A recent interview on Mad in America (MIA, on May 15th) with professor David Cohen, Ph.D focused on his work on psychiatric coercion. His illuminating insights provide an understanding of how psychiatry gets away with forced treatment with drugs that have clinically demonstrable adverse effects.
Psychiatry’s authority is relegated by the government – unlike other medical specialties — except healthcare providers who administer government-recommended vaccinations.
Dr. Cohen, is a social worker, professor of social welfare, and Associate Dean for Research at the Luskin School of Public Affairs of the University of California, Los Angeles. He has also taught in Canada and France, and for over 20 years held a private practice to help people withdraw from psychiatric drugs.
He studies the social construction of psychoactive drug effects, the union of law and psychiatry within a criminalization/medicalization system and envisions alternatives to the current mental health industrial complex and the medicalization of everyday life. He is the author of over 100 book chapters and articles. His first book, published in 1990, was Challenging the Therapeutic State: Critical Perspectives on Psychiatry and the Mental Health System. His latest book, published in 2013, with colleagues, Stuart Kirk, and Tomi Gomory is Mad Science: Psychiatric Coercion, Diagnosis and Drugs.
What follows is a transcript of the interview, conducted by Peter Simons, edited for clarity, in which Dr. Cohen discussed his path to becoming a researcher focused on mental health, coercive practices, and discontinuation from psychiatric drugs.
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PS: Hi David, and welcome.
DC: Thank you, Peter, for having me.
PS: Thank you for being here. First, I would like to ask about your background. How did you become interested in the mental health field? I know that you do have a social work background — what was your experience, in the beginning, working with people?
Dr. David Cohen
DC: I started out as a social worker in late 1975 in Montreal, Canada, and about nine years later in 1984, I entered a PhD program in social welfare at Berkeley. In that intervening time, I was a caseworker and a community organizer in a family counseling agency, in a juvenile court, in a civil liberties association, and in a community health center.
In each of those places, I witnessed firsthand how psychiatry was used to constrain misbehavior. This was pre-DSM III, so I can’t really say what the mental health field was about because even that expression: “mental health field” wasn’t that popular. But at that time there was a lot of ferment about different ways of counseling. There were experiments in family therapy, communication theory, systems thinking. There was a lot of activity and a lot of different ways people were thinking about how to help people, and I felt part of that. I was steeped into these kinds of trainings with different ideas.
In my very first job I met with and worked with people that had diagnoses of schizophrenia and were taking prescribed drugs—I didn’t even know what they were—but because of my own experiences with psychedelics, I asked these people pretty blunt, simple questions about what they were going through.
They were very happy to educate me, and I understood that they felt the drugs made them feel different and the drugs made them look different to other people. I thought there was something there that was interesting and I was also concerned because some of them expressed that they were forced to take the drugs or felt forced to take the drugs. That bothered me. I thought, “This is a deep experience to take drugs. This can be very upsetting to force someone to do that.” All of this raised dozens of questions for me and helped my nascent understanding of the very complex relationships that people established with drugs. I was also fortunate to have a really wise, no-nonsense, psychoanalytically trained supervisor.
Her name was Sylvia Benjamin, and she was wonderful. She encouraged any questions I had. She didn’t seem to mind if I didn’t like her explanations for things. She would say, don’t you think this person needs a doctor? And I’d say, no, I think that’s the last thing they need. They need a vacation, they need money in their pocket, they need time off. So she encouraged me to explore elsewhere, and that was at the very first job that I had in this field. I was also reading these constructivist authors: Francisco Varela was one, Paul Watzlawick was another, Virginia Satir, people like that. That was my beginning experience in this field.
PS: I can see how that gives you a through-line of starting to be critical of the prevailing medical model, even as that was just starting to be the way that people looked at things in the 80s?
DC: Yeah… to be critical of the medical model, I have to say that started earlier. Without being able to put my finger on it, but early on in life because of where I was brought up, because of what I read—I read adventure stories, I read complex things. I was quite familiar, as a child, with the Bible. I was reading it as an adventure; it was full of characters. So I already was getting a sense of interpreting family issues intergenerationally.
