How can one consent to treatment if one is mentally ill?
Consent is a hot topic in psychiatric theory and practice. Those on the left, if you like, the more radical critical psychiatry fraternity, suggest that psychiatric practice is often coercive. The more conservative side of psychiatry tend to believe psychiatry is about care and not about power relations.
The relationship between a psychiatrist and patient is inherently a power relationship. The psychiatrist diagnoses, treats and monitors the patient. The patient's agency or choice is limited to agreeing to treatment or not. Importantly, patients (in theory) do have this choice. However, most mental illness is defined by not being of sound mind so is that choice then informed and free?
Certainly in the past incarceration against one's will was more prevalent. With the asylum closures (at least partly instigated by the anti-psychiatry movement) in Europe and North America in the 1960s onwards and a move to community care, the chances of being locked up for deviant or mentally ill behaviours has lessened. Most see this is a move by psychiatry towards a more caring, understanding approach. That hides factors such as the many exposes of asylum life (including anti-psychiatrist, Franco Basaglia's work in Italy) that forced a change. More importantly, there was the rising cost of incarceration. It's a damned sight cheaper to let the community or family nexus care for the mad. It's ironic that the asylum system's heyday in the 19th Century was fed by family's discarding unwanted members into the work house/asylum system because they were a burden to them. And things aren't quite as simple as this idea appears. After all, though asylums were appalling they did offer shelter to the mad. Often care in the community fails and the mad either end up homeless or in another form of prison. Actual prison prison.
Cost is a guiding factor in psychiatric practice. It's why the predominant treatment approach to madness is drugs. They are by far the cheapest approach. It's worth noting here also, that the most prevalent drugs, anti-psychotics like Quetiapine and anti-depressants such as Mirtazapine are sedative drugs. They dampen symptoms by dampening consciousness. One could argue this is a form of restraint in itself. Importantly, the chances are that one you are prescribed these medications the side effects will not be explained to you. Is that informed choice? Especially as the side effects are often heightened versions of the symptoms you bring to the doctor, suicidal feelings, anxiety, restlesness, etc.
As I mentioned in a previous post, a recent study by Andrea Cipriani et al hailed the effectiveness of anti-depressants (the most effective being Amatriptyline and Mirtazapine, both sedatives). Intriguingly it found that the wonder drug hailed as an anti-depressant breakthrough, Fluoxetine (Prozac) did rather badly in studies. This isn't a surprise as there's a long history of wonder drug breakthrough's for treatment of madness that weren't exactly the breakthrough that they first appeared to be. Largactil (Thorazine) was the drug most used in the late 50s and 1960s in psychiatric practice (later Lithium). It's an anti-psychotic but was used for everything from the most profound psychosis to mild depression (alongside incarceration). Thorazine is only used in 'extreme' cases now. Whatever they are.
Of course, we all live in a present. We all assume, Panglossian-like, that this is the best of all possible worlds. Consequently, we tend to forget historical context. Alienists in the 19th Century, believing phrenology, that inner madness showed on the outside of the skull, were just as certain that we had reached a full understanding of madness.
In reality, of course, we're no nearer understanding what madness is in all its forms, and why it exists, than the mad doctors of the 18th Century. Treatment has changed, that's all. In fact, the psychiatric profession still works exhaustively (with absolutely no success) to prove that madness is a biological condition caused by physiological illness. See the previous post and psychiatrist Carmine Pariante's quest to prove madness is caused by an inflammation on the brain. You know, like lumps on the head showing inner distress. We've come so far.
It's also worth noting that psychiatry really comes to the fore historically at the time of medical magic bullets. The discovery of penicillin, antibiotics and so on. Medicine becomes defined through breakthrough, mostly, drugs. Think of news stories now about medicine, they will almost certainly be about some kind of new wonder treatment (usually drugs) for Alzheimers or Cancer etc. And psychiatry followed suit and tried to align itself with actual medicine.
Except they're all terrible, don't cure at all, have appalling side-effects and are rarely used now.
So when you see your physician (medical doctor) because you're feeling or exhibiting signs of madness (say anxiety or depression) they will most often prescribe anti-depressants. They're cheap, in theory quick and effective (between 6-8 weeks and most studies show they're marginally better than nothing). If symptoms persist you may see a psychologist or psychiatrist. They will most likely prescribe drugs. You can, in theory, refuse this treatment at any time. In fact, many people stop taking the medication before the 6-8 weeks.
