The biomedical model of psychiatry and the right to refuse medication


As an inpatient, I have seen the prevailing biomedical model of psychiatry and how it compels doctors and nurses to act. The cavalier attitude many healthcare providers have in prescribing powerful drugs often with horrific side effects becomes evident shortly after you are committed.
The rush to medicate those who have found themselves in the psychiatric system is
breathtaking to observe. The casual way doctors resort to drugs to induce recalcitrant patients to docility and the callousness one is treated with when the effects of these drugs include horrors like extrapyramidal syndrome is chilling and indeed terrifying. It is all in a day’s work for these practitioners. The patient’s physical integrity has been violently violated yet no regrets are expressed. It is the cost of doing business.

An inpatient in a psychiatric ward who is not under a court order can refuse medication. In this blog, I recount my personal story, as a refusing patient, of what awaits those who have the temerity to question the biomedical model of mental illness. And I ask why this model is so precious that doctors invoke it without remorse and despite its all too evident depredations.
Western society takes for granted the right to forcibly treat the mentally ill. Once patients are committed, forced treatment follows as a matter of course. Mental patients, the argument goes, lack the competence to consent and the state has the right, in the absence of such competence, to determine what is best. After all, how can a psychotic person evaluate a proposed treatment?
Psychosis is itself involuntary mind control that represents an intrusion on the integrity of a
human being. But while constitutional factors may determine the form a patient’s symptoms take, many mental disturbances are environmental in origin. The patient, seen in isolation and removed from their environment, appears to the practitioners of the medical model of mental health like a bizarre animal.

The patient is treated solely as a disease entity. Under the biomedical model, the neutral and disinterested attitude of the clinician quickly becomes a lack of empathy and professional competence. This is seen nowhere more so than in the treatment of a patient who refuses medication. Any pretext under this model of care is good if it justifies medicating a patient.
Shortly after my admission, I had what I thought was a minor disagreement with a nurse. This became grounds for my forcible injection with Haldol. I awoke the next day in the Isolation Room with EPS, extrapyramidal syndrome. I had parkinsonian tremors. I paced about the small room like a trapped animal unable to relax. The fearfulness of this experience cannot be described adequately by any words. A general practitioner entered the room. I remembered him from the week before when he had done his rounds. I had no idea what was wrong with me except that it had been caused by my forcible injection with Haldol the day before. The GP silently went about his duties and left the room. In the afternoon I was seen by a psychiatrist. He palpated my inner elbow and wrist. I asked to see a neurologist not knowing if the horrors I was experiencing would ever end. Once again, my only response was silence. When I complained later to my treating physician about the side effects of the drugs I was administered, the silence was no less deafening. (I took the benzos doctors fed me to help me sleep but refused antipsychotics.)

What was behind this wall of silence?
The silence of the doctors served only to increase the sense of isolation I had felt since my
incarceration. I can only surmise that the purpose of my treatment was to induce apprehension and fear in me. One product of the biomedical model is the cynicism and indeed contempt it induces in its adherents towards a recalcitrant patient. (Hence the silence and indifference that the patient is greeted with when he presents symptoms of EPS.) By my refusal of treatment, I had put the tenets of biomolecular psychiatry into question. The intellectual prestige and scientific legitimacy of the dopamine hypothesis was on the line. I evidently suffered from an unbalanced cerebral metabolism. The only possible treatment was to relieve my symptoms by blocking excessive flows of serotonin or dopamine, or both. To think otherwise was to believe the world was flat. I would learn the truth of the dopamine hypothesis in the Isolation Room. My dopaminergic system would be disrupted by injecting Haldol. Doctors now decided how much dopamine coursed through my brain. Too little and I developed EPS. Too much and I was taken back to the Isolation Room. The right amount and I would be granted a discharge. If my individual autonomy was attenuated by my psychiatric symptomology and I functioned in a reduced capacity, what of the ability of my caregivers to predict adverse events like the EPS they would induce in me? Was it not also compromised and if so by what? If I suffered from a discrete disorder characterized by abnormal brain chemistry, what were the biological underpinnings behind the behavior of the doctors and nurses who forcibly administered the drugs that brutalized my dopaminergic system and caused my EPS? Were they not also, by the same reasoning, under the sway of an excess of dopamine?