I was also brought up as a member of a fairly oppressed minority in a far-away land. Growing up in a very intensely multicultural environment, I had a sense early on that the same behavior could mean quite different things to different people depending on where they were standing. At an early age, I got a sense that life was quite complex and intricate socially. Then, as a budding social worker, I was observing psychiatrists at work. I was there when they were conducting interviews; I was reading the reports they drafted, I was seeing how they were talking to judges in court hearings, and how they were talking to families. It kind of appeared stale to me. It didn’t ring true, and I could see no connection to medicine. I mean some of the buildings were the same, some of the language was the same, but I saw no other connection. And so I thought, already at that time in my early twenties, this needs debunking. Then I fell into a book by Thomas Szasz called Ceremonial Chemistry. I think it was 1977 when I first read that book.
That book raised a lot of questions and fired me up. Szasz was way ahead of his time, putting all psychoactive drugs, licit and illicit, in the same ecological niche. I was beginning to draw dots, make links to the effects of drugs and the statuses of drugs. Not so much their properties and molecules, but just the way they were treated by different groups at different times. That gave me a sense that maybe that’s why they have the effects we attribute to them. So it opened up a way of thinking that was already nascent, but I that I couldn’t put words to. So that got me critiquing the medical model, I would say. For the next few years, I turned my attention to studying drugs in a social, anthropological, historical manner.
PS: I’m wondering how you go from the reading of those critiques and Thomas Szasz to being able to write your first book in 1990, Challenging the Therapeutic State. What led up to that?
DC: That was an edited anthology, so I went to every person that I thought was doing something quite critical, because, at that time in the late eighties, I thought we were just drowning in this medical model. I thought, wait a minute, I’m hearing other sounds. But before that, more importantly, I started to get interested in antipsychotic drugs. And that was, as a social worker, let’s say 1980. I began to be interested because schizophrenia was for me just the latest word that we were giving to madness, and psychiatry was claiming to own the resolution of that problem.
They owned schizophrenia, and they owned the response to it, and their leading response was antipsychotic drugs. What exactly was it about these drugs that made most of the writings I was reading quite laudatory and praiseworthy about the drugs? They were talking about it as if it was penicillin and I wanted to know what’s there because that did not quite jive with some of the subjective voices I was hearing from people taking them. So I wanted to know what was going on there.
I was fortunate to live very close to the McGill University Medical Library—an extraordinary place. I just spent countless hours there, reading everything I could on the antipsychotics and the neuroleptics. I wrote up my observations, and then I wrote a paper—I think it was 1983—and I sent it off to the Journal of Mind and Behavior, and the editor and the other reviewers liked it. I think it was published in 1986, and I was already then a PhD student. By then I had written other papers. The first paper I wrote was a critique of involuntary commitment. I think that was published in 1978. I was wondering about why social workers are enlisted in collaborating in forced psychiatric interventions. I just didn’t understand that, so I started from first principles, such as what are we doing, what is that for, what justifies it? So I was aware, but I got into focusing on the antipsychotics, and then I went to do my PhD, specifically to study with professor Steven Segal, who was following up a large cohort of people that he had first interviewed in the early seventies when they were being deinstitutionalized from psychiatric institutions.
I went to study the effect of antipsychotics on their social integration, which was a hip term at the time. So I bored ever more deeply into the topic of the antipsychotics from historical perspectives, pharmacological perspectives, anthropological, economic perspectives, power perspectives, epidemiology. That was my PhD.
Then I got an academic job. In a stay in France in the mid-1990s, I wrote a number of essays on antipsychotics, including one which was called “A Critique of the Use of Neuroleptic Drugs in Psychiatry.” That was published in a well-known book at the time called From Placebo to Panacea, which came out, I think, in 1996. That put together all I had been reading, interviewing about, and getting from primary sources in different countries. It was about the antipsychotics and what they were actually producing as we could document rather than just as people were saying they’re doing. Even before that, in the late eighties, I was already getting involved with survivor groups in Quebec. That led to coauthoring the French language book A Critical Handbook of Psychiatric Drugs, in 1995. That was one of the first books that really focused on coming off of psychiatric drugs. There was a whole chapter on withdrawal effects and how to come off drugs.
