views from another about whom we can say “they lack insight to know better”.
Yet all this having been said, I do take a modest departure from Szasz. There are those persons who retain the normal architecture of thought who might benefit from a conditional and time limited imposition on their freedom to hear an argument that ought to be made, on the off chance their ear is receptive. Once again, this is a normal folk human impulse as a normal part of human life, requiring none other than normal humans who care for the other. One must be a casuist here in the best sense of the term. We can dispense before we begin with the legal positivism, i.e. questions of who might have the authority to temporarily deprive a person of their liberty, for how long and who might police its excesses. Such reflexive concerns around technick are held by statists and socialists and public servants who are terrified of freedom and good sense. Managerialists always wish to have ordinary human life instantiated into law, regulated, mechanized and sterilized of its proper place in the praxis of your relationship to me and vice versa. I refuse on principle to be drawn into such minutia and its traps as common sense really can prevail and the village calibrate itself as to new limits of what is reasonable. Enough to say that anyone in good faith who latches the door and insists on “the conversation” is acting humanely. The conversation with the “psychotic” other can involve how destructive the person’s behaviour is to themselves and others and how divided their perceived world is from the rest. This time limited obstruction of liberty is also the way spouses play out their last ditch pleas and grievances when on the verge of divorce, the bags are packed and one is heading out the door. They obstruct the path and attempt the have the conversation. This is what parents do when their adult child is about to marry whom they perceive to be the wrong person. This can also be the conversation held between the drug user or alcoholic and the concerned other who holds them until they are sober, then lingering the incarceration long enough for a brutally frank plea to change. And this can be the conversation between the one whom we might call psychotic and the one who cares, health professionals being entirely optional. But then as all things do, the conversation must end. The door must be unlocked to a world of freedom and responsibility. None of this requires the psychiatrist to ever have existed.
Then there are those, labelled schizophrenic or not, whose architecture of thought is in such ragged disarray that we cannot infer what they are thinking (these are far rarer than the propaganda would have us believe), or those whose mind is thrown into turmoil by some unambiguously somatic psychosis (more common) or drug toxidrome (these are very common) that has rendered them mad for a time. Naturally we might find due place for the doctor here, though any species of doctor ought to be up to the task. Naturally also the hand of care is extended in such an instance and the inference is made that the patient lacks the capacity to assent to what we assume they might retrospectively agree in time. That is to say, unless and until they have regained the capacity for "the conversation" they can be detained. But when the conversation is had, even with a threadbare modicum of logic, we subsequently accept the choice of what the patient wishes to do with themselves. They may tell us to go to hell and alight into the street, a transiently sane person seeking that maddening substance and maladaptive behaviour all over again. What is the doctor to do with these frequent flyers? Continue to stretch out the caring hand to the one who bites it with ingratitude? Or might the doctor be able refuse to partake in what has become a sadomasochistic vicious cycle? This is an ethical question, and ought to be an individual one. We must admit for now that just as every trapeze artist is more daring when the safety net is under them, sometimes one has to be cruel to be kind. Remove the net and allow some to fall. Then people who may recklessly climb the pole may think otherwise. And no trapeze artist ought to have the right to compel a whole industry of potential net manufacturers. So have the assertive conversation if you wish. Have it once, maybe twice. But make it short and shake on what is understood to be agreement or disagreement. If the latter, let them go.
