“Depression” by shattered.art66 is licensed under CC BY-ND 2.0
The Antipsychotic Medication Paradox: A cause of systematic Gaslighting in the NHS?
Recent research has uncovered a potentially systematic gaslighting mechanism within the NHS, the National Health Service in the UK. This appears to show that NHS may be in breach of the Mental Capacity Act, and is, as such, showing itself to be a potentially narcissistic organisation.
The issue that has been identified is related to the patients ability to think higher level thoughts after being prescribed some types of medication. Antipsychotics, for example can cause very significant impairments to executive function, our ability to adapt to new challenges, reducing the ability to cope.
It is becoming clear that the NHS systematically fails to check for this significant, medically induced vulnerability. One that could place that patient in real physical and mental danger. Making them far less able to adapt to environmental challenges. Potentially removing entirely their ability to learn, or even realise that this is the case.
The NHS seem to actively ignore this issue in regard to antipsychotics, specifically, and for most medications, overall. Instead, it is an elephant in the room, casting a huge shadow, which those that do know, see, but cannot mention. This problem revolves around our metacognition.
Metacognition
Metacognition refers to the process of thinking about thinking and self-analysis of one’s own thought processes, evaluating their effectiveness, and adapting strategies as needed. This includes self-assessment, self-regulation, and deliberate revision, which are all part of what you called “high-level oversight”[Flavell, 1979].
There is a growing body of research showing that antipsychotics, especially at high doses or in cases of over-medication, can significantly impair metacognition, sometimes having a huge impact, affecting self-awareness, self-monitoring, insight, and reflective thinking. The impact is not just quantitative (measurable deficits in tests), but also deeply qualitative, affecting how people experience themselves, others, and their own agency [Harvey et al., 2012; Grandjean et al., 2012].
On paper, one would expect the NHS to have this covered:
The National Institute for Health and Care Excellence (NICE) provides guidelines for monitoring and managing side effects of psychiatric medication, including cognitive effects. NICE recommends regular review of treatment and its impact on the patient’s functioning.
As a reminder, the Mental Capacity Act (2005), requires that if a person’s ability to understand, retain, use, or weigh information is impaired, formal capacity assessments are done, and best interest decisions are made. This is the official process for safeguarding patients whose decision-making, including metacognition, is impaired. So any significant decrease in executive function, such as impairment of metacognition, could be the trigger for significant additional support.
However, those NICE guidelines do not lay out a specific, dedicated protocol for testing the metacognition of any patients. Therefore, prior to medication, the NHS almost always fail to discuss the issue with the patient, and no baseline measure is taken.
No baseline – no attempt at monitoring
As any clinician will tell you, in order to meaningfully assess how medication affects metacognition, it is essential to use a “before and after” approach, with a clear baseline measure taken before starting medication, and follow-up assessments after.
Yet, speaking to many people prescribed antipsychotics, we can confirm that the reality is, that attempts to raise issues related to impaired executive function are almost always thrown back at their “illness”, and there is still no mention of any cognitive testing. To add to this quandary, of authenticity and truth, those poor patients are then “threatened”, with increased dosages, to see if that will “help”.
That is systematic incongruence – it has recommendations and a secret “understanding” that they are not to be followed, not unless a patient or treatment situation insists. NICE clearly have no measures for this, adding official “undersight” to allow for that clearly abusive systematic behaviour to continue unnoticed. There is no evidence, of course. No baseline means that direction has not been followed, and there is “no evidence”, of any patients with those problems. Everyone just “forgot” to follow any part of that guideline, in their case.
But. those patient records, for those those on high doses. If we looked at them, what would we see?
- No mention of any testing.
- No follow up meeting to see how they are doing, on that new medication, often promised, but, more often than not, never delivered.
- We will also see perhaps, an occasional meeting that the patient, demanded, due to “lack of insight”. Meetings where their failure to cope with the medication, was also, “just in your head”.
NICE could do some analysis of those records, quite easily, one would have thought?
Why is this happening?