That’s why Peter Breggin and I, in 1999, were able to write Your Drug May Be Your Problem. So I had all this background too; he had his background with critiques of neuroleptics already. That’s why we focused on coming off drugs and withdrawal, which I thought was really the issue of the day at the time. That put together a number of influences and things I did that got me ready to be doing the work that I continue to do.
PS: Yeah, it really puts into perspective that you were working on this for so many years. Then to come out with several books that really critically look at the idea of how these drugs are affecting us and what it means to come off of them and what happens when you try to discontinue them. It’s fascinating to me that these books were out there. You wrote these books in the ’90s, the one with Peter Breggin in 1999, and yet it seems that, somehow, this never made its way into our culture. Hey, maybe people want to get off these drugs. Hey, what’s going to happen when that does happen?
DC: Well, eventually it made its way. I think you had asked me a question about, “Why do you think your critique didn’t punch a bigger hole in the prevailing wisdom?” You had sent me that question, and I thought about that. It’s obvious to me that it couldn’t punch a hole, by definition, because the prevailing wisdom was not then, and is not now, based on science. Science is a system to rigorously test your hypotheses and reject them if they fail continuously to pass the test. But it’s not based on science. It’s based on other things that we can explore. It’s based on the acceptance of what psychiatry does for people. The system is not based on critical thinking. So the critique, I don’t think would punch a hole in the prevailing wisdom. Certainly not in the short term.
Focused critiques of psychiatry, by definition, don’t punch holes. Instead, they get recycled incognito within psychiatry. It’s like a digestion process. Psychiatry feeds on critiques. It ignores them, first of all. It then incorporates them into its own practice and passes them off as the natural evolution of the discipline but doesn’t give any credit to who does it and never provides an accounting for why the critique was not accepted when it was first voiced. But my critique, I dare say, was prescient. It really announced the whole floundering of the “evidence-based” (quote-unquote) giving of neuroleptics. Then the CATIE studies, in the mid-2000s, publicized widely that the whole thing was floundering. The evidence base just was not there, and I was announcing that very specifically in my critique a decade earlier.
I also think it really helped to reinforce both early critiques, like those by Peter Breggin, for example, and a handful of neurologists, and the later critiques by David Healy, Bob Whitaker, and Joanna Moncrieff. All of us somehow reinforced each other. It was part of mounting this opposition, which is now pretty conventional thinking in critical psychiatric circles. I think it emphasized the view of drug effects as global states that completely defy reification into therapeutic effects and side effects. That’s what my critique emphasizes: that at every step of the way we’re dealing with quite global effects that if you have the power you’re going to say that this is a therapeutic effect, but this one is an unfortunate side effect, when from my perspective they all look to be affecting the person and the decision to say this is therapeutic and this is adverse or side is a political decision.
PS: Could you give an example of how, specifically, a drug might have effects that are called therapeutic and called side effects?
DC: The antipsychotics are a good example; the stimulants too. During an acute crisis, anything that’s going to slow a person down will look to those around a person, and the family or the physician, as if it’s calming them. The person would probably feel them differently, but it would look that way. And they’d say, “There, that’s the therapeutic effect of the drug. Look, it’s quieting them. They’re not voicing their delusion. The drug’s working.” Then two or three months later, sustaining that effect is turning the person into a vegetable. At that moment we start saying, “Oh my God, look, that’s akinesia, that’s parkinsonism.” So the same effect in one situation will be desirable, but over time, that same effect is no longer desirable because the person can’t function. So that’s a simple example which I think is obvious.
The same thing with akathisia, which is that drug-induced hyperactivity and preoccupation with your discomfort, which makes you half the time unable to address anything else going on outside of you. You are completely obsessed with what is happening to you; you’re pacing back and forth; you want to jump out of yourself. That itself, in certain situations, is looked at as if it’s therapeutic. In other words, because the person is unable to do anything else, they’re contained that way. Then, after a little while, when they’re back home, and they’re in that state, everyone is panicking and asking what’s happening to them. This is also the same effect being looked at differently. This is the notion of the effect either at different times in the process or from different eyes, being defined quite differently though it is the same action of the drug. That illustrates that the effects don’t come packaged in molecules. They are really interpreted according to the needs of the participants in the situation.