What to do with the addict and addiction psychiatry
Some wake one morning and decide they are done with a bad habit. Like the Roman conception of genius as having leapt out of walls and into the body as a benevolent possession, we are left wondering at the mystery of why some so easily and suddenly make changes for the better. These are the lucky few. For most, breaking away from a bad habit or breaking into a good one might be the most challenging quests they ever embark on. Success in beating an addiction really is something worth telling your grand kids about. On the way to victory your life may be a meditation where abstinence and sobriety are the mantras of every waking moment. You must guard yourself against every temptation, and the liar within is a wily fox. Every step you take is the question whether turning left or turning right will increase the likelihood of use. The wall of fire to the left and the wine bottle to the right, walking into the fire will be the truer and safer course. Along the way there are medications which can aid you, though this is hardly an argument for a biological basis to addiction. Along the way there are those who can guide and walk with you. Along the way too are unavoidable moral questions. Proximal relations to your unrealised potential and neglected or abused significant others is only a fragment of these concerns. You must ask yourself also if what you inject or smoke or sniff bankrolls somewhere side operations in forced prostitution in South Asia or some innocent literally fed to the dogs in Mexico to make a point. “Will power” is mocked as intolerant, stigmatizing and victim blaming by a psychiatry wanting you to need them as a proxy for yourself and what you might achieve in self-governance. Reflect upon this. Reflect upon the praxis of all deliberate human action. If not by the power of will, then by what power do you do anything that you choose to do?
What to do with the mad who do bad
Forensic psychiatry is the adjunct adjudicator over two forms of punishment. Through one door is the prison, likely for a term of incarceration with a fixed upper limit. Through the other is an indeterminant and perhaps lifetime sentence in psychiatric hospitals, a sentence that bends and stretches as much as it contracts. At minimum the parole is for life and release is conditional. Domesticating zombifying medications are almost always part of the mix. Psychiatry is to prisons what Huxley’s Brave New World was to Orwell’s 1984. The hateful love of SOMA or the loving to hate of O’Briens torture chamber, makes no difference to me. Either way ethics dies. Individual dignity consists in part in acknowledging personal responsibility. One of many marks of a dignified society is the humane treatment of its prisoners. When a crime is committed by one who might fall within the orbit of madness, the question of “diminished responsibility” is a Trojan horse. It’s sophistry. The trick is first in convincing you it is relevant. The psychiatric defence is the appearance is love and the reality is dehumanization and othering. Dignify the guilty with responsibility. Dignify the consequences of crime with a just punishment. And dignify society with a humane prison system blind to the motive and all peddlers of excuse making.
What To Do with the Neurotic and Melancholic
A book such as this is not the place for an extended review on what depression and anxiety are, or personality and the personality disorders for that matter. Suffice to say for now that medication (especially SSRIs and SNRIs and off label use of so-called antipsychotics) are rarely anything but glorified placebos and/or have nonspecific emotional blunting or drive blunting effects even before we talk about unacknowledged adverse effects. This is my opinion, held not without some basis in evidence. In any case, coercive psychiatry has no place in the vast majority of patients who are described as depressed, and never in those who are anxious or with so called personality disorders, regardless of whether they threaten to kill themselves or others. This is not to deny the place of the non-coercive doctor who become trained in one of the other so-called psychotherapies. These and other “clinicians” can compete with pastors, gurus and wise grandmothers within a marketplace inhabited by a plethora of rational actors and rational consumers. The secular mindfulness practitioner can compete with the practitioners of the contemplative schools of the major world religions, with my humble advice being to choose the latter over the former. The doctor in particular might additionally compete with the local bartender and drug dealer in leveraging their own unique talents as potential experts in psychopharmacology. That is if that is be their interest with caveat emptor both practitioner and patient alike. Zooming out, the voter can negotiate with government what therapies are to be tax payer funded to these voluntary patients, or not as the case may be.
