Primum non Nocere: A Psychiatrist’s Review of “Medicating Normal”
I was lucky to see a screening copy of the documentary Medicating Normal (2020, directors: Lynn Cunningham & Wendy Ractliffe) earlier this weekend, and this post is intended partly as a review and partly as a way of organizing my preliminary thoughts and reactions to it.
As described by the filmmakers: “Medicating Normal is the untold story of what can happen when profit-driven medicine intersects with human beings in distress.” The film is well-made and remarkable. It is engaging and rewards emotional investment.
The focus of the documentary is on the harms of psychiatric medications, the harms these medications can do while one is taking them, and the harms these medications can do when one tries to stop taking them or has stopped taking them. The documentary primarily focuses on the stories and experiences of five individuals who took psychiatric medications and experienced derailment of their lives. There are also interviews with various authors/commentators/experts (which include Allen Francis, David Cohen, Anna Lembke, Robert Whitaker, Peter Gøtzsche, among others). In terms of medications, the focus is mostly on benzodiazepines and stimulants, to a lesser extent on antidepressants, and very little on antipsychotics and other psychotropics. The documentary doesn’t make much of a differentiation between these different medication groups in terms of their harms and risk of dependence and withdrawal, and generally paints them with the same brush.
The personal narratives of the ex-patients/survivors are certainly the most powerful component of the film. They are also the most persuasive: the tremendous suffering of these individuals is indisputable and heart-wrenching. Common threads among these various stories are: high “premorbid” psychosocial and occupational functioning; experiences of anxiety/trauma/grief/stress/insomnia which were diagnosed by various clinicians as specific mental disorders (PTSD/GAD/MDD, etc.) with little to no exploration of the psychosocial context; these diagnoses were offered with a generally implicit disease-based understanding; psychotropic medications were prescribed, with little to no informed consent, and the potential harms of these medications were either not discussed or discussed in a manner that severely minimized them; there was typically quick short-term relief, followed by onset of side-effects and problematic experiences (emotional blunting, cognitive impairment, suicidality, psychosis, worsening anxiety, etc.); these new experiences were attributed to the progression of their disease with little to no consideration that these might be due to the medications; this led to a cascade of multiple additional diagnoses (ADHD, MDD, psychotic illness) with compounding polypharmacy such that many of these individuals were on psychotropic cocktails which included benzodiazepines, stimulants, antidepressants, and antipsychotics; this was followed by a rapid decline in psychosocial and occupational functioning leading to a disabled status; years of misery and disability in which their disability continued to be attributed to their illness and not to their medications; slow loss of trust in the system; decision to go off medications; experiences of withdrawal; finally coming off medications and slow restoration of psychosocial and occupational functioning.
Supplementary to these terrible experiences with psychotropic medications is another background narrative that pops us repeatedly. That narrative challenges the validity of psychiatric diagnoses – and the attribution of disorder/disease status to the experiences of these individuals – which provided the justification for the use of medications, with the subsequent iatrogenic cascade. The sentiment is that: “We were experiencing stress, trauma, grief, life issues. What we needed was reassurance, normalization, empathy, time, and psychological support for healing. Instead we were offered quick diagnostic labels, told we had a disease, and prescribed medications with no informed consent, which made everything exponentially worse, and destroyed our lives.”
This narrative is sometimes accompanied by criticism of the DSM, in which the DSM is described as having no scientific basis, in which the diagnoses are “all made up” by committee votes and have no basis in reality. There is some discussion of our culture in which we have become intolerant of any sort of distress and suffering and see it as a medical problem. There is also much discussion of the evils of pharmaceutical companies, their nefarious tactics, and their corruption of science as an instrument of profit.
On twitter I’ve recently been talking about the relationship of text and subtext. Arguments and evidence exist in a certain ideological and structural context. If we look only at the subtext, we risk losing the tether between our worldview and reality. If we look only at the arguments, we risk ignoring the ways in which arguments are tools to be wielded as means to an end.
