Concern, angst and doubt…

There has been an interesting discussion taking place this week through the Critical Psychiatry Network regarding the interplay between critical ideas and prevalent practice in mental health services. I thought it might be interesting this week in my blog post to share the e-mail that I sent to the group and see if any replies come in through the wonders of the internet… These concerns, as I state at the end of my post, worry me a great deal and leave me in quite a considerable sense of doubt. So, if anyone wanted to put me out of my misery by instantly dismissing my concerns in a comment I would be very grateful…

The e-mail

I’m currently in a, somewhat, privileged position in that most of my time is spent on my PhD with clinical contact maintained through a prison clinic, out-of-hours work and the occasional court report.

I prescribe, including antipsychotics, in my clinical practice – but try to formulate this as the beginning of work together, not the end point. With the intention of prescribing being relief of distress and allowing for development of a therapeutic relationship for future work. Prescription is intended to be short term for management of crisis, or transition points. I find myself distanced from diagnosis, which simply does not represent the distress I see in my clinic, or reflect what I find in my reading of the academic literature.

My academic work is based in a strongly bio-medically orientated psychiatry department that also emphasises risk through epidemiological assessment. I am fortunate in that my own academic work is more psycho-socially orientated and, although this alienates me from many of my academic psychiatry peers, I am supported by one supervisor with a background in medical sociology.

My joint academic – clinical work spares me from many of the frustrations of the paperwork that Clare describes at present, although this will obviously become more of a problem in the future.

My position leaves me with a number of concerns however that I wanted to share:

1. Paranoia and distress among prisoners: – Many of the people I meet through my prison clinic present with high levels of distress accompanied by low grade feelings of paranoia, auditory hallucinations associated with rumination and impulsive outbursts of anger and aggression towards peers or authority figures. I find that these experiences respond well to very low doses of antipsychotic medication and that there is a marked decrease in experienced distress and improvement in engagement with myself and other clinical staff. While the person remains in prison it is easy to monitor for side-effects and investigations, e.g blood tests, are easily arranged. I am left concerned however by a number of factors:

◦ The prevalence of these experiences within prison highlights to me that this is a “normal” response to the prison environment and alienation from your family / friends. This point is emphasised by the high rates of antipsychotic diversion and abuse in prison populations.

◦ Prison stays are, mercifully, often brief in this population. This means that many people will leave prison during a planned brief course of antipsychotic medication. While I try to send an accompanying care plan to their GP / CMHT indicating my intent to discontinue the prescription in the near future I have no way of knowing that this plan is followed through and am concerned that the prescriptions continue into the longer term.

◦ As I stated above I formulate the role of medication as allowing development of a therapeutic relationship. However as I have also said prison stays, where I work, are brief. This leads to fragmentation of care and a number of re-formulations of experience / alterations of treatment paradigm as people shift between clinical teams. Many of these people have experienced adversity during early life interactions affecting their ability to relate to others – development of therapeutic relationships is therefore difficult, and rendered almost impossible by frequent changes of clinical team.

2. Diagnosis and the interaction with criminal law: – While the rates are low there are a small number of people who do come into contact with the criminal justice system during an episode of what, I conceptualise as, acute distress with loss of reality testing capacity (I think of this as defence). The criminal justice system works in very black and white fashion – how then do we convey the complexities of our concerns with diagnosis to the courts? What is the correct legal “disposal” of these highly distressed and vulnerable people – prison or hospital? If we drop the language of disorder how do we work with the home office in their own language of recidivism rates? I am aware that “Risk” is likely a dirty word to many in this group – but while working with the home office and prison and probation networks I am concerned it is something that needs to be addressed in order that we can maintain hope for our clients?