Nevertheless, psychotherapy is nothing special. It is not something you do to the person, as in take two tablets or ten sessions of psychotherapy. It is a journey taken with the person who walks alongside and occasionally thrust ahead to journey forth on their own. Let us please not be mystified, psychotherapy is nothing more than guided conversation plus/minus a few extras. After all the empathic hooks and rapport building (i.e. so called therapeutic alliance) are put to one side, it all boils down to a confrontation with self, world and choices. The past is a film we can watch without influencing the objective plot already played out. Insomuch as we are doomed to a certain degree of subjective interpretation, we have certain constraints here also. What are the boundaries to knowing the truth of it all? What are the boundaries to me wanting to know? To what extent do I gas light myself as to who I was to the world and what the world was to me. You can pick your metaphor in looking to the past. Is it a boil that simply must be lanced, squeezed and washed out of its pus? Or is it a stain that can never be washed out. The past can be both or neither, both infused with positive and negative value. Then there is myth of the present forever becoming the past and the future that dies in the ever vanishing present. The world presents us with constraints of what others are willing and able to do. Our thoughts and emotions emerge from mystery. We can at best choose what to attend to and make effort to bend ourselves to our own will. All psychotherapy is this. What do you choose to do and be with what you have? How can you endure the outcome good or bad?
What to do with the Suist.
In an earlier chapter I imagined that certain readers may view my formulation of suicide and its (anti) management as cruel, a charge against which I offered some meandering defences. Suffice to say that no one can, or at least no one should, deny the tragedy in all suicides. Similarly it usually requires tremendous stressors to bring one to the point of contemplating self murder. Many of lives of almost unimaginable trauma. So let us not trivialise the shoes of those we have not walked in. But…….in the previous chapter as in this one, what will be repeated is a call for heeding the warning of the rule of unintended consequences. Herein I’ll expand. Were we to completely turn a blind eye to suicidality as expressed/threatened suicidality, then the mainstream psychiatric industry would predict that there would be an explosion of suicides and umpteen persons suffering in the silence of having their darkest thoughts unheard. They would say there would be countless cases of untreated mental illness and a core feature of the patient’s psychopathology (i.e. suicidality) would be cruelly swept under the rug. They think that a constant focus upon suicidality is the recognition of a monster. I claim that to the extent there is a monster, it will be what it will be. To the extent we hunt the monster as a focus of concern we create more monsters than we discover.
Additionally, I stand firm to the unfashionable and much maligned view that suicide is to be left as a choice. Any discussion about it ought be couched back in the context of all the persons problems, this in turn part of an entirely voluntary discussion between the person themselves, along with significant others.
With such a change as I propose I offer the following prediction; were psychiatry to vanish some would suicide as they always have. I’m thinking here for example of the bankrupt farmer amongst other bankrupt farmers who quietly walks into the barn one evening and hangs himself. He never came to the attention of psychiatry and he was never likely to reveal any hints of what would be his final behaviour, even were he to be asked. Of course, the retrospectoscope is a most powerful instrument and people will make all manner of posthumous “I can see he was going to do it”. But beware those false prophets who give you the lottery numbers after they have been drawn and never reliably the week before. We will all be able look back and see the signs after our farmer friend departs from us, none of which could predict why him and why now any more than a thousand other farmers who will be found alive the next day. Or there will be the impulsive suicide from the drug addled mind previously not known to psychiatry, the only preventative remedy of which is to lock up all users and envelope them in bubble wrap. Such a preventative remedy will last as long as the addict remains wrapped up or enjoying that particular high where they are not dysphoric, their mind somewhat organized and not inclined to kill themselves. In either of the above cases the only preventative remedy is the furtherance of a socialist nanny state under the guise of care and compassion. This I believe is axiomatically evil on one hand, and on the other will create in some of the populace many thousands of state suckling infants with no resilience. In the case of our farmer and other liberty loving folk, the intrusions of the state into his life may be enough of an incursion as to actually encourage a desire to kill himself. I’m not joking. Deprivation of freedom by a nanny state is a stressor the likes of which may contribute in small or large part to death. Missing the root causes misses the point.
