Notes on a Recent Appointment with a Psychiatrist (Guest Post)

Guest Post

by

Anonymous Philosophy Student

I will be attending a philosophy MA program in the UK soon, and as I have never been to the country, I planned a preliminary trip to the city in which my university resides to orient myself. I was soon reminded of my severe fear of flight. I canceled the trip less than a week before I was to leave, forfeiting a substantial amount of money in flight and lodging fees. I decided to do the mature, rational thing, and seek a medical solution: I made an appointment with a psychiatrist. Something I hadn’t done in many years.

Sociologist of medicine Howard Waitzkin wrote about what he calls the “micro-politics of the doctor-patient relationship,” in his book, The Second Sickness: Contradictions of Capitalist Healthcare. It contains a number of transcriptions of doctor-patient interactions and analyses of them elucidating the political commitments and power relations embedded in the seemingly sterile clinical scenes. He writes that “certain features of doctor-patient encounters do medicalize, and thereby depoliticize, the social structural roots of personal suffering.” He contextualizes this as a form of Gramscian cultural hegemony or Althusserian interpellation. In order to reproduce social relations supportive of capitalism, a brute force police state could be used, but a more efficient method is to let this reproduction play out in the space of “free” choices. That is, while medical professionals hold the authority to physically confine patients, often their power functions at a less corporal level. On the Foucauldian taxonomy of power, this is closer to biopower than it is to sovereign or juridical power.

An example of this form of power might be: instead of recommending an Amazon fulfillment center worker to unionize and demand better working conditions, a doctor might instead prescribe a medication for back pain and another for stress and anxiety. My recent visit to a psychiatrist both fell into line with Waitzkin’s ideas, and in other ways, flew in the face of the obscuring effects of ideology, erupting into a deliriously comic Real.

I should provide some background information. My first encounter with these “psy-professions,” as sociologist Nikolas Rose calls them came when I was 17 years old. I was diagnosed with depression, attention deficit disorder, and general anxiety disorder. I have received other diagnoses over the years, but they are all variations on the above, given the ever-shifting nature of the Diagnostic and Statistical Manual. I have been prescribed anti-depressants, anti-psychotics, anxiolytics, and stimulants for these “illnesses” over the years, though I currently use no psychiatric medication. I have been psychiatrically hospitalized. I believe the distress leading to this hospitalization was caused by abrupt discontinuation of both daily stimulant and anti-depressant use, and the subsequent withdrawal symptoms. I have a history of illicit use of opioids – a much more effective antidepressant, I think, than anything in the psychiatric pharmacopoeia – but I no longer partake. This will become relevant later.

I made a grave mistake at my appointment: I did not lie to the psychiatrist. I followed all the instructions and gave family history, medical history, history of drug use, and so on. I was told by the psychiatrist that, due to my past issues with substance abuse, I could not be prescribed anti-anxiety medication. The psychiatrist used this turn of phrase multiple times: “I wouldn’t give a diabetic chocolate.” What is implied here is that drug-addiction is a disease in the same way diabetes is. Philosopher Jacob Stegenga, in his book Medical Nihilism, has written forcefully about deficiencies in medical science generally, but particularly with regard to “magic bullet” theories of medical intervention. Ironically, Stegenga says that insulin treatment for type 1 diabetes is one of the few true magic bullets that medicine has. Insulin targets a very specific biological site and no others. It has its singular desired effect: it regulates blood sugar in those whose bodies’ naturally do not, and does nothing else. Very few pharmaceutical interventions meet these criteria.

Even though the DSM 5 contains variations on “substance abuse disorder,” I do not believe that these disorders are at all analogous to a disorder like diabetes. Sociologists Peter Conrad and Craig Reinarman have written about the origins of the disease model of addiction, noting that it was the Alcoholism Movement and 12-step Movement who originally enlisted medical doctors to popularize the disease model of addiction. The Big Book of Alcoholics Anonymous contains descriptions of the condition like this: addiction is a progressive disease, and if you do not abstain from substance use completely, you will die. You cannot moderate substance usage. Any exposure, no matter how limited, will engage the relinquishment of your autonomy to the power of the demon drug, leading to increased usage and death. The underlying assumption of the DSM 5 is that, eventually, science will locate the specific physical bases of mental disorders and develop drugs which treat them in the way that insulin treats type 1 diabetes. So far, this paradigm has categorically failed.