Unfortunately, antipsychotics actually target metacognition. Metacognition is that part of us that monitors ourselves in order to spot threats, and deal with them accordingly. In the distressed mind, we can see that this monitoring, recognises the threat and informs the awareness. It is therefore a messenger, that is silenced by the medication, thus reducing the patients anxiety and panic. The problem is that it has the same dampening effect for all metacognitive processes, not simply those the medication is claiming to correct.
So now we can see that the system is saying that some types of patients might be monitored, but others, those on high dosage antipsychotics, for example, will not be, The NHS seems to have decided that dumbing down people to the point of unemployability, is preferable, to them struggling to sleep sometimes. Once they are on that medication, continued avoidance of this very touchy subject means the only option is to “up, the dose”, it seems. This also shows, another signpost that is often missing: Access to talking therapies.
Organisation Incongruence
This situation is a clear example of organisational incongruence because the stated goals and policies of the NHS (and the wider mental health system) are misaligned, or even in direct conflict, with the actual practices and outcomes experienced by patients.
Organisational incongruence occurs when there is a mismatch between:
- What an organisation says it does (its mission, values, policies, promises).
- What it actually does in practice (its real-world actions, outcomes, and the experiences of those it serves).
The Impact of Incongruence
False Promises: The NHS claims to provide individualised, person-centred care, but in practice, it often fails to measure, monitor, or act on key aspects of that care (such as metacognition).
Conflict between Values and Practice: The system values “recovery,” “self-management,” and “patient agency,” but the effects of medication and the lack of baseline assessment undermine these very things.
Disregard for Evidence: There is clear evidence that metacognition is affected by antipsychotics, but the system does not implement routine testing, dismissing the evidence in favour of blanket “symptom reduction” as a measure of success.
Gaslighting: The system’s dismissal of patient reports creates a “double bind”; patients are told they are being helped, but their experience of loss, confusion, and disconnection is ignored, denied, or pathologised.
Loss of trust: Patients lose faith in the system, feeling that their experiences are not taken seriously.
Systemic harm: Practices that undermine self-awareness, adaptability, and agency are reinforced, even when the system claims to protect these things.
Moral injury: Staff and patients alike may experience distress from participating in a system that says one thing but does another.
Organisational Narcissism
However, the issue is not just organisational incongruence, but organisational narcissism; a pattern where the institution prioritises its own image, authority, and perceived competence over the needs, agency, and lived experience of the individual.
Organisational narcissism refers to a system (such as a healthcare trust, a mental health service, or a public institution) that:
- Places its own reputation, self-justification, and power above the needs of the people it is meant to serve.
- Views itself as inherently “good” and “legitimate,” even in the face of evidence to the contrary.
- Controls, dismisses, or silences the voices of individuals who challenge its narrative.
- Uses its power to enforce compliance, submission, and dependence, rather than genuine care or equality.
Why the NHS Example Illustrates Narcissism
Power Imbalance: NHS mental health services hold significant power over patients, especially those on medication; power over diagnosis, medication, and legal safeguards (such as the Mental Capacity Act).
Self-Righteousness: The system often presents itself as uniquely “helpful,” “evidence-based,” and “caring,” even when its actions undermine agency, self-awareness, and autonomy.
Dismissal of Dissent: Individual reports of medication-induced harm, loss of self-awareness, or “blunting” are dismissed as “symptoms,” pathological, or unreliable.
Self-Protective Behaviour: The system is more focused on maintaining its image, resource allocation, and professional status than on truly listening to, supporting, or adapting to patient experience.
Illegal Organisational Behaviour?
if NHS medication causes life-ability blunting (such as loss of metacognition, agency, and capacity), and the NHS fails to monitor, inform, or support patients as required by law, then it may be in breach of the Mental Capacity Act (MCA) and related legal duties.
Under these circumstances, a class action could be a valid pathway, but there are several key factors that would determine its likelihood of success.
Legal Basis: The Mental Capacity Act (MCA)
Section 1 and Section 2 of the MCA require that:
- Capacity should be assessed before decisions are made about a person’s care or treatment.
- A person is presumed to have capacity unless it is assessed otherwise.
- The least restrictive option must be used.
If medication causes cognitive/metacognitive blunting:
- The impact on a person’s capacity to make decisions must be assessed.
- If this is not done, and the person is deprived of the right to challenge, consent, or object, the NHS is arguably in breach of the MCA.