The one who has the most power will impose their definition of what is happening. I see that happening with a lot of drugs, especially drugs that have quick effects like stimulants or even benzodiazepines. Benzodiazepines: it’s good when you’re trying to go to sleep, but when you’re getting up in the middle of the night, if you’re losing your balance, then it’s considered an adverse effect. But it’s the same thing happening to you.
PS: There’s something in what you said about the authority of the psychiatric establishment to make those definitions. Something about “the person who has the most power gets to define what is a therapeutic effect,” and often that’s not the person who’s taking the drug.
DC: Yeah. And even when I would look for definitions of “side effects” in the literature, it was always defined as something that was unintended. Well, unintended, okay, fine—by whom? Who intends, who does not intend? So, right away, it brings us right back into social relations, interpersonal relations. Something isn’t unintended from nowhere, down from the sky. People have intentions.
PS: I believe you’ve also done some work about forced treatment in psychiatry. How do you think that plays into the sort of authority that psychiatry has?
DC: In the early 1990s, I reviewed hundreds, if not thousands, of decisions in Canada from administrative tribunals that were ruling on whether someone who was committed could have their release. So I obtained all of the written decisions justifying that and just wrapping my head around the tortuous, always circular logic between mental illness, dangerousness, and drug treatment. It was always this logic that: they’re dangerous because they’re not taking their medications; therefore they’re mentally ill, or they’re mentally ill because they’re dangerous because they’re not taking their medication, or they’re not taking their medication; therefore they’re dangerous, and so that makes them mentally ill. No matter which way you looked, there was no way out. Also, around that time, I was an advocate, as an independent expert in some of those hearings, I would go on behalf of people who were trying to gain their freedom. So my work has been looking from the outside and being somewhat involved in it.
The authority to coerce is fundamental to psychiatry’s authority in society. First of all, it’s given to every psychiatrist, as a psychiatrist. It’s almost a unique rite of passage. I would bet that if you don’t participate in some coercion and if you’re not observed to participate in coercion, frank coercion, I don’t think you can become a psychiatrist. Now I’ll pronounce that as something that I’m not certain about. But I’m guessing that that’s the case. If it’s not the case in one country, it’s probably the case in another. I would say that that authority, given to psychiatrists, in my view, is the basis for all of psychiatry’s influence in society, for all its reputation, for all its influence theoretically on the radio, even things that don’t seem connected to commitment.
We accept psychiatry’s authority and influence in many other spheres because we give them that authority to intervene involuntarily. That influence, that power, is all the greater because it’s rarely acknowledged by all the rest of us, who depend on that power to control people who bother us in our midst. That person creates or opens cracks in the fundamental institutions of society: the family, the school, the workplace; that person often lays them bare. Psychiatry is the institution that comes to the rescue—often enthusiastically.
I want to stress that no matter the main political system in a modern society, whether it’s been totalitarian, or communist, or social democrat, or socialist, or neoliberal, or free-wheeling capitalist, psychiatry always enthusiastically serves that system to handle the deviant or to justify how that system is going to handle the deviant. Whether the deviant wants to emigrate out of the country or wants to emigrate out of life, psychiatry is always there, no matter the political system. Involuntary psychiatric interventions to me are really part of the fabric of social life. They’re embedded in there; they’re a glue. They hold a lot of our society together for better or worse.
PS: I feel like that’s a huge statement, a statement that sort of takes in the entire concept of what is sanity and what is madness.
DC: As I heard myself say, “the person that I call the mad person opens cracks in the fabric of society,” artists do that too. Artists open these cracks up, can provoke us dramatically. Of course, there are differences. Maybe the person we call mad does it unprompted, does it right inside those institutions themselves. It’s like performance art, squared. It’s right there. It’s right in the family that the crack is open whereas the artist has the luxury to be away from it and to kind of show to us, not right in our face.
PS: From the beginning of what we were talking about, there is a way that giving psychiatry that authority, which is inextricably linked to the society as a whole, also serves to reify psychiatry’s authority over a lot of other things?