The way this documentary is received by psychiatrists will depend heavily on the subtext as well as some aspects of the text. The body of works and opinions of individuals such as Robert Whitaker and Peter Gøtzsche with their long history of controversy shapes that context; the active adoption and endorsement of this documentary by various groups and platforms long felt to be unfairly critical of psychiatry also shapes that context. Aspects of the narrative – which rather simplistically see psychiatric diagnoses as unscientific – will also provoke certain typical reactions. There are many legitimate criticisms to be made along those lines. There is also the case that the clinical practice and prescribing patterns that we get to see in the documentary fall well below the standards of good psychiatric practice that I was taught as a resident as well as standards that are enshrined in current practice guidelines. So many psychiatrists can reasonably protest that what happened to the individuals in the documentary was not supposed to happen. Yet it is also the case that it did happen and that it has happened and continues to happen to a woefully large number of individuals across the world. The question of good psychiatric practice aside, it is the case – and I speak from my experience of psychiatric training and from what I’ve observed in my psychiatric colleagues and teachers across many institutions – that many psychiatrists severely underestimate considerations of certain sorts of iatrogenic harm and withdrawal reactions.
What we are witnessing is a failure of pharma, a failure of regulatory agencies, a failure of legislation, a failure of academic medicine, a failure of funding agencies, a failure of psychiatric institutions, on such a massive scale such that the only thing left for ex-patients/survivors and other concerned citizens to do is to take up the mantle themselves, armed with their personal experiences and the tools and information at their disposal. They were sold a hollow understanding of their distress, and they were offered cures which turned out to be poisons for them, and now they are reclaiming their stories, and understanding and interpreting them on their own terms.
Just as the disease-based understanding of psychiatric diagnoses is simplistic, misguided, not-the-whole-truth, the notion that psychiatric diagnoses are “all made up” and unscientific is also simplistic, misguided, not-the-whole-truth. Yet I say this from a position of power and privilege; I say this with years of philosophical and scientific reflection, which allows me to think of psychiatric diagnoses in a conceptual manner that is different from that of the average clinician as well as the lay individual. My ivory tower philosophical search for truth is far removed from the experience of the harmed patient in the documentary, who cries out at one point, “What have all these diagnoses ever done for me?” (I am somewhat paraphrasing here based on my recall).
I can anticipate that many psychiatrists will react to this documentary in a very defensive manner. They will bring up legitimate criticisms and will focus on the subtext of the movie, some of which I’ve briefly touched on above. They will focus on how this is not representative of all psychiatrists, how this is not representative of good practice. They will also focus on how normalization fails to do justice to the experiences of individuals with serious mental illness who are genuinely impaired and suffering, and psychiatric medications, for most of them, offer a realistic hope at some semblance of normalcy and alleviation of suffering. I agree with all that.
Yet to do so exclusively will also miss the larger point of the documentary. Psychiatry can continue to be aggrieved and defensive for good reasons, but in my view that is a precarious strategy and may simply be a recipe for future irrelevance. The conversation is no longer in the hands of the psychiatrists. The conversation has moved into the community. The pandora’s box is open. Many individuals have lost trust in the medical system, they have lost trust in organized psychiatry, they have lost faith in the ability of psychiatric diagnoses and medications to help them. These individuals are taking ownership of their distress and making sense of it in ways that speak to them in more authentic ways. Organized psychiatry has a choice to make here. It can continue to pretend that everything is hunky-dory, and it can continue to dismiss the experiences of harmed patients as anecdotal evidence. Or it can begin to acknowledge the reality of harmed patients, the myriad ways in which we have ignored them and let them down, the ways in which we have allowed the profit and greed of pharmaceutical companies to corrupt our science, and the ways in which we as a profession are failing to offer narratives to our patients that do not reduce their existence to disease and disability.
Awais Aftab is a psychiatrist in Cleveland, Ohio.
* My interview series for Psychiatric Times “Conversations in Critical Psychiatry”