Failure to baseline or monitor:
- Not assessing capacity before and during medication could mean patients are unable to exercise their rights under the MCA, which is a clear failure to uphold the law’s intent.
Denial of Access to the Law
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If the NHS does not assess capacity or fails to act on a loss of capacity, it is denying the patient access to the legal protections and rights (e.g., Best Interests, Independent Advocacy, Right to Challenge) that the MCA is intended to provide.
Is This Illegal?
Yes, it could be considered a breach of statutory duty:
- The MCA and associated Codes of Practice require regular assessment of capacity, especially when medication is known to cause cognitive blunting.
- Failure to do so, particularly if it results in a loss of agency, informed consent, or the right to advocacy, may constitute a breach of the act.
Are Those Professionals Supporting this Behaviour Innocent?
This is a challenging and important question. The ethical and legal responsibility of individual NHS staff, particularly psychiatrists, needs to be considered in light of the fact that “following orders” or “following guidelines” does not automatically absolve professionals of personal, ethical, or legal responsibility, especially when harm is foreseeable, significant, and ongoing.
The Nazi Doctor Analogy: The “Nuremberg Defence”
The “Nuremberg Defence” refers to the claim made by Nazi doctors and officials during the Nuremberg Trials that they were “only following orders.”
The Nuremberg Principles (established at the end of the trials) made it clear that individuals are not excused from criminal acts simply because a superior ordered or permitted them.
The principle is that professionals have a duty to act ethically and lawfully, even if it means resisting or challenging unlawful or unethical orders[Nuremberg Tribunal, 1947].
The Duty of Care and Ethical Practice
All healthcare professionals are bound by:
- Professional ethics (e.g., General Medical Council guidance)
- Legal obligations (e.g., Mental Capacity Act, Human Rights Act)
- Duty of care to do no harm (“do no harm” is a core principle)
- Conscientious objection—the right and duty to refuse participation in practices that are unethical or unlawful.
The Case of the NHS Psychiatrist
If a psychiatrist:
- Prescribes or maintains medication, knowing it causes severe cognitive, metacognitive, or personal harm.
- Fails to assess, monitor, or act on the legal and ethical requirements for capacity, consent, and safeguarding.
- Uses “blaming the illness” or “following guidelines” as an excuse to avoid accountability,
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Then they are NOT morally or ethically innocent.
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Their actions would be in breach of ethical and legal duty, regardless of whether the harm is overt or systemic.
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They cannot be absolved by “just following orders,” just as the Nuremberg doctors were not.
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If they knowingly allow harm and deny agency, autonomy, and access to justice, they are complicit in the harm.
The “Hidden Guidelines” and Organisational Narcissism
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Many harmful practices are enabled by unwritten, informal, or “hidden” guidelines—such as “never challenge the diagnosis” or “manage the patient, not the illness.”
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Not following the visible, legal, and ethical guidelines in favour of these hidden practices does NOT absolve individuals of responsibility.
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Ethical responsibility is to the individual, not to the system.
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Ignoring or “overruling” the explicit duty to protect patient rights is a form of complicity.
What about the Professional Bodies?
The organisations that set and monitor the ethics and behaviour of healthcare professionals, such as the General Medical Council (GMC), Nursing and Midwifery Council (NMC), Health and Care Professions Council (HCPC), and other professional bodies, are also deeply implicated.
Their role is to set standards, hold individuals accountable, and ensure the safety and rights of patients are protected. If these organisations fall short, or if their own guidelines and practices are designed or interpreted in ways that enable, ignore, or even encourage harmful systemic behaviour, then they too are complicit.
The Role of Professional Regulatory Bodies
Setting Standards: These bodies produce codes of ethics and conduct, which are meant to guide professional practice, uphold patient rights, and promote accountability.
Monitoring and Enforcement: They are responsible for investigating complaints, disciplining professionals, and, when necessary, raising systemic issues with healthcare providers and the government.
How These Bodies May Be Complicit
Loose or Ambiguous Guidelines: If guidelines are vague, poorly enforced, or open to interpretation, they can allow professionals to justify harmful practices as “within professional standards.”