DC: Yes. That’s it. That almost exactly my point. Because of that authority we give psychiatry to “handle the deviants” (quote-unquote), we give them a pass over everything else. They get a free pass on their theories. Psychiatry tries hard to portray itself as medical pioneers, probing synapses, surfing the genome. But there are no results there at all. Despite that, we accept their discourse; it’s almost like we politely nod and accept that yes, you can say that and we don’t ask for the evidence. We don’t say, “But you’ve continually failed to support this hypothesis. You haven’t found the chemical imbalance. You did not find the aberrant gene. In fact, you’re saying it’s ALL of the genes right now.” We never hold them to account for what has been proposed as the test for their hypothesis. We give them a free pass because we need them to keep the social fabric together. That’s my point. Authority is based on many things like the knowledge of people, or maybe the wisdom of people, or maybe their example—or their power. The authority that rests on your sheer power, and that to me is the determining one that takes over all the other types of authority, and we give them a free pass on those other authorities.
PS: In the interest of your work that’s somewhat critical of the medical model of psychiatry, and is critical of some of that authority that psychiatry has, like forced treatment—what is the goal that we can have if society is going to give them that pass?
DC: Well, the goal is that we should try to understand that we probably need coercion. I have a hard time imagining a coercion-free society. I think coercion is necessary to maintain social groups as a final measure. The question is, who should be coercing? As a member of a helping profession, a so-called helping profession, I don’t believe that I should be the one to have that power to coerce. I think that if I have that power to coerce it should be clearly announced; I should be wearing a kind of a uniform that identifies me as a coercer, not a healer.
PS: To make the analogy to a legal system, there are laws that help to keep society together in a particular way, and the population knows those laws, and when they break those laws, then there’s coercion—something needs to happen to ensure that the laws of society are followed. The coercion that’s employed by psychiatry is different from that. The laws aren’t really necessarily clear. When you’re going to be the agents of coercion is also sometimes unclear…
DC: It’s like a shapeshifter. You know, the person is there for you, you have some distress, and you might go see someone, and that’s a story of course that I have heard countless times: “I went to see them for this problem; the next thing I knew, I was locked up in this room by that person.” That comes from blurring the role of the therapist with the role of the coercer. They’re important functions, but they can’t be in the same person. That leads to a critique of all of the interventions we have that try to blend the juvenile court model, where you’re at once a father and a judge and a helper and the doctor and the probation officer and the babysitter altogether in one. We don’t know what to expect. It becomes arbitrary, and we don’t know why you change roles instantly and you justify it on the basis of some science that I don’t know, or that’s not accessible to me.
PS: I wanted to ask more specifically about some of your papers that we recently covered on Mad in America. In those articles, you make the case that withdrawal symptoms confound a large portion of the studies that are purporting to demonstrate psychiatric drugs’ effectiveness in relapse prevention. I was wondering what this withdrawal confounding factor means for the evidence base that psychiatry promotes for the use of these drugs, both in the short- and long-term?
DC: Many types of studies in psychiatry, both short-term and long-term, use deliberate discontinuation from drugs as a kind of a paradigmatic procedure, a foundational procedure, to reach all sorts of conclusions about how useful patented psychoactive drugs are to people. So deliberate drug discontinuation, deliberate removal of a drug, is used in all kinds of studies to reach conclusions about how useful it is to remain on drugs. These studies—in the popular mind, and in the professional mind too—they hammer away the message that people with problems need to take drugs and especially need to remain on drugs indefinitely.
The fact is, deliberate drug discontinuation, especially abrupt discontinuation, is absolutely not equivalent to no drug treatment. To use such a procedure and to use it most of the time not transparently, to just kind of hint and not give details as to how you’re using this deliberate drug discontinuation to conclude that no drug treatment is worse than drug treatment… at best it’s disingenuous. Withdrawal symptoms from taking away drugs overlap with the treated symptoms, the symptoms of your distress that got you on drugs in the first place. So if your aim is to conduct a study to promote a drug, you’re not going to focus on the withdrawal symptoms, you’re going to ignore withdrawal symptoms rather than identify them. You’re going to exploit this lack of consensus in the field, the lack of clear definition of what this strange stuff is that comes out when you’re withdrawing the drug. Well, let’s just call it relapse rather than really dig into it and while not too many people are talking about it, all the better. Let’s just continue to do business as usual in these studies. That’s a problem.