At the end of my appointment, I was prescribed a high daily dose of an SSRI anti-depressant, its anxiolytic effects being a so-called “off-label” use. The psychiatrist told me that the medication would initially exacerbate my anxiety, and that each step of “ramping up” my dosage to the proper anxiolytic amount would further worsen my anxiety. The paperwork attached to the prescription bottle lists “side-effects,” including “anxiety.” I was not warned of the physically addicting properties of anti-depressants, or that coming off of them often carries with it a physically and emotionally brutal withdrawal syndrome. I have experienced this before, and have witnessed friends and family go through it in misery and confusion, with no doctor prepared to acknowledge the cause of the condition. I was not presented with any evidence of the efficacy of the medication I was prescribed (A utopian dream, to be sure.).

It is unclear if selective-serotonin re-uptake inhibitors are effective treatments for depression. It is even less clear if their “off-label” uses are effective either. The “chemical imbalance” theory of depression has many detractors, including influential members of the American Psychological Association. The chemical imbalance theory has not been confirmed by evidence, and as such the APA has opted for a “biopsychosocial” approach to depression. In his recent book reviewing the state of psychiatry, Our Psychiatric Future, Nikolas Rose writes: “while anomalies in neurotransmission in living patients diagnosed with psychiatric disorders were hypothesized, these have never actually been demonstrated in the synaptic clefts of living patients diagnosed with a disorder.” Many anti-depressant drugs have been introduced since the first generation developed in the 1950s, but none have improved upon the efficacy of that first generation. Rose notes that “none of the new smart drugs [have] improved on the efficacy of those discovered by chance, and in no case has the actual mode of action been identified or demonstrated in living patients.”

In any case, even if medical science were to identity the physical bases of mental disorders, we would not need to concede that mental disorder is caused by biological dysfunction. As the late Mark Fisher wrote in Capitalist Realism: “It goes without saying that all mental illnesses are neurologically instantiated, but this says nothing about their causation.” While groups like the APA and individuals beholden to them may acknowledge the inefficacy of treating people as disembodied brains and choose instead the “biopsychosocial” model, I am unsure how often this makes it into clinical practice. I have no faith that taking a high daily dose of an SSRI would be beneficial to me in any way.

Waitzkin writes that “one can postulate that social control in medicine largely involves the transmission of ideologic messages. These messages, voiced with the symbolism of medical science, arise at the micro level of professional-client interaction.”  This leads to my next point of contention, regarding treating addiction as a psychiatric disorder. Mental illness is not caused by the brain, and addiction is not caused by drug (ab)use.

The physiology of opioid dependence, for instance, looks roughly like this: the body produces opiate-like chemicals which help regulate the production of noradrenaline, leading to normal levels of alertness. Exogenous opioids take the place of those endogenous chemicals at opiate receptor sites, and levels of noradrenaline are decreased. Tolerance builds when the body reacts to repeated use of higher dosages of opioids. It attempts to mitigate abnormally low noradrenaline levels by making another chemical which increases noradrenaline production. Larger doses of opioids are then required to beat this reaction. Upon cessation of use, the body is still producing an elevated level of noradrenaline to combat the downregulating effects of exogenous opioid intake, leading to physical withdrawal symptoms. But does this mean we can say the cause of opioid addiction is opioid use? Psychologist Bruce Alexander, in his book The Globalization of Addiction, urges us to reject the wisdom that tells us addiction is caused by drug use.

He offers, instead, the dislocation theory of addiction. Addiction is caused, not by overuse of substances, or careless dentists over-prescribing five milligram hydrocodone tablets for toothaches – hijacking our brains and our capacity for autonomous action – but by psychosocial dislocation. Alexander writes:

Lack or loss of psychosocial integration was called ‘dislocation’ by Karl Polanyi. Dislocation, in this broad sense of the word, does not necessarily imply geographic separation. Rather, it denotes psychological and social separation from one’s society, which can befall people who never leave home, as well as those who have been geographically displaced. Like psychosocial integration, dislocation has been given many names, perhaps the most familiar being ‘alienation’ or ‘disconnection’.

Addiction is not the problem; it is a solution to the problem: dislocation. Advanced societies are plagued by dislocation because the excoriating powers of capitalism have subsumed all individuals and relations to the logic of the commodity and the market. Capitalism has destroyed traditional forms of psychic and social integration, and has provided us with something profoundly inadequate and immiserating as replacement. To be clear, I am not a political reactionary. Salvation will not be found in the return to tradition.

Here are three aspects of my interaction with the psychiatrist which do not exactly fall in line with the above theories of power and ideology. One: I was asked multiple times – five or six – if I have suicidal thoughts. This is universal in screening for depression, and each time I answered in the negative. This is an example of the direct power to confine that psychiatrists wield. In this case, a power seemingly eager to be deployed. Many of the people I met in the psych-ward stated that they were confined due to some variation of this: “I said something which I thought was innocuous to my psychiatrist/psychologist, and next thing I know I’m in handcuffs riding to the hospital.” Example phrases may be: “What’s the point?” “I wish I was dead.” “I can’t keep going.” To the medical professional, these all represent a dead-end regarding treatment: the only option is confinement. Seen from outside of this authoritarian orthodoxy, they are rational responses to the pains with which modern life burdens us all.

