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 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 with more authenticity. 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.
See also:
* My
interview series for Psychiatric Times “Conversations in Critical Psychiatry”