In reality, things aren't quite this clear cut. I can attest to going through this process and at one point in the psychiatric interview there is a crunch question that changes the whole complexion of your treatment. The psychiatrist will ask if you hallucinate or hear voices. I do. Now the crunch question. Do you know they're not real? If you answer no then your treatment can be complicated by what those voices say to you. I mean, typically, the voices do not, as in common tropes, tell you to go and kill people. They tend more often to tell you to harm yourself. If you are considered a harm to yourself or others then the psychiatrist does still have powers to detain you.
Interestingly, in my own case, I answered that I know the hallucinations were not real but that I did experience continuous suicidal ideation (thinking about killing myself). The psychiatrist suggested I stay in the secure unit of the hospital overnight. And how exactly would that help? I asked. We can observe you and support you. The support was upping my anti-psychotic drugs. The observation sounded too Benthamite or Foucaultian. I declined. They reiterated it would be good for me. I declined. Really it would be good for me. This seemed like coercion. And if I weren't slightly less mad than I clearly appeared to be would this have been reasonable consent if I had given in and agreed? Would this have helped me? I can say with the same certainty that I believe that there is no god and that evolution is the correct theory of the existence of humanity that no. It would have been terrible for me. And there would be no guarantee that I could easily leave.
The Rosenhan Experiment is, of course, a famous example of those considered perfectly sane (in this case, actual psychiatrists) being coerced into psychiatric units and then having great difficulty proving they are in fact sane. That can't happen now. Well, not in that form. Of course, it can. I could have answered the question above 'correctly' and claimed the voices were telling me to harm myself. In theory, at least, I could still be secured in a psychiatric hospital based on my testimony.
Would anyone believe that I'd had a sudden conversion that first night and no longer wished to harm myself?
Of course, some people are a danger to themselves and others. I'm in no way, in any of these posts, suggesting that madness does not exist and that some people are not deeply psychotic. Simply, that madness (in the form we tend to think of it, depression, psychosis, etc.) isn't a biological condition but a mental reaction to unlivable circumstances. It isn't an illness in the conventional biological sense.
Of course, one of the key symptoms of psychosis is very often either wanting to, or hearing voices telling you to, harm yourself. Self harm is a symptom of madness. And as others have suggested in the past, well, that's everyone isn't it? I mean, I'm sitting sweltering here in 30 degrees heat in a northern town in Britain. Northern Britain! There's a worldwide heatwave almost certainly typical of climate change. What's our response to climate change and the dire need to cut CO2 emissions? To emit more, of course. Everyone hates themselves and want to die as quickly as possible. It's the only explanation.
Consent is a complex moral argument. Generally, the view is that sometimes individuals who are a danger to themselves or others should be detained without their consent. It is hard to argue with this general concept. Though, it's complicated by who decides that they are a danger? Is it the individual themselves or the psychiatrist? If coercion takes place (as in my own vignette) is that consent? Is it informed consent? The anti-psychiatrist Thomas Szasz argued that there is a difference between consent and informed consent. Being a libertarian he felt that as long as an individual had the relevant information and that was open to all equally then that was fair and reasonable to accept consent in those cases. Of course, being a libertarian he ignores capital, social status, class, education, etc. which alters the value of information and the ability for an individual to evaluate that information.
Hanging over the idea of consent is the fact that psychiatrists do still have the power to detain individuals they see as a threat to others (or in 'extreme' cases, themselves). If that power exists then the notion of consent between patient and psychiatrist is always weighted and never truly free consent.
Imagine a conversation between you and me. Say, we're both roughly the same class and have the same educational attainments. The balance of power in our relationship is relatively even (discluding ethnicity/race, gender, dis/ability). Say now, you knew I had the phone number to a special legal force that could detain people indefinitely at my say so.
What if I, along with my co-workers, decided what behaviours were deemed normal or not with no consultation with you, the person whose behaviours we've deemed abnormal?
My research and/or the lecture days I attend are financed by companies who produce the medicine that allegedly affects these abnormal behaviours.
I'm employed by a health service and have the same legal capacity as bio-medical doctors to prescribe medicine despite my studies being in the humanities.
I have no idea what your illness is. I have no idea why it occurs. I'll ignore your environmental circumstances and look at your medical history instead.
I have only two courses of treatment to offer. Both have marginal success rates based not on any bio-medical effectiveness but on self reporting by the patient. Is this perhaps empowering for patients? Not really, when the only courses are two, which do not affect the illness but ameliorate the symptoms. Most often through sedation.
You can refuse this treatment. That is consent.