Failure to Act: If professional bodies turn a blind eye to systemic issues, fail to investigate, or prioritise the interests of professionals and institutions over patient safety and rights, they are complicit in the harm.
Silence on Systemic Practices: If these bodies do not challenge or condemn systemic issues—such as the routine failure to monitor metacognition, disregard for patient agency, or the dismissal of medication side effects—they are enabling organisational narcissism.
Power and Influence: These bodies are often under-resourced, influenced by healthcare institutions, or subject to political pressure. This can limit their ability (or willingness) to hold the NHS and individual professionals to account.
Implications Beyond the NHS
Wider Health and Social Care Sector: Issues of organisational narcissism, lack of accountability, and failure to monitor patient outcomes are not unique to the NHS.
Similar patterns are found in care homes, social services, and private healthcare providers.
The culture set by professional bodies often shapes practice across the entire sector.
Professional Culture: If professional bodies tacitly support or overlook systemic issues, they create a culture where professionals feel comfortable ignoring patient rights, silencing dissent, and prioritising compliance over ethical care.
From Metacognition to Organisational Narcissism
It began with our observation that antipsychotic medication, especially at high doses, can severely blunt metacognition—the ability to reflect, self-monitor, and adapt. This is not just a side effect; it is often a core part of how these drugs “work,” reducing anxiety and distress by diminishing self-awareness and agency.
We then explored how the NHS, and the wider mental health system, routinely fails to measure metacognition before or after medication is prescribed. This means there is no baseline, no monitoring, and no way to distinguish medication-induced harm from the “natural” progression of illness. When patients report cognitive blunting or loss of self, their experience is dismissed as “symptoms,” not side effects.
This pattern is not just a failure of care, it is organisational incongruence: the NHS claims to be person-centred, evidence-based, and committed to safeguarding, but its actions undermine these values. The system prioritises symptom reduction over meaningful function, agency, and self-awareness.
We then identified a deeper problem: organisational narcissism. The NHS, and the wider profession, use their power to protect their own image, authority, and self-justification, often at the expense of the individual. The system silences dissent, dismisses patient experience, and enforces compliance, rather than genuine care or equality. This logical train of thought led us to our proposed conclusions:
Breach of the Mental Capacity Act
- The Mental Capacity Act (MCA) requires that capacity be assessed before and during treatment, especially when medication is known to affect cognition and metacognition.
- The NHS’s failure to carry out these assessments, and its dismissal of patient experience, is a clear breach of statutory duty.
- This breach denies patients access to the legal protections and rights the MCA is meant to provide, including the right to challenge, consent, and advocacy.
Implications for Service Users and Providers
Service Users:
- Loss of agency, self-awareness, and the ability to challenge or consent.
- Denial of access to legal rights and protections.
- Increased vulnerability to harm, coercion, and gaslighting.
Providers:
- Professionals are complicit if they knowingly cause harm, fail to uphold their ethical and legal duties, or prioritise compliance over patient safety.
- Regulatory bodies are complicit if they set or enforce weak guidelines, fail to act on systemic harm, or prioritise institutional interests over patient rights.
Suggested Class Action Text
“We, the undersigned, are individuals who have been prescribed antipsychotic medication by NHS services, and who have experienced severe, life-altering blunting of metacognition, self-awareness, and agency as a result.
We assert that the NHS has failed to carry out baseline and ongoing assessments of our capacity, as required by the Mental Capacity Act. This failure has denied us access to the legal protections and rights the Act is meant to provide, including the right to challenge, consent, and advocacy.
We further assert that the NHS has routinely dismissed our reports of medication-induced harm, blaming our experiences on our illness rather than on the medication or service failures.
We demand that the NHS be held accountable for its breach of statutory duty, and that it implement routine assessment of metacognition and capacity for all patients prescribed antipsychotic medication.
We seek compensation for the harm we have suffered, and changes in practice and policy to ensure that no one else is denied their rights and agency in this way.”
References
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General Medical Council. (2013). Good Medical Practice.
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Nursing and Midwifery Council. (2018). The Code.
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Health and Care Professions Council. (2016). Standards of Conduct, Performance and Ethics.
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Nuremberg Tribunal. (1947). Nuremberg Principles.
- Mental Capacity Act 2005.
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