Behind the wall of silence that meets the drug-evading patient is an ideology. It obscures
underlying tensions and gives clinical sanction to the medical assault and battery that a patient is subjected to in the Isolation Room.
The legitimacy of “science” cannot be put into question and certainly not by a diagnosed
psychotic. Five psychiatrists agreed on my diagnosis (schizoaffective bipolar 2 with paranoid personality). At no time would anyone rethink their devotion to neuroleptics because of a rejecting patient. My treatment, brutal and inhumane, came with a scientific pedigree. For my caregivers, there was no question of treating a patient poorly, of course. No, I had been treated with an implacable scientific rigor. Yes, they had induced a pathology in my dopaminergic system akin to Parkinson’s disease but the intent was to correct my brain chemistry. They were clinicians and they had taken what they deemed a reasonably foreseeable risk. But what if my suffering had been caused not by an organic brain disorder but by situational factors beyond my control?

It has been almost fifty years since Ivan Illich wrote Medical Nemesis. The trends he noted then have only increased, this nowhere more so than in psychiatry. The medical imperialism he decried with its domain of biological explanations is now the dominant philosophy in psychiatric hospitals. The medical model, with its assumption that diagnosable conditions are a function of underlying pathology or illnesses, has minimized the role of social and cultural factors in psychiatry. The otherwise vague and problematic nature of the concept of mental illness is now expanded to include an all-encompassing array of diagnoses. It is a point of controversy whether such diagnoses of mental illness explain anything.The patient and his symptomology must be seen not solely in biomedical terms but also and no less importantly as a product of larger social conditions. Compounding these is the perpetuation of these very same debilitating conditions in the “curative” environment where the power of doctors is absolute and the isolation of the patient becomes complete.
The medical appropriation of health so aptly delineated by Illich is now complete. If psychiatry presents itself as a technical activity that is immune to political considerations, the medical nature of psychiatric terminology and knowledge obscures the values and judgements that are embedded in its practical execution. The language of mental health must be thought of as an ideology in the Marxist sense insofar as it helps to obscure real underlying tensions or concepts.
A medical framework has been superimposed onto the psychiatric system in order to give it the legitimacy associated with science. Instead of mobilizing the patient’s self-healing powers, modern medical magic turns the patient into a limp and mystified voyeur. The medical profession is defining increasingly narrowly what it understands by a healthy normal person.
People who do not fall within these narrow limits are classified as deviants of one sort or
another. They become patients under the tutelage of the profession. Doctors go to ridiculous and fanatical extremes to force their patients into the sort of narrow strait jacket which Illich describes.
Iatropic disease is contracted in the very place that you are taken to be cured — a hospital. In the case of a recalcitrant patient, large doses of iatropic disease may be indicated and liberally administered.
One product of the assiduous administration of the drugs a patient is forced to take after his commitment is that their bowels seize up. A few weeks after my admission, I suffered an important constipation. My requests for a laxative were continually refused. I was told that none were available. I was chided by my nurse to stop my pleadings. The hospital, she said, was “not a hotel.” Another nurse told me to force myself to defecate. I was shown how to place myself on a toilet to better empty my aching bowels. I was shocked that a nurse could suggest such a thing when a powdered laxative was all I needed.
The head nurse who had injected me with the Haldol that caused my EPS came to my room. She was now my angel of mercy. I drank the orange juice with the powdered laxative that she had brought for me. She said that she could have the kitchen add fiber to my meals. The cold manner she had treated me with only days earlier was now gone. All I could do was thank her for her seeming compassion.