Were psychiatry to vanish tomorrow I will grant that the marching brigade of suists would continue turn up at emergency departments. They would be drawing on the expectations and enculturation up to that day, as would the emergency room staff themselves. Some may find it difficult to adjust to the change. Under the inertia of habit, the patient may lead by playing the suicide card and know other card to play. Were the emergency doctor, nurse or psychologist refuse to play the game and instead empathically discuss practical issues, personal agency and insist suicide to be a personal choice, its currency devalued to purchase action or fear, the resultant would perhaps be a temporary spike in threats, attempts and even completed sincere suicides. But I predict people would gradually adjust after the spike. They would talk suicide less and attempt suicide less. Insomuch as suicide would lose its instrumentality towards other ends……shelter, medication, attention towards psychological pain not in proportion to the pain itself, the cultural idiom of unhappiness that people take most seriously and the social contagion of the idiom, suicide as punishing others etc……., we would see a radical stripping away of all that is constructed and perpetuated by psychiatry itself. Suicide would lose its sting. Any temporary worsening of things I would not frame as the proverbial price worth paying. Such would be to imply I do not care about the loss of human life, this hardly being the case. Such would also imply that a change in strategy was towards some instrumental utilitarian goal operating upon objects without agency. Not so. Mine is a strategy necessarily following from a recognition of what it is to be a human being with free will. Now I said in a previous chapter and here to repeat, placing suicide back into the hands of the person themselves is one of the greatest acts of respect and love we can give another. It recognizes the most precious existential qualities we have (or ought to have) within ourselves, i.e. free will and personal responsibility. If psychiatry went away there would still be family physicians, nurses, pastors, spouses, lovers and grandmothers who, as humans, can hear and care about the lives and stories of others. They could continue work towards practical solutions and the mobilization of resources within the community with which to address the problems within and between people. And when the subject of suicide arises as it inevitably will from time to time, the response ought to be that such an act would be supremely regrettable for sure. Yet we ought to affirm it to be the choice of the potential suist nonetheless. Suicide as a subject of conversation ought to always be redirected into a recognition of personal agency. That is not to say that I am a radical libertarian completely against all deprivation of liberty made by caring others. If a loved one is about to reach for the noose then tackling them to the ground and conscripting the others to action against liberty is a very human and very understandable thing to do. It naturally unfolds not as a technik response to a public health policy, a mechanization of morality. Nor ought action to follow from the constructions of psychiatry as an elite to define what suicide is. In such a world as I imagine psychiatry would be no more and so no more to be leaned on. Neither would it be the business of police unless and until police get a grip on crime or the police officer were acting as a free citizen acting in good faith. Why? Because police are in the business of preventing crime and suicide is no crime. But the question is not what to do in the heat of human passions and the impulse to save another. The question is what to do the next minute or the next day. What could or should follow a thwarted attempt is a frank conversation, human to human, a beseeching and petitioning if required, even perhaps a prayer or two. The “conversation” is that time to remind the suist of their duty to self and others and any reason left to live or at least postpone death for a time. I commend the reader to Mccarthy’s novel “The Road” (or it’s film adaptation) for a conversation such as I describe, this between the character of “the man” and “the mother”. The scene depicts the brutally conflicted and devastatingly tragic tension between holding on and letting go. Nonetheless all conversations come to an end. At the end of this conversation the potential suist would either take a step towards life or a step towards the noose. Surely it is their choice to make.
