Tuesday, 15 December 2015

The Reverse-Placebo Effect – or, How to Make People Ill and Keep Them Ill


In last week’s post, I wrote about the Placebo Effect and the ability of subliminal suggestion, particularly within a therapeutic context, to destabilize a person’s sense of identity. Although this post had little bearing on theories of literary interpretation, the ostensible purpose of this blog, I thought the topic important enough to comment on via the interweb. It is, I suspect, an issue that seriously deserves public attention. In today’s post, I want to talk a little more about how the power of belief can create (as well as alleviate) mental illness, and, in particular, how beliefs in the efficacy of medications can, in fact, have counterproductive outcomes. I feel sure this topic is associated with the misery of many thousands of people around the world in the present era; I have no idea how many people are on prescription psychotropic drugs but I understand that the number is constantly increasing. I think this is wrong. What I am going to suggest may seem to go against the grain of common sense but, on occasion, uncommon sense is the better bet.

I’ll start with an anecdote. A couple of months ago I met a youngish man who had recently been put under a Community Treatment Order. He was being compelled, effectively coerced, as so many people are these days now that Community Treatment Orders have been incorporated into our legal systems, into going into his local clinic to receive a dosage of antipsychotic medication, I think Olanzapine, administered every fortnight or month via needle in the backside. I asked him why he had been put under the Mental Health Act and he related the following story. This young man had first experienced psychosis as a teenager and had been under the umbrella of the Mental Health Service ever since; at the time prior to being put under the Act, he was living in a supported accommodation for people classified mentally ill. During the period immediately before being put under the Act, he was thought to be taking his medication voluntarily and orally, in pill form, but in fact he had, for some significant duration, secretly been spitting it out. One night, a strong smell of cannabis was noted in the environs of the facility. The Mental Health workers who administered the place decided to search all the rooms and, when they searched this young man’s room, found all the pills he had been refusing to swallow. Consequently, he was put under the Mental Health Act. His crime? Non-compliance with his drug regimen. His punishment? Being forced to take the drugs he had gone to such lengths to avoid.

The Mental Health System is based on one fundamental axiom or tenet: people are well when they take their medication and become sick if they stop. Consequently, if a patient does not take his pills voluntarily, he or she should be made to. This belief is so profoundly entrenched not only in modern psychiatric discourse but also in the general culture, that it seems absurd to even question it. One can understand why. Psychiatrists are doctors – they are professionally biased towards viewing mental ‘illnesses’ as physical diseases. And surely doctors know best. Moreover, medication is pretty much the only form of treatment the psychiatrists recognize and put any faith in. If it became general known that antipsychotics are at best useless and at worst detrimental, every psychiatrist in the world would immediately be put out of his or her job.

Naturally, therefore, there is a bias towards a belief in the efficacy of medication. People diagnosed schizophrenic, it is thought, have a congenital disease that can be managed by treatment with antipsychotics but cannot be cured; if someone diagnosed schizophrenic refuses to take his medication or dares to suggest that he has recovered and no longer needs it, he lacks ‘insight’ – he is delusional. And a lack of insight is, of course, a symptom of the disease. Either the patient accepts his diagnosis and takes his medication like a good boy or, if he refuses, he must be sick and so should be forced to take his medication. It’s a Catch 22. There is simply no way out.

