From the point of view of the psychiatric patient and survivor, the practice of psychopharmacology probably comes across as insufferable.
The claims of scientific authority and the rhetoric of evidence-based practice is transformed into a medical obligation to take the prescribed medications. Its principles are condescendingly spoon-fed to patients and the public using the misleading language of things like correcting ‘chemical imbalances’. Many people across the world are forcibly medicated, with little regard for the disabling burden of adverse effects or their wishes and preferences. Even those who take them willingly are poorly informed of the risks, only discovering them after years of use, or when they try to stop taking them. In such a context, psychopharmacology leans so heavily on the side of oppression that it can be hard to imagine that things could be otherwise.
Yet, at the same time, lives of countless individuals have been positively transformed. On platforms like twitter, students joke about dedicating their theses to the particular brand of antidepressant they take. Stimulant medications allow millions with attention-deficit problems to function and maintain productive lives. Medications from virtually every class of psychotropics have been passionately described as lifesaving by some individuals who have benefited from them. Therefore, it seems clear that psychiatric medications can be a liberating tool when used in the right way. If so, what principles might guide such a liberatory pharmacology? How can psychopharmacology serve the needs of the mad, distressed and psychosocially disabled?
As a psychiatric clinician I am admittedly biased and constrained by my role. However, as a philosophically informed practitioner, who confronts these issues every day, I would like to offer some suggestions about what these principles could be.
# The dual nature of psychotropics
A liberatory psychopharmacology would do justice to the diverse experiences of individuals who take psychiatric medications. The effects we see in one person may differ radically from effects in another and can’t be predicted in advance. We can describe patterns of response at the group level, but for any particular individual we are in the dark. Some people experience symptomatic relief and even remission of their problems, others do not. Some do not experience any adverse effects while others experience intolerable ones. Some experience relief in the short-term but encounter new problems with long-term use. The dual nature of psychotropics is evident in the Greek word phármakon, which can mean a remedy as well as a poison. Fully appreciating this duality must be at the heart of a liberatory psychopharmacology.
# Diversity of explanations
Since diversity of experiences and outcomes is the norm in psychopharmacology, a plurality of pharmacological mechanisms is also implied. Our understanding of these interactions must allow for and explain such diversity. The effects of medications arise from a complex interaction of the effects of the substance and the unique bodily and mental characteristics of the person taking it. Understanding medications in this manner means not assuming that psychiatric medications are simply correcting a brain abnormality. In this sense, psychopharmacology is similar to pharmacology in general medicine: many medications produce bodily effects that relieve symptoms but do not act on disease processes or causes. Diuretics (water pills) increase the amount of water we urinate, and analgesics (pain relievers) disrupt the bodily pathways that process pain. Although these effects also occur in healthy individuals, they are either benign or harmful; but when used in the presence of certain symptoms, they can produce relief. The effects of psychiatric medications can be understood similarly. For example, medications that slow down the activity of the brain can help in the short-term with severe anxiety, and medications that reduce the mental importance (salience) we assign to sensations can help with distressing states of psychosis. We should remain open and curious about all such possibilities.
# Inclusion of all experience and evidence
Unfortunately, “scientific” is often used as a tool to dismiss lived experience as anecdote, as an excuse not to take a phenomenon seriously until randomized controlled trials and meta-analyses have been carried out. A liberatory psychopharmacology should be scientific in the broadest and most virtuous sense of the word. It should be informed by all sources of evidence – experiences of individuals who use substances, the clinical experience of clinicians, the observations of families and caregivers, clinical trials, observational studies, animal studies, and neuroscientific hypotheses. It should use multiple methods of investigation and be subject to open scrutiny. I believe that understanding how medications work and the effects they produce is not simply a matter of personal opinion. There are right and wrong answers, but we arrive at these answers through a process of inclusivity and critique. For example, we should be able to recognize the false promise offered by interventions such as homeopathy. A liberatory pharmacology should include multiple perspectives and sources of evidence, making room for phenomenology, meaning, and lived experience, and including them in the process of conjecture, empirical testing, and error-correction.