The new patient in a psychiatric ward finds themselves in an alien and frightening environment. It is certain, however, that methods like those above of bringing a patient closer to their caregivers are not taught in nursing schools. They stretch belief but are the treatment allotted to a patient who refuses medication.
My misery had been deliberately prolonged, I could only surmise, to impress on me to what
point I was beholden to staff for my every need. The lesson in this was that doctors decide when you defecate. If I was to have even my most basic needs met, I would have to placate my doctors and “take my medicine.”
The duress I was under as a drug-evading patient was relentless. I was put in a room where the patient that had resided there for the previous six months had been incontinent. I choked when I tried to breathe. I was deprived of my sleeping medication (I have a profound insomnia) and was awake for weeks at a time.
I took the benzos I was given in the hope that they would help me sleep. They did not. After a few weeks, my sleeping medication was restored only to be stopped once more. I refused the Risperdal and Serax that I was told would replace my sleeping medication and demanded that I be put back on the 150 milligrams of Seroquel that had allowed me to sleep.
The idea that a doctor would deprive a patient of his sleeping medication for twelve days to
compel him to ‘voluntarily’ take a drug he had prescribed seemed impossible to me. Behind a doctor, however, stands a clinico-administrative edifice. I would have twelve sleepless days and nights to contemplate what it means to be powerless before this edifice.
Forcibly depriving a person of sleep is a profound assault on the entire biological system at the foundation of that person’s mind and body.
Sleep deprivation can trigger mania in people who have bipolar disorder. Other psychological risks include impulsive behavior, anxiety, depression, paranoia and suicidal thoughts. It can also suppress the immune system, make a person more susceptible to bacteria and viruses, increase recovery time from illness, and affect blood sugar and inflammation levels.
The use of sleep deprivation as a form of duress is not new.
Sleep deprivation had been used by the NKVD on prisoners in the Soviet Union as a form of
torture. The European Court of Human Rights ruled that sleep deprivation amounted to a
practice of inhuman and degrading treatment.
Obtaining something by causing the other party duress is hardly a civil manner to proceed no matter recommended medical practice. Yet this was a modus operandi in a modern psychiatric facility. The suggestion that a patient has a choice to “voluntarily” accept to “collaborate” in his treatment under such conditions is a legal absurdity.

The authority the public vest in doctors is not an unrestrained power. But for my doctors, the discretion the State gives doctors was only one more means to the further end of manipulating and exploiting the vulnerabilities of a patient.
Sleep deprivation affects dopamine regulation and is linked to hallucinations. If you want to
break someone, deprive them of their sleep. Again, my dopaminergic system was assaulted by doctors. I was broken and finally took the Serax doctors were forcing on me, if only to sleep a few hours.
During an evaluation, the psychiatrist who had deprived me of sleep told me that I had a brain tumour which, he said, he would remove. The surgery, he promised, would be performed. The suggestion that what I suffered from was a malignant growth is the apotheosis of the dopamine hypothesis. This was more than hyperbole and a manner of speaking. It was a bold assertion of belief by my doctor in the dogma of biological reductionism.
The patient in the biomedical model of mental illness must doubt his reality. To adjust to this new interpretation of their reality, they must accept the biomedical explanation of mental illness, with its system of unstated values, i.e. its ideology and implicit hegemony.
As Illich so presciently forecast, the pharmacological model of mental illness now constitutes an infectious disease of which the medical profession is the pathogen. Statistics tell the story. In the last decades, the number of people that are medicated as clinically disordered has exploded. It is an epidemic.
Diagnostic boundaries are continually being loosened. My diagnosis, bipolar 2, is a recent
addition to the DSM. I suffer, I am told, from an organic brain syndrome. My diagnosis is further proof for doctors of the prevalence of mental disorders and the effectiveness of psychiatric drugs. Psychiatry stands on the threshold of becoming an exact science, as precise and quantifiable as molecular genetics.

An era of psychic engineering and biopsychiatry is beginning. Those of us who decry its depredations are psychiatric Luddites.
The medical profession can call on the police to force consumers to use its products. This, of course, is necessary in the control of epidemics and the detention of the violent. I, however, had committed no crime. There were no victims (other than those my doctor claimed I had threatened I would attack during an evaluation). I was viewed through a very particular paradigm, a scientific myopia that reduced all situational factors to a cognitive impairment and discrete disease. I would be saved from myself and the cancer that perturbed the neurotransmitters in my brain. Doctors would foist their ministrations on me, willing or otherwise.
We are told that the evidence must be overwhelming to compel a court order for forcible
injection, but such rulings can be based on little more than opinion. The defendant has broken no law. It is his “potential” that is in litigation. If psychiatry is evidence based, there is little to support the contention that such hearings protect anyone. But who protects the patient prosecuted for crimes he has not committed?

The ideology behind the silence that meets the patient with drug-induced EPS blinds the
proponents of the biomedical model. In the Isolation Room, the patient with his tremors and involuntary movements indeed becomes the bizarre animal doctors had so astutely diagnosed. I have been disabused of my innocent and naïve ideas about the biomedical model. I once accepted what I was told by doctors that neuroleptics protect against brain damage and that I was indeed damaged.

Phil Nolin was treated for Tourette’s Syndrome with neuroleptics, anticonvulsants and antidepressants. He now lives with the long-term effects of these drugs. He is the author of The Skull Behind the Face: Canada/Cambodia relations 1980 to 1986 and has published articles that have appeared on syllabi for health economics courses at Queen’s University and the University of Regina. He lives in Montreal where he plays guitar in Opioid Crisis.