To Reform or to Dissolve
I want to repeat here a point earlier made. In the 21st century there are nominal psychiatrists who dislike diagnosis a la DSM, dislike the “biological model”, favour psychotherapy, dislike excess use of medication and personally eschew the wielding of coercive power that defines their profession. Often heresy extends to being completely at odds with their entire guild machine and all that it promotes as orthodox psychiatry. In the UK they call themselves “critical psychiatrists”, a fitting name given the implication that the guilds are not self critical at the least, or not critical thinkers at all. One may find psychiatrists critiquing psychiatry at criticalpsychiatry.co.uk or in the US clustered around the journalist Robert Whitaker and his madinamerica.com website. And yet I wonder why these gadflies do not take a leaf out of the book of Martin Luther or a million other heretics before and since and make a complete break. How far can they find themselves at odds with their guild whilst in good conscience or logical coherence say “I am a psychiatrist”. Don’t they tacitly embrace a pragmatism taken too far, a rather strange notion that a psychiatrist can be anything and everything they want it to be whilst still claiming to be experts? Speaking personally, I have certain experience in psychiatry sure. Yet I find the idea I could ever identify with the title of “psychiatrist” logically incoherent and dishonest if one is radically critical of it. Speaking personally, I amassed a dozen years of experience without being ordinated into the guild of psychiatry for the simple reason I would not be comfortable identifying with the title. I would ask so called critical psychiatrists do the same. Cease involvement with the guilds. Cease identifying with the use of the term psychiatrist. Stop trading on the legitimacy of a title whose guild, history, and current practice you so deeply critique and have so soundly divested of value. Start over if you are truly progressive. My challenge is hardly progressive, for mainstream psychiatry is hardly the product of the conservative mood either. It taps into a different politic. That being said, I do not wish to alienate myself from critical psychiatrists whose virtue and brave honesty deserves commendation. But there’s hypocrisy in wanting to deconstruct ones cake and have it too. Mainstream psychiatrists are therapeutic statist socialists wishing to use force to liberate the patient from the clutches of their mental illness, in so doing engineering the new man of homo psychiatrus. The critical psychiatrists want to rescue the mentally ill from the guilds, and much more so the bogey man pharmaceutical companies and the side effects of the poisons they peddle. But who and what is ill and who and what are you to save them? Moreover, drug manufacturers only exist because there are drug dealers, that being the psychiatrist. And drug dealers only exist because there are drug users, that being the patient. And excuse makers only exist because there are excuse consumers, which may be all of us. Where is agency in this? Where is personal responsibility and liberty under a rule of law that sits outside psychiatry in whatever form it may take? Where is the scepticism that a person is only truly free if free from even the well intentioned reformer? Why not just dissolve all that is and might be psychiatry back into the world of person and family, or free citizen living community and (ideally) a minimal state?
I wish to penetrate deeper here into a critique of the critics of psychiatry. They are in danger of being like those characters of certain science fiction films, longing to wake from an unreal nightmare world only to be unwittingly find themselves in another. Problem arise even when we eschew the so called biological or medical model of psychiatry, the myths of chemical imbalances and the pushing of pills, the excesses of coercion etc etc etc etc and begin talking of mental illness being more socially informed and constructed, and more amendable to therapies on the social and psychological axes. But what have we achieved and have we really escaped our prison? By extension who else have we really liberated from theirs? We still place the person within the domains of functionality and dysfunction, of being the product of formal and efficient causes, of being a co-ordinate system of bio, psycho and social, of having an illness for which we simply have arrived at a different more humane formulation. But we would still be operating thoroughly within an engineering meta-schemata void of moral and real human life. We still seek to identify causal chains, classify, compartmentalize, formulate, plan, measure and act upon the problem to the ends of its correction. And were we to progress to an alternate psychiatry, the hue and cry would still be for the care of the mentally ill. Each year the funding would become larger, the mental illness disability pool would continue grow in disproportion to physical illness, the ranks of the mentally ill would balloon as they have done for each previous successive wave to address the mental health crisis in the past three decades. An end to all this! We can do away with ninety percent of the drugs and ninety-nine percent of coercive treatment. We could do away with one hundred percent of the jargon. Psychiatry should replace itself with this; two individuals situated in moral space, one ideally wiser than the other. What do you wish to be and what ought you to be? What is the life worth lived? No diagnoses. No talk of recovery. No promises. This should be the beginning and end of psychiatry, which is to say psychiatry would no longer exist as an arm of the state or a specialty of medicine. Time to work towards the dissolution of psychiatry. Time for community to grow up and not outsource its heart and mind to managerial parent objects. Only then can the person truly exist and truly be free in a community of others. And it is freedom, existence/existenz (and responsibility) I wish for you.
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