# Open minded curiosity
A liberatory psychopharmacology necessitates fundamental changes to how we study and understand pharmacological compounds. We need to go beyond symptom rating scales, which are designed more for the benefit of researchers and regulators rather than patients. A liberatory psychopharmacology should be effects-centered, considering the full-range of effects produced by psychiatric medications and what that means for the person taking them. It should also be outcome-centered, looking at how psychotropics influence not only relapse prevention, but also quality of life, mortality, disability, employment, and other outcomes that matters to people. It also must also be iatrogenic, paying attention to adverse effects and harms in all their manifestations. However, it should not simply assume, as many critical psychiatrists and psychologists do, that psychiatric medications are simply toxic, sedating, numbing or blunting. It shouldn’t discount the possibility that psychiatric medications may act in other ways to produce both positive and negative effects.
# Humility and Transparency
A liberatory psychopharmacology requires humility and practical wisdom. A lot of our understanding of psychopharmacological mechanisms is speculative and hypothetical. There is little we can say with confidence or certainty. This means we have to approach the art and science of psychopharmacology with humility and transparency. We should maintain an openness to the unknown, the undiscovered, the poorly studied and, most importantly, an openness to learning from patients.
A liberatory psychopharmacology should provide effective tools for Mad and distressed people to accomplish what they desire and what might give them the opportunity to flourish and live well – whether that is symptom control, relapse prevention, cognitive or psychological enhancement, a temporary retreat from the world, or psychedelic experiences. If psychopharmacology can be a tool of oppression, but also a means to live a flourishing life, it needs to be divorced from the goals of biomedical coercion and control. Applying a Social Model of Disability, we could even see medications as offering possibilities for Mad people in the same way as glasses, wheelchairs and crutches offer new possibilities for disabled people.
Our current practices rely too heavily on the judgment of physicians or the courts regarding what would be best for patients. A liberatory psychopharmacology would support a person’s will and preferences. It would mean making other alternatives available if people don’t want to use medications, and giving people more choice in how they wish to use medications, if they wish to. Practice guidelines and treatment manuals may offer a useful way of structuring treatment, but a liberatory psychopharmacology recognises that they can become oppressive when they are used to deny people the ability to tailor their regimens in ways that work better for them, for example using unconventional doses or as-needed use.
# Challenging power relations and access
A liberatory psychopharmacology would be acutely aware of the power that surround the practice of psychopharmacology and the imbalance that exists between prescribers and patients. It would challenge these power relations and ensure the presence of robust checks and balances to make the relationship more democratic. It would also argue for increased access to information and knowledge about medications, how to use them safely, and how to come off them safely as well. It also needs to be aware of the unequal access to medications, within nations and across the globe. For example, the poor and the uninsured (who are disproportionately black and brown) are often condemned to lives of disability with sedating psychotropics used for behavioral control while the rich and well-insured often receive psychotropics that are better tolerated and allow for a better quality of life.
# A staunchly non-moralising attitude
Finally, a liberatory psychopharmacology rejects all forms of moralising about medication use and doesn’t shame people for using them, or not using them. To take or not take a medication is a personal decision informed by costs and benefits. A liberatory psychopharmacology recognises that there are no “good drugs” and “bad drugs.” There is no natural boundary between substances used recreationally and those used medically, between substances obtained on the street and substances prescribed by doctors. The differences are primarily in how regulated they are, their addictive potential, and how safely and effectively they can be used. Many substances inhabit both realms and other substances move from medical to street use and back again over time; that is only to be expected.
A liberatory psychopharmacology doesn’t romanticise suffering. It rejects what has been referred to as pharmacological Calvinism, the notion that “if a drug makes you feel good it must be morally bad”, the idea that abstinence from substances is the highest ideal, and that recovery using psychiatric medications is inevitably inferior or a sign of weakness. A liberatory psychopharmacology doesn’t dismiss people’s positive or negative experiences of medications. Instead, it sees them as morally neutral. What makes them good or bad is how they are used. When used badly, they can be oppressive, but when used with these principles in mind they might even be liberating.
Awais Aftab is a psychiatrist in the US and his work focuses on critical and philosophical issues in psychiatry. He blogs at Psychiatry at the Margins: https://awaisaftab.substack.com/