Consent is a hot topic in psychiatric theory and practice. Those on the left, if you like, the more radical critical psychiatry fraternity, suggest that psychiatric practice is often coercive. The more conservative side of psychiatry tend to believe psychiatry is about care and not about power relations.
The relationship between a psychiatrist and patient is inherently a power relationship. The psychiatrist diagnoses, treats and monitors the patient. The patient's agency or choice is limited to agreeing to treatment or not. Importantly, patients (in theory) do have this choice. However, most mental illness is defined by not being of sound mind so is that choice then informed and free?
Certainly in the past incarceration against one's will was more prevalent. With the asylum closures (at least partly instigated by the anti-psychiatry movement) in Europe and North America in the 1960s onwards and a move to community care, the chances of being locked up for deviant or mentally ill behaviours has lessened. Most see this is a move by psychiatry towards a more caring, understanding approach. That hides factors such as the many exposes of asylum life (including anti-psychiatrist, Franco Basaglia's work in Italy) that forced a change. More importantly, there was the rising cost of incarceration. It's a damned sight cheaper to let the community or family nexus care for the mad. It's ironic that the asylum system's heyday in the 19th Century was fed by family's discarding unwanted members into the work house/asylum system because they were a burden to them. And things aren't quite as simple as this idea appears. After all, though asylums were appalling they did offer shelter to the mad. Often care in the community fails and the mad either end up homeless or in another form of prison. Actual prison prison.
Cost is a guiding factor in psychiatric practice. It's why the predominant treatment approach to madness is drugs. They are by far the cheapest approach. It's worth noting here also, that the most prevalent drugs, anti-psychotics like Quetiapine and anti-depressants such as Mirtazapine are sedative drugs. They dampen symptoms by dampening consciousness. One could argue this is a form of restraint in itself. Importantly, the chances are that one you are prescribed these medications the side effects will not be explained to you. Is that informed choice? Especially as the side effects are often heightened versions of the symptoms you bring to the doctor, suicidal feelings, anxiety, restlesness, etc.
As I mentioned in a previous post, a recent study by Andrea Cipriani et al hailed the effectiveness of anti-depressants (the most effective being Amatriptyline and Mirtazapine, both sedatives). Intriguingly it found that the wonder drug hailed as an anti-depressant breakthrough, Fluoxetine (Prozac) did rather badly in studies. This isn't a surprise as there's a long history of wonder drug breakthrough's for treatment of madness that weren't exactly the breakthrough that they first appeared to be. Largactil (Thorazine) was the drug most used in the late 50s and 1960s in psychiatric practice (later Lithium). It's an anti-psychotic but was used for everything from the most profound psychosis to mild depression (alongside incarceration). Thorazine is only used in 'extreme' cases now. Whatever they are.
Of course, we all live in a present. We all assume, Panglossian-like, that this is the best of all possible worlds. Consequently, we tend to forget historical context. Alienists in the 19th Century, believing phrenology, that inner madness showed on the outside of the skull, were just as certain that we had reached a full understanding of madness.
In reality, of course, we're no nearer understanding what madness is in all its forms, and why it exists, than the mad doctors of the 18th Century. Treatment has changed, that's all. In fact, the psychiatric profession still works exhaustively (with absolutely no success) to prove that madness is a biological condition caused by physiological illness. See the previous post and psychiatrist Carmine Pariante's quest to prove madness is caused by an inflammation on the brain. You know, like lumps on the head showing inner distress. We've come so far.
It's also worth noting that psychiatry really comes to the fore historically at the time of medical magic bullets. The discovery of penicillin, antibiotics and so on. Medicine becomes defined through breakthrough, mostly, drugs. Think of news stories now about medicine, they will almost certainly be about some kind of new wonder treatment (usually drugs) for Alzheimers or Cancer etc. And psychiatry followed suit and tried to align itself with actual medicine.
That'll stop those crazy kids twisting
And in the 1950s onwards we begin to see a medicalization of relatively normal behaviour. I've never cooked breakfast.
Notice the gender divide in these old ads. Why could that be? This is a particularly terrifying one, like a poster for an old Hammer Horror film.
That seems a bit sexist now
See, Hillary Clinton used it
So when you see your physician (medical doctor) because you're feeling or exhibiting signs of madness (say anxiety or depression) they will most often prescribe anti-depressants. They're cheap, in theory quick and effective (between 6-8 weeks and most studies show they're marginally better than nothing). If symptoms persist you may see a psychologist or psychiatrist. They will most likely prescribe drugs. You can, in theory, refuse this treatment at any time. In fact, many people stop taking the medication before the 6-8 weeks.
