Towards the end of Fragile Minds, described by the Guardian as “a furious assault on NHS psychiatry”, author Bella Jackson considers the problem of criticising mainstream mental health practices. There will always be someone who tells you the system is working perfectly well for them.
Only “at what cost,” asks Jackson, “do people have their good experiences?”:
At what cost to all those who are silenced? To those who are frightened of being called ‘ungrateful’, who are shouted down as ‘anti-psychiatry’, shamed as conspiracy theorists. Or are simply derided, and told they are mad?
It’s something I’ve considered myself since becoming more sceptical of mental health diagnoses and the long-term impact of psychiatric drugs. It is much easier — and you look much more reasonable, much saner — if you say nothing at all.
If you speak from a position of patient experience, your criticism betrays your lack of insight; if you speak as an outsider, then you are naïve. Perhaps you are one of those people, to quote Esmé Weijun Wang, who “may have been diagnosed with depression or anxiety at some point, but are usually symptom-free”. What do you know of how bad things can get for the truly disturbed?
In his 1976 book Schizophrenia: The Sacred Symbol of Psychiatry, critical psychiatrist Thomas Szasz argued that schizophrenia — as a word and a diagnosis — occupied a particular status and performed a particular function. The idea of the schizophrenic — better yet, the paranoid schizophrenic — is used to bolster the moral authority of psychiatry as a discipline and to justify coercive practices. In Fragile Minds, Jackson notes that a schizophrenia diagnosis invokes fear in a way that other diagnoses do not. Many contemporary critiques of diagnosis culture steer clear of questioning such a “big” label. Indeed, one thing I have noticed in social media debates on this issue is a tendency for defenders of the most extreme practices to chest-beat over having walked among the schizophrenics, the properly insane, portraying their critics as having all lived sheltered lives.
It can become impossible to distinguish between extreme diagnoses justifying extreme treatment, and extreme treatment justifying extreme diagnoses
This is not true of Jackson, who recounts her experiences of training as a mental health nurse amongst patients who have been sectioned (it’s not true of me, either, but as my experiences are less professional in nature, they can always be slotted into the “lacking insight” category). Early on in her placement, Jackson is advised that she will eventually get wise to patients, come to accept the labels applied to them and the treatments chosen, understand that many are violent, delusional and do not know what is best for them (“you can’t let yourself be sucked in”). Fragile Minds is not written from a perspective of privileged ignorance. On the contrary, it describes, with great empathy and restraint, the way in which it can become impossible to distinguish between extreme diagnoses justifying extreme treatment, and extreme treatment justifying extreme diagnoses (you wouldn’t do this if they didn’t need it — would you?). I found it to be both shocking and not surprising at all.
The book is particularly effective in illustrating how a chosen response to one episode or period of disorder can trigger what is potentially a lifetime of labelling and enforced physical decline. Especially damaging treatments such as electro-convulsive therapy and medications such as clozapine send the message that sometimes, the body is worth sacrificing for the mind (watching a patient suffering from tardive dyskinesia — a side-effect of antipsychotic medication often mistaken for “mad” behaviour — Jackson reflects on the right of staff to decide “that these contortions were better than the unknown. That perhaps his physical health was less important than his mental health. That maybe he wouldn’t mind as much as a ‘sane’ person”). When I have mentioned to people that my own sibling nearly died due to side-effects of clozapine, it has often struck me that the response is not shock at the medication itself, but at how ill he must be to need something that could kill him. This thought takes on a particular edge at a time when assisted dying for mental illness – for those “resistant to evidence-based treatment” — is considered at least worthy of debate. The more extreme the solution, the more it is seen to be justified — unless, of course, it’s lobotomy (near-universal condemnation of lobotomy as a “dark ages” practice seeming to serve as proof that we are more enlightened, not that we have found less gruesome ways of achieving the exact same objectives).
In her Guardian review of Fragile Minds, Rachel Clarke accuses Jackson of “scaremongering”. “Psychiatrists do indeed have an almighty power to do things to patients that in any other context would be considered human rights abuses,” she writes:
— restraining them, injecting them with drugs, depriving them of their liberty. Yet this is because the most seriously unwell patients often have no idea they are ill and will not engage with treatment voluntarily. […] The truth is, we still understand very little about the root causes of serious mental illnesses and are painfully aware of what blunt tools psychotropic medications are.
At least, I suppose, this is honest (but how is it not scary?). I think Clarke is wrong that there is never any callousness or cruelty underpinning these treatments. There doesn’t have to be a conspiracy or a desire to do harm, but — I have certainly noticed this myself — if you are forced into complicity, you might as well grant “bipolar disorder and schizophrenia” the status of conditions pertaining to those who need not be listened to.
It is not naïve to think there needs to be a different approach. On the contrary, it takes bravery, since it means confronting and owning past abuses as opposed to mindlessly ploughing on (“we still understand very little” is just not enough for stealing whole lives). Fragile Minds is an important book in this respect. It could have been written fifty years ago. At least it has been written now.