3. Aggression in the context of distress: – Within the framework established by most mental health services acts of aggression are met with efforts towards de-escalation, isolation, restraint and ultimately chemical restraint through “rapid tranquillisation”. In my experience, and in my reading of the literature, there is also evidence that prison officers construct opinions regarding mental disorder in the face of aggression that does not respond to intervention on their part. I am concerned about the iatrogenic effects on agitation of antipsychotic medication used during rapid tranquillisation – to me if you isolate the individual from their distress through antipsychotic treatment you risk escalating the aggression still further. However, while I may disagree, the role of antipsychotics seems firmly established in the minds of many – witness the prevalence of the “5 n 2” prescription (Haloperidol 5mg, Lorazepam 2mg). While I have concerns about the support / treatment routinely offered I have no doubt that agitation and aggression in the context of distress do exist; so how do we best manage this in a woefully under resourced service? I am strongly against the use of medication in order to contain the individual within an environment but my own research has shown that this is a consideration in the minds of psychiatrists when they make prescribing decisions (publication in press).

4. Alienation of those taking psychotropic medications: – There are a substantial number of people, including many prominent service user voices, who accept medication and perceive benefits from its prescription. They read and engage with debate around the nature of diagnosis and psychotropic prescription. Much of the tone of the debate however leaves them feeling alienated and concerned that by accepting medication they are portrayed as being “weak”, unable to cope without the “chemical crutch”. My argument would again be that accepting medication is only part of an on-going dialogue and that asking for help can never be perceived as weakness. For many the limits and idealogical frameworks of the mental health services restrict their access to any dialogue beyond medication and so we return to their initial problem of wishing to engage with discussion and debate, but not wishing to be stigmatised. I find that this tension can be handled through individual, face-to-face, discussion (or even tweet-to-tweet through Twitter) but the narrative of “weakness” does persist. How do we handle this message?

I’m sorry for the length of this e-mail (rant) but these questions have been known to keep me awake at night. If they can be dismissed through simple argument, by someone more intelligent than myself, I will be extremely grateful.


I’m struck by the uncomfortable position that I find myself in. At medical school I was trained in a biological approach to disease that brooked no uncertainty – there was pathology within the person that caused them distress, the ultimate response was to excise the pathology and relieve the distress. This approach was extended to my psychiatry training, which while mentioning biopsychosocial approaches to mental disorder seemed to use this more as a shield against critique than to actually be informed by its implications.

My own reading and clinical experience has left me in a far more uncertain place than when I graduated from medical school –  with only one clear conclusion – ignorance is bliss

One way to address these concerns would be in some form of personal therapy no doubt, if only I had the money for that. In the mean time I will continue to work through my doubts while walking the dog…

3 thoughts on “Concern, angst and doubt…

  1. “…role of medication as allowing development of a therapeutic relationship”
    I firmly believe that people form relationships not medications, but I do empathise with what you say about the alienation of those taking meds and I have directly challenged this of activist peers and been accused of being some medical model sop allegedly wanting everyone forcibly medicated for life.
    The reality of my position is this – I respect anyone’s choices, so long as it’s a real choice i.e. full info/trial data in an accessible format, access to SU experience, and for this to not be the automatic default 1st line of treatment, sole line of treatment, or to be made contingent on further/on-going support. I have friends who have made a real informed choice and I respect that, because all choices have positive and negative costs and no one has the right to gain say what people “should” do.
    I also have friends who take medication because they fear they would lose support if they did not, or be viewed as non-compliant. I worry about SU’s viewed as ‘treatment resistant’ when the drugs they have taken have seriously adversely physically affected them.
    I do want everyone to have the right to manage their distress unmedicated if they so choose, even with negative consequences. A diabetic can choose to smoke, drink, eat badly, mismanage their meds/checks to the point of kidney failure, blindness and amputation, therefore mental health SU’s should have the same right to manage or mismanage whatever the consequences because for some people they would rather take those risks than endure the effects of meds day in day out. It’s right/wrong/weak/strong to take or not take medication, it should be an informed choice without prejudice.

    • Medical ethics – respect for autonomy is paramount.

      I agree that it is people forging relationships, not the medication per se, but I also believe that relief of distress through use of medication can facilitate this process.

      Having said that – medications are symbolically rich in their own right and our relationship with them – both as service user and clinicians are deeply complex and endlessly fascinating.

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