Two: At the end of the appointment, though I had been denied anxiety medication because of my history of “addiction,” the psychiatrist assured me that they “Did not think I was a bad person.” This is interesting because it is an explicit example of the move from the moral model of mental illness to the medical model. In earlier times, madness was believed to be caused by moral degradation or being in possession of a sinful nature. The medical model is now our dominant method for dealing with madness, and it takes the form of the search for the biological bases of mental distress outlined above. The psychiatrist’s assurance that I won’t burn in hell for the things I’ve done did nothing to temper the harsh gaze and general skepticism I had encountered throughout the examination. The psychiatrist demanded that I produce lists of medications I have taken, doctors who prescribed them, hospitals I have been treated at, lists of family members with psychiatric diagnoses, etc.… When I could not accurately recount the events of more than a decade ago, the psychiatrist simply stared at me, letting silence hang in the air.

Three: While Waitzkin analyzed medical encounters in order to bring to light their murky ideological content, my psychiatric encounter at one point – of its own volition – dropped any pretension of medical or scientific rigor, effectively auto-demedicalizing. At the end of the appointment, after assuring me that my SSRI would treat ambient, generalized anxiety (An affliction I had not claimed as my own in the encounter.), the psychiatrist told me: “If you believe it will work, it will work.” Because SSRI drugs are no more effective than placebos, this may be the only statement I heard throughout the hour-long encounter approaching the truth.

 

Bibliography:

Alexander, B. K. (2010). The Globalization of Addiction: a Study in Poverty of the Spirit. Oxford: Oxford University Press.

Cohen, Bruce. M. Z. (2017). Psychiatric Hegemony: a marxist theory of mental illness. S.l.: Palgrave Macmillan.

Conrad, P. (2007). The medicalization of society: on the transformation of human conditions into treatable disorders. Baltimore: Johns Hopkins University Press.

Fisher, M. (2010). Capitalist realism: is there no alternative? Winchester, UK: Zero Books.

Foucault, M., Marchetti, V., Salomoni, A., & Burchell, G. (2003). Abnormal. New York: Picador.

Hacking, I. (2003). Rewriting the soul: multiple personality and the sciences of memory. Place of publication not identified: Diane Pub Co.

Hall, W. (2012). Harm reduction guide to coming off psychiatric drugs. New York, NY: Icarus Project.

Kosten, T., & George, T. (2002). The Neurobiology of Opioid Dependence: Implications for Treatment. Science & Practice Perspectives1(1), 13–20. doi: 10.1151/spp021113

Moncrieff, J. (2009). The myth of the chemical cure: a critique of psychiatric drug treatment. Basingstoke, Hampshire: Palgrave Macmillan.

Reinarman, C. (2005). Addiction as accomplishment: The discursive construction of disease. Addiction Research & Theory13(4), 307–320. doi: 10.1080/16066350500077728

Rose, N. S. (2019). Our psychiatric future: the politics of mental health. Medford, MA: Polity.

Sedgwick, P. (2015). Psycho Politics: Laing, Foucault, Goffman, Szasz and the future of mass psychiatry. London: Unkant Publishers.

Stegenga, J. (2018). Medical nihilism. Oxford, United Kingdom: Oxford University Press.

Steingard, S. (2019). Critical psychiatry: controversies and clinical implications. Cham, Switzerland: Springer Nature.

Trigg, D. (2017). Topophobia: a phenomenology of anxiety. London: Bloomsbury Academic, An imprint of Bloomsbury Publishing Plc.

Waitzkin, H. (1993). Politics of Medical Encounters: How Patients and Doctors Deal with Social Problems. Yale U.P.

Waitzkin, H. (2000). The second sickness: contradictions of capitalist health care. Lanham, MD: Rowman & Littlefield.

Whitaker, R. (2015). Anatomy of an epidemic: magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Broadway Books.

 

Reading list:

Our Psychiatric Future by Rose, Medical Nihilism by Stegenga, Anatomy of an Epidemic by Whitaker, The Myth of the Chemical Cure by Moncrief, Critical Psychiatry by Steingard, and to a lesser extent Rewriting the Soul by Hacking provide information about SSRI drugs, or more generally, information about ambiguities and failures of the medical model of mental distress. A harm reduction guide to coming off psychiatric drugs can be downloaded and used under the Creative Commons copyright here.

 

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