‘…there is nothing either good or bad, but thinking makes it so. To me it is a prison.’ (Hamlet Act II, Scene II)
I taught a 2hr seminar today under the influence of a benzodiazepine. This was a good thing. I have epilepsy which is usually under control but recently I have suffered breakthrough seizures which are unpleasant and subsequently disrupt my memory, mood, behaviour and energy levels. This term I have had to rearrange classes at short notice when recovering from seizures, but thanks to an incredibly good service from my GP and consultant after suffering a minor seizure last night, I popped a new type of pill and was well enough to work this morning.
Ironically, at the moment I am writing a paper on the good of medication, or the challenging problem of defining whether it is the effectiveness of medication or the circumstances in which it is administered which make it a good intervention in some cases. But a conversation I had at the weekend where the phrase ‘chemical cosh’ was used made me realise how uncomfortable I feel about coming out about how I use medication to control my brain and psychological ‘mis’behaviour.
Benzodiazepines are literally a ‘chemical cosh’. They work by increasing the extent to which neurons respond to the neurotransmitter GABA and GABA in turn reduces the excitability of neurons; it reduces the overall amount of electrical activity occurring in the brain. As a result benzodiazepines are useful in providing short-term symptomatic relief of seizures, acute anxiety or any other situation where abrupt and reliable sedation is called for. They are safe drugs, since adverse responses to them are rare and they are not known to have teratogenic effects in pregnancy. They are valuable drugs in epilepsy because they can attenuate tonic-clonic seizures which have not ended spontaneously and which could cause brain-damage or death if left untreated. They are also fast-acting so can play a major role in the management of adults and children with any type of neurological disorder which causes behavioural problems.
Subjectively I find that unlike most anti-epilepsy drugs (AEDs) which can be quite hard work to adjust to benzodiazepines are at least pleasant to take. AEDs work but they temporarily made me depressed, grumpy, tired, thin, itchy, thirsty and gave me blurred vision as I adjusted to them. Benzodiazepines just make me feel calm and sleepy.
Benzodiazepines are also extremely dangerous drugs. When taken for long periods brains can rapidly develop a tolerance for their effects and withdrawing the medication can cause more serious symptoms than those the drugs were originally used to treat.
We have become used to the idea that the language we use to describe mental disorder has powerful effects. There may be no right answer to the question of how consumers/patients/service user/survivors wish to be described, but we have at least largely absorbed the lesson that retard and schizo are wrong answers.
But what about language used to describe practices associated with the treatment of mental disorder? When I talk about my experiences of epilepsy, psychosis and self-injury I am intrigued by how many people still find it appropriate to joke about hiding the knives if I come round, the use of medication to stop me ‘losing it’ or alternatively how it would be better not to combat my symptoms with chemicals but to rely on ‘natural’ methods or will-power to control my seizures.
I can see these responses are ill-informed and not intended to hurt but I have noticed that I feel more inhibited than I used to when talking about the role of psychiatric medication in the management of mental disorder. And since that is a significant part of my job, examining this inhibition seems important.
When I hear people talk in absolute terms about the abuse of psychoactive medication using phrases like ‘chemical cosh’ or ‘chemical strait jacket’ I feel mildly ashamed and defensive about my dependence on psychoactive medication. Running through much critical discourse on the use and abuse of medication in the control of mental distress is an implicit assumption that medication is an inferior form of intervention to…well pretty much anything else.
One could argue that the phrase ‘chemical cosh’ is not directed at my experience but only the practice of over-prescribing drugs for the primary purpose of behaviour management. But this is problematic. Psychoactive medication clearly is prescribed to manage my behaviour, which can be aggressive and self-destructive when I have experienced multiple seizures. ‘Over’-prescription is to be deplored, but it is not self-evident when appropriate use of medication ends and over-prescription begins.
I would never argue in favour of uncritical acceptance of medical practice (!). But we should recognise that the phrase ‘chemical cosh’ and others like it risk closing down debate rather than opening it up. It is not wrong to be a person with dementia who takes anti-psychotic medication, a young person who takes anti-depressants to reduce their self-injurious behaviour or an adult with learning disabilities who receives sedation before a routine medical procedure. Listening to the experiences of people who have used medication in these situations and had negative and positive experiences is a vital dimension of the debate.
It is wrong to be a care provider whose care is so inadequate that the people one cares for cannot be kept safe without sedation, or a clinician whose approach to patients with disabilities is so indifferent that medications are prescribed to control problematic behaviour without exploring the causes of those behaviours or whether other social, environmental or interpersonal interventions could be employed instead. But if we are concerned with these phenomena we should name them and try to address them specifically, rather than label any use of medication to control disruptive behaviour as a ‘chemical cosh’ and risk inhibiting the very people whose voices most need to be heard.