Families that communicate with Double Binds create children who often spend an inordinate amount of time in their lives trying to find solutions to problems that really have no solution [part one: the bind…]. To review the elements of a Double Bind: [1 & 2] Two mutually exclusive commands ["lose weight" and "clean your plate"];  the injunction that you have to act;  the prohibition against addressing the impossibility of the situation. What does a "healthy" person do in that circumstance? In the words of the ancients, they "go between the horns." Said in other ways, they deny that [1 & 2] are the only possibilities; they break rules  and  by talking about the impossibility of the task, that neither action is correct [in this case, "silence is not golden"]. In the real world, the problem needs to be reframed in a more realistic way to look for solutions.
In the case of the challenging/disruptive intellectually impaired child, the Hamlet question, "to prescribe antipsychotics, or not to prescribe antipsychotics" is hardly the right way to formulate the clinical problem. Probably the first order of business is to explore the situation of the specific patient and the specific caregiver and the specific living situation to see if one can figure out what’s so upsetting, what’s wrong? Sometimes it’s something you can’t do anything about, but often it is amenable to change. Mentally retarded people are just like the rest of us – just less able to figure out and communicate what needs to be dealt with. Trying to control behavior with medication if there is ongoing conflict is a dubious enterprise. You end up with a sleepy conflicted person.
The next thing that comes to mind is that such things are rarely acute problems that need to be solved in a single visit. The challenging/disruptive behavior is usually chronic and deserves more than a one-shot decision – so there really is no requirement to act immediately – prescription or otherwise. And as for medication, we really don’t know the answer as to whether psychoactive medications like antipsychotics or anxiolytics are helpful in these situations [part two: the dogma…, part three: the questions…] – when or if to use them. We do know that the Dogma that they are helpful is not based in science.
We’re still in the midst of a climate that has been pervasive for much too long – the fantasy that we’re going to knock the ball out of the park, crack the great riddles of the causation of mental illness, figure out the brain. Our National Institute of Mental Health is currently obsessed with discovering new treatments to make up for the deficiencies of the ones we currently have. The solutions remain in the as-yet-unrealized future. Dr. Insel’s NIMH is now saying that future NIMH Clinical Trials will need to contain probes that look for etiological clues – "a focus on learning more about the disorders, as well as the mechanisms of intervention" [time for a sabbatical…].
But what about the treatments we’re currently using? One would have to have been in a prolonged coma state not to know that many of our current practices and beliefs about psychoactive medications have been heavily shaped by influences that don’t have to do with patient care – the profit motives of PHARMA, the cost-cutting motives of third party carriers. Medical science has been clearly twisted to serve both masters. It seems to me that the onus falls on the National Institute of Mental Health [and our professional organizations] to investigate problems like the one addressed in Tyrer et al’s editorial. It’s time to stop simply decrying over-prescribing, and provide some solid evidence-based science to the practitioners who sit in their offices seeing patients.