My take on “A Psychopharmacology Fit for Mad Liberation? by Awais Aftab”

In the latest edition of Asylum Magazine, Dr Awais Aftab published an article on the relation between Psychopharmacology and Mad Liberation and brought it to my attention. The full article has been posted online and can be found at the following link:

A Psychopharmacology Fit for Mad Liberation? by Awais Aftab

I want to thank Awais for picking my brain about this, as it helps me re-think and re-word what my views are and what exactly I’m trying to say.

As always, I am mindful of the fact that the focus of the social media debate on issues related to mental health care is generally not what I would concentrate on. There tends to be for example an ongoing vibrant debate on technical interventions offered by care providers, and on evaluations on which interventions are the best, which are the most scientific and even which are the most liberating.

In this respect, in this article Awais quite appropriately asks what principles might guide a liberatory psychopharmacology. That is a more promising line of enquiry, as it implies that the problem is not about psychopharmacological interventions being good or bad, or scientific or not scientific in absolute terms, but about how psychopharmacology and the related science are used.

Is this a question about psychopharmacology though? Or is it once again a question about how institutions are organised? To me, this immediately brings us to a broader question: how should any knowledge be used in this field?

Should it be used to provide a personalised response to any person who asks for help, or should it be used to achieve good results on RCT’s, which may well mean nothing to many of the people who get supposedly successful evidence based interventions?

I think that in this respect we probably all, in different ways, experience a tension between the urge to organise knowledge in an easy to understand and implement way, e.g.: “when you take opioids you feel better” or in a more comprehensive way, e.g.: “when you take opioids there could be all sorts of effects depending on all sorts of circumstances, ranging from extreme relief to total destruction and death”.

What do we do with such a puzzling picture? I don’t think that there is a univocal, infallible method on this, which can be learnt from a checklist.

Organising knowledge, in my view, is an art. We can all improve our skills but ultimately it’s a personal, subjective path. This does not mean that there is total relativity about everything. Like all art, there can be good art and bad. There is a general agreement on many things but the edges of knowledge are often blurred. There can also be general rules about what good art and what bad art is, yet periodically these rules bend, change or get completely dismissed. An artist must arguably craft their work in ways that blur these tensions harmoniously.

Even the most obvious general principles have hidden flaws. Picasso was on the surface totally unwilling to draw people properly, yet the results were absolute masterpieces, and he drew people which were a striking expression of a multi-faceted reality.

The instinct to draw down fixed rules on good and bad psychopharmacology for populations can in the same way easily become treacherous, as there’s nothing more appealing to institutionally driven practice than fixed rules.

Awais suggests that “a liberatory psychopharmacology would support a person’s will and preferences”, and yet we know that our systems are expert manipulators, and that the choices on offer are far too often all bad choices. “Do you want meds or do you want to be on your own in your home with nothing?”.

It is true therefore that choice could be a liberatory use of psychopharmacology, yet it is also true that it could be yet another form of coercion, perhaps even more insidious than lack of choice, but with a smile. This depends on power dynamics on a range of institutional dimensions and levels, which go way beyond the technical intervention in itself.

What about the false promise of homeopathy? And the false promise of prayer? And the false promise of an abusive partner which comes back asking for forgiveness for the 10th time? And the false promise of a technical, non-ideological science?

Once again we find ourselves in a conundrum. The person who believes in these false promises does so for a complex set of reasons. The related conceptualisations or behaviours absolve a function, and our belief that they are only false promises or, as Awais puts it, that there are “right and wrong answers” simplifies their complexity in ways that may prevent us from fully understanding the person.

Letting a person who prays know that this is fruitless, or even only listening to them with this working assumption, may for example be way more damaging than the prayers themselves could ever be. The soothing that may come from rituals is not entirely a false promise, it is an immediately obvious benefit. Homeopathy, like going fishing or writing poetry or counting the bricks on a wall, does not have any special institutional healing power. The examples I just made are all largely lies if that’s what they claim, but at a personal level the matter can be way more complex. What function an apparently absurd behaviour or conceptualisation has, including the chemical imbalance idea (I’m looking at you, PTMF supporters), cannot be pre-determined and accurately classed as right or wrong. It has to be understood on different levels.

It goes without saying that the opposite approach, that of believing that prayer, or homeopathy, or abusive partners, or NICE guidelines are the basis for organising our knowledge and practice is of course catastrophically misguided (Just look at the NICE based UK IAPT programme!).

I could make similar observations about other points that Awais makes in the article, but the bottom line is the same…

The solutions to the system’s problems (unlike at times part of the solutions to a person’s problems) are not to be found in technical interventions, and not even in any specific organisation of technical interventions, but in the gradual overturning of the institutional mandate that professionals have towards patients. This means that what gets in the way of personalised relationships and solutions has to be changed in practice.

It is true that the tension between freedom and responsibility, rules and rebellion, is an art which will always need rules to avoid descending into a false anarchism, which would inevitably bring new implicit rules with it. At the same time art is hindered by rules.

What we need, in order to prevent any approach from being co-opted, is to embed it in subjectivity. The more every person who asks for help gets a tailored response, the less institutions can co-opt the resulting relationships, because there is no ritualistic mechanism for them to do so. When the mechanism is there, it always has a controlling function (in both good and bad ways at the same time).

Perhaps, rather than grand proclamations about clinical excellence, master clinicians or “evidence based practice” or similar insecure labels, when we discuss how to overcome the oppressive rules of our systems, we should work at temporary compromises that involve different stakeholders, are not set in stone and get eventually codified in new rules… before we start inevitably thinking about how to undermine institutional power further.

Is there however enough space to openly discuss change in our mental health systems?

Vincenzo

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