Then the other side of the coin is that on the “clinical” side, the practice side, this neglect, this ignorance of the withdrawal symptoms, leads the therapists to misrepresent to clients that coming off drugs cautiously may have some really good positive consequences. So what I’m trying to say here is that there’s a dark side of withdrawal that’s being exploited in the drug studies, and there’s a positive side of withdrawal that’s being hidden in the clinical world.
So all I can say is big confounds everywhere. Big challenges to the evidence base, as usual. It’s always been like this. This is the business that I’ve been observing for decades. The issue of withdrawal confounding just means that a lot of what passes as the strength of your mental disorder that needs to be contained is actually a function of how drugs are withdrawn from you. Now, despite what I’ve just said, I don’t want to say that I accept everything that somebody says is a withdrawal effect. I do think there’s a sociology of withdrawal and an anthropology of withdrawal that’s yet to be written. But I am saying that withdrawal is a word that I don’t want to work to also reify and say that because somebody calls something a withdrawal effect of a drug, no matter who they are, whether they’re a user or a prescriber, that I’m going to accept that on faith. I want to see what exactly it is, and what it signifies, what relationship you have with that drug.
So I’m still questioning what withdrawal symptoms are, really. But I do recognize that there is this big black hole, a lack of consensus looking at probable withdrawal effects, and that is screwing up the drug studies and the evidence base. And on the other hand, it denies patients very common, sensible ways to taper their drugs and feel better.
PS: So you’ve just put out a couple of pretty major papers on that subject. Do you feel like the conventional narrative about this is starting to flounder in the public mind?
DC: I think that in line with this notion I have that psychiatry regularly recycles critical ideas and kind of takes them in, the whole issue of drug discontinuation is currently now being staked out as this professional turf issue in some ways. You know, besides geriatric medicine, psychiatry for decades had practically nothing to say about deprescribing except take your meds. So people are rushing in to fill this space. They see this as some niche they could be filling, and the media is following. But typically the media angle seems to be how do we bolster the medical authority? The fact is that almost all of the solid practical knowledge about coming off psychiatric drugs comes from completely nonprofessional consumer circles. Almost everything we understand about micro-tapering and going slow that has not been part of any real strong professional knowledge in any discipline I know of.
What that means to me is that I’m not sure if the narrative is really changing about drugs. I think that there are always narratives and counter-narratives that are going on at the same time. We see accelerating the movement to make illicit drugs licit—oh look, ketamine is now approved by the FDA for depression, or they’re doing a clinical trial of psilocybin for example. Everything gets recycled, licit becomes illicit; illicit becomes licit. The categories change, the language changes and then new products come in, and they go through the cycle again.
So it’s hard to tell if the narrative is changing about drugs per se. But is the narrative about psychiatric power, psychiatric influence, is that changing? Possibly. I think that Mad in America is a good example of ordinary enterprising individuals using information technology to change the channels of construction of information and dissemination of information. We always face changes in how institutions are seen, and psychiatry’s reputation generally is always mixed. I find it’s sometimes the subject of ridicule, or we don’t take it seriously, while at the same time we respect it or we’re in awe of it. These counter-influences are happening simultaneously.
PS: I’m curious about what your hopes for the future of your work are, whether there is any research that’s coming up for you that you wanted to talk about, and how that might play into the overarching goal of criticism of the authority of psychiatry.
DC: I think a lot these days about the power of nature, the power of green space, the power of gardens to calm us, to heal us, to center us, to situate us in our context, and maybe even paradoxically to bring out the best of us as social beings. So I just want “mental health,” if that means anything, to mean that we respect planet Earth, our only home. That, to me, is more important than any of the mental health and psychiatric issues. The students I see, rarely have they encountered any serious critiques of psychiatry or mental health ideology. They think, you know, “mental health” or “serious mental illness.” They think those are categories of nature. They’ve been steeped into this ideology. I’m glad they’re asking me questions because I’m an educator, and my task is to present my views and then help them to attend to their own thinking so they can challenge their own views. I’m just concerned that many of the jobs they will go into will expect them to take these categories, these concepts, as categories of nature; they will expect them to not be so challenging. That’s part of the way things go. So I’m not pessimistic. I’m not particularly optimistic. To inverse a famous title of a book by Paul Watzlawick, the situation is serious but not hopeless.
PS: Well, thank you very much. That has been really enlightening.
DC: I hope so.