In reality, things aren't quite this clear cut. I can attest to going through this process and at one point in the psychiatric interview there is a crunch question that changes the whole complexion of your treatment. The psychiatrist will ask if you hallucinate or hear voices. I do. Now the crunch question. Do you know they're not real? If you answer no then your treatment can be complicated by what those voices say to you. I mean, typically, the voices do not, as in common tropes, tell you to go and kill people. They tend more often to tell you to harm yourself. If you are considered a harm to yourself or others then the psychiatrist does still have powers to detain you.
Interestingly, in my own case, I answered that I know the hallucinations were not real but that I did experience continuous suicidal ideation (thinking about killing myself). The psychiatrist suggested I stay in the secure unit of the hospital overnight. And how exactly would that help? I asked. We can observe you and support you. The support was upping my anti-psychotic drugs. The observation sounded too Benthamite or Foucaultian. I declined. They reiterated it would be good for me. I declined. Really it would be good for me. This seemed like coercion. And if I weren't slightly less mad than I clearly appeared to be would this have been reasonable consent if I had given in and agreed? Would this have helped me? I can say with the same certainty that I believe that there is no god and that evolution is the correct theory of the existence of humanity that no. It would have been terrible for me. And there would be no guarantee that I could easily leave.
The Rosenhan Experiment is, of course, a famous example of those considered perfectly sane (in this case, actual psychiatrists) being coerced into psychiatric units and then having great difficulty proving they are in fact sane. That can't happen now. Well, not in that form. Of course, it can. I could have answered the question above 'correctly' and claimed the voices were telling me to harm myself. In theory, at least, I could still be secured in a psychiatric hospital based on my testimony.
Would anyone believe that I'd had a sudden conversion that first night and no longer wished to harm myself?
Of course, some people are a danger to themselves and others. I'm in no way, in any of these posts, suggesting that madness does not exist and that some people are not deeply psychotic. Simply, that madness (in the form we tend to think of it, depression, psychosis, etc.) isn't a biological condition but a mental reaction to unlivable circumstances. It isn't an illness in the conventional biological sense.
Of course, one of the key symptoms of psychosis is very often either wanting to, or hearing voices telling you to, harm yourself. Self harm is a symptom of madness. And as others have suggested in the past, well, that's everyone isn't it? I mean, I'm sitting sweltering here in 30 degrees heat in a northern town in Britain. Northern Britain! There's a worldwide heatwave almost certainly typical of climate change. What's our response to climate change and the dire need to cut CO2 emissions? To emit more, of course. Everyone hates themselves and want to die as quickly as possible. It's the only explanation.
Consent is a complex moral argument. Generally, the view is that sometimes individuals who are a danger to themselves or others should be detained without their consent. It is hard to argue with this general concept. Though, it's complicated by who decides that they are a danger? Is it the individual themselves or the psychiatrist? If coercion takes place (as in my own vignette) is that consent? Is it informed consent? The anti-psychiatrist Thomas Szasz argued that there is a difference between consent and informed consent. Being a libertarian he felt that as long as an individual had the relevant information and that was open to all equally then that was fair and reasonable to accept consent in those cases. Of course, being a libertarian he ignores capital, social status, class, education, etc. which alters the value of information and the ability for an individual to evaluate that information.
Hanging over the idea of consent is the fact that psychiatrists do still have the power to detain individuals they see as a threat to others (or in 'extreme' cases, themselves). If that power exists then the notion of consent between patient and psychiatrist is always weighted and never truly free consent.
Imagine a conversation between you and me. Say, we're both roughly the same class and have the same educational attainments. The balance of power in our relationship is relatively even (discluding ethnicity/race, gender, dis/ability). Say now, you knew I had the phone number to a special legal force that could detain people indefinitely at my say so.
What if I, along with my co-workers, decided what behaviours were deemed normal or not with no consultation with you, the person whose behaviours we've deemed abnormal?
My research and/or the lecture days I attend are financed by companies who produce the medicine that allegedly affects these abnormal behaviours.
I'm employed by a health service and have the same legal capacity as bio-medical doctors to prescribe medicine despite my studies being in the humanities.
I have no idea what your illness is. I have no idea why it occurs. I'll ignore your environmental circumstances and look at your medical history instead.
I have only two courses of treatment to offer. Both have marginal success rates based not on any bio-medical effectiveness but on self reporting by the patient. Is this perhaps empowering for patients? Not really, when the only courses are two, which do not affect the illness but ameliorate the symptoms. Most often through sedation.
You can refuse this treatment. That is consent.
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