The young man I described above had made the mistake of going against prevailing psychiatric wisdom. You might ask: during the period when he had discontinued his medication, did the young man I described become ‘sick’? Apparently not. Apparently, his mental health team had repeatedly been telling him how well he was doing. The young man told me that, in fact, he did actually become sick again but “weirdly it didn’t happen until after they found out”. To me this doesn’t seem so weird. Knowing that you are almost certainly going to be subjected to bullying by the mental health service, paraded like a trained ape in front of a judge and, despite anything you might say, forced to take a drug you don’t want to take, all would obviously constitute a significant source of stress – and psychotic episodes are most frequently the result of environmental stress. The anxiety related to an attempt to secretly wean oneself off one’s medication is enough, in itself, to provoke an episode. Germane to this story is another I heard recently. Another young schizophrenic, one who had been diagnosed ‘treatment-resistant’ (a typical example of psychiatric double-speak to cover up the failures of the system) had been experiencing suicidal ideation but didn’t want to tell anyone because he was terrified of being put in hospital, an institution which he regarded as being like prison. Rather than allow himself to be bullied, he took the terrible step of taking his own life. Stories like this, which I believe are all too common, evince, yes, the fragility of schizophrenics, but also the fact that the mental health system too often lets down the people it is supposedly designed to help.

As you might have guessed, I do not subscribe to the myth that schizophrenics are well when they take their medication and sick when they don’t. It doesn’t tally with my experience of the schizophrenics I have met. If it was true, than schizophrenics who take their medication should be able to go on and live normal lives involving productive satisfying work and harmonious familial relations. In my experience, the schizophrenics I’ve known, the ones who accept the label, never get better, never improve. To me this evinces the fact that medication simply doesn’t work. Psychotic episodes come and go based on exogenous and endogenous factors that have little or nothing to do with dosage. I concede I cannot prove that the idea of the efficacy of medication is only a myth. To do that one would need a large controlled experiment with a sizeable group of people diagnosed schizophrenic who don’t take any kind of medication at all – and such a group does not exist.

Nevertheless I believe the myth is false. If it is false, as I contend, you might wonder how could it become so entrenched in the Mental Health System and in society at large? It is a myth that effectively consigns people to a box and makes them life-long drug users. I believe that there are two explanations. The first is confirmation-bias. Mental health professionals of any rank tend to look for evidence that medical treatment is effective and that a cessation of such treatment results in relapse. Such evidence is always easy to find if one is deliberately looking for it. Psychiatrists in particular, I believe, tend to over-estimate their ability to ‘read’ their patients. Even those patients who report no symptoms at all can be unriddled as secret psychotics if a psychiatrist wishes. This may be a compensatory device. What psychiatrist would be prepared to concede that he or she is inadequate, incompetent or even just fallible? Why would they risk their job and livelihood? Mental health professionals further down the pecking order moreover tend to defer to the psychiatrists. It is safer to pass the buck. All in all, the culture of the Mental Health System is highly conducive to confirmation bias and to the promulgation of false myths.

The second explanation is what I call the reverse-placebo effect. The reason patients who discontinue their medication become sick again may simply be because they subconsciously believe that they will. They have been brain-washed by the prevailing discourse. It is established wisdom that is at fault, not some kind of neurological susceptibility. To successfully discontinue his medication, a patient needs two things. He needs a social environment that actively supports and encourages his decision and he needs to expunge the idea that medication actually helps entirely from his mind. I said at the beginning of this post that what we need now is uncommon sense and this last statement is an example of that.

This post is a most unscientific opinion. It is based on experience and rumination rather than methodical studies. To really bolster my argument, I would have to describe my own experiences of psychosis – and I am not prepared to do that yet. I would recommend though, for those interested, the previous post “An Unpalatable Suggestion” and the post “Why I hate ‘A Beautiful Mind’” Alternatively, if you want to read just about the best theory of schizophrenia around, I would point you in the direction of the essay “The Stress-Vulnerability Model” written by Zubin et al, in 1977. Zubin’s theory is not perfect but it resonates with me more than any other. In the essay, Zubin cites an extremely interesting study. Patients diagnosed schizophrenic were divided into three groups: label deniers (patients who never accepted the label), label acceptors (patients who accepted the label) and label rejectors (patients who accepted the label for a time, albeit grudgingly, and then later rejected it). What the researchers found was that, counter-intuitively, it was the label rejectors who had the highest rate of recovery.

How can one reject the label without also rejecting the medication?

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