Book Review: Toxic Psychiatry: The British Edition

Toxic Psychiatry: The British Edition by Peter Breggin, Harper Collins (Fontana) (1993), £7.99 PB.

In March 1993, Dr Peter Breggin, American psychiatrist, psychiatric critic, and Director of the Center for the Study of Psychiatry based near Washington, D.C. came to England for a 10 day period to help launch the British edition of his new book Toxic Psychiatry (First published in the States by St Martin's Press, New York, 1991). During his stay his itinerary was tightly packed and consisted of a series of lectures, conferences, and radio interviews in various parts of England and Wales. Throughout, he was indefatigable and courageously debated the issues with several prominent British psychiatrists. It was 10 days, I believe, that shook the British psychiatric world.

Toxic Psychiatry is a wonderful read and a veritable tour de force representing the culmination of 20 odd years of reform work that began in the early 70s, when, soon after having left the National Institute of Mental Health (NIMH) where he had worked as a consultant, and gone into private practice, Dr Breggin took up the struggle against the resurgence of psychosurgery in the States, and set up the aforementioned Center for the Study of Psychiatry. It is comprehensive, well researched and up-to-date and clearly is the best contemporary book about what is wrong with psychiatry today. Divided into 5 clear parts and helpfully annotated by psychologist Dorothy Rowe, with a comparative drug glossary and two appendices at the back, the book argues mainly against what Dr Breggin refers to as 'biopsychiatry', that tendency within psychiatry, which has become dominant both here and in the U.S.A., not only to view various forms of mental distress and problems in living as symptoms of 'mental illnesses', but also to see the latter as reflecting underlying genetic, biochemical and brain abnormalities - that is, real diseases with real demonstrable biopathology, which, therefore, ultimately require biological treatments (drugs, electroshock, lobotomy, etc) for their cure. The main problem with biopsychiatry, according to Dr Breggin, is that by medicalising what are essentially psychosocial problems it tends to ignore more human and potentially humane psychosocial solutions (which are less costly and often more effective), and ultimately brings about more harm than good by bringing about, through its various treatments, the very brain pathology it purports to cure.

The first three parts of the book cover the topics of 'Schizophrenia', 'Depression' ('manic-depression') and 'Anxiety', respectively. Dr Breggin is at pains to show how each of the above medical diagnoses actually refers to what he calls a profound 'psychospiritual crisis' in which the person often feels overwhelmed and helpless. Rather than being met with human kindness in the form of a caring network of people offering love, understanding and support, in order to enhance the potential growth inherent in the crisis, the person is more likely to receive a dehumanising response from psychiatry, in that he or she is treated as a defective machine requiring a mechanical treatment. The person's respective passionate 'overwhelm' is thus suppressed with one or another of psychiatry's potent drugs, (or, as in the case of severe depression, electroshock). For example, in 'Schizophrenia', the treatment of choice is one or another of the 'neuroleptic' (='attaching to the nerves'), or, as they are more commonly called, major tranquillizers. Dr Breggin argues that these substances actually produce the chemical equivalent of a lobotomy and that therefore they 'work' by actually disabling the brain. In addition, they are potentially addictive, and a whole host of rebound phenomena may become apparent when the person attempts to stop taking the drug. Breggin believes that this is as a result of the brain fighting back against the effects of the drugs so that ultimately the drug brings about the very symptoms it is supposed to cure. He refers to a whole series of Tardive (late-developing) Syndromes that are produced in this manner (including Tardive Dyskinesia (abnormal movements), Tardive Psychosis, and, potentially, Tardive Dementia, syndromes which often prove to be irreversible thus representing permanent brain impairment. He estimates that there are at least 2,000,000 people suffering from Tardive Dyskinesia in the U.S. alone (a veritable plague of brain damage!) and that there is a roughly 50% risk of developing the illness in long-term treatment. He believes that similar brain-disabling principles, risks and hazards apply to the 'antidepressants' (whose effects he summarizes as a potential combination of emotional blunting, enhanced placebo - i.e. inert substance - stimulant effect and organic brain syndrome and the 'minor tranquillizers' (central nervous system depressants whose effects are similar to alcohol), although each class of drug produces its own unique combination of blunting effects, withdrawal symptoms and potentially permanent brain damage. Lithium he describes as a highly toxic substance which is anything but 'the magic bullet' it is purported to be, and electroshock he sees as, alternatively, a closed head injury or an electrical lobotomy. In addition to the above, all the treatments have a host of so-called 'side-effects' which affect other bodily systems - heart, kidney, liver etc. The sad irony for patients is that when they suddenly stop taking their medications and begin to experience the rebound effects these are often mistaken for a recurrence of the original illness and the person is encouraged (even coerced!) into going back on the very same medication. Dr Breggin's advice in these circumstances? Don't stop any psychotropic medication suddenly or without supervision.

Having examined the way in which biopsychiatry diagnoses and treats schizophrenia, depression and anxiety, Dr Breggin moves on to consider the evidence allegedly supporting the efficacy of its treatments, as well as the claims for the underlying genetic and biochemical abnormalities on which these treatments are based. In each case, with a sleuth's eye, and backed up by a wealth of well-documented research, Dr Breggin exposes the fact that there is no known proven biological causation for any of these so-called 'mental illnesses'. If anything, the research, as for example the best twin studies done vis-a-vis schizophrenia, actually tends to suggest the influence of environment, thus reinforcing the need for a more psychosocial orientation. As for the treatments themselves, the research indicates that they are often not much better than placebos, that their 'positive' effects, if any, tend to be shortlived (in the case of ECT and minor tranquillizers not more than 4 weeks) and that they are the result of the treatment brain-disabling effects, which constantly raises the spectre of permanent brain damage. In addition, psychosocial alternatives do just as well, if not better in the long run. One interesting phenomenon which Dr Breggin highlights is the fact that people who do suffer brain damage tend to be unaware of their impairment and therefore, on testing, tend to underreport it (a phenomenon known as 'anosognosia'). This, understandably, tends to skew some of the research findings towards supporting a more biological viewpoint. But, even so, the biopsychiatric model tends to be oversold to the public and represents more of a mythology (Breggin calls it 'biomythology') than science. And the main reason for this? Simply that it is good business for psychiatry. If it turns out that there is no biological causation of depression, elation, anxiety, schizophrenia, etc., then there is no reason to privilege the MEDICAL speciality of psychiatry in the mental health field. Psychiatrists would then have to compete, in the open market, alongside of social workers, psychologists, counsellors and others offering psychotherapy and other psychosocial supports - without the unfair advantage of having the power to lock people up against their will if they refuse to avail themselves of psychiatry's medical treatments.

In part 4, Dr Breggin looks at a number of groups who find themselves particularly vulnerable to psychiatric treatments namely women, children, and the homeless. He offers a cogent critique of the various childhood diagnoses (invented more for the convenience of the professionals) again demonstrating that they have no known underlying biological foundation (e.g. 'hyperactivity', 'attention deficit disorder', 'learning disabilities' and even 'autism'). He points out that most childhood difficulties are psychosocial in origin and often reflect the abuse and neglect that the child has suffered in the family. He laments the fact that parents tend to blame and scapegoat their children and progressively hand over their care to professional 'experts' resulting in, for example, more than one million (1,000,000) children in the U.S. being treated with the highly toxic and addictive drug ritalin (methylphenidate) which is amphetamine-like and tends to suppress children. With regard to the plight of women, Dr Breggin draws on a number of feminist principles and writings to highlight the fact that in the kind of patriarchal society in which we live women are continuously oppressed and, therefore, it is not so difficult to understand how they end up more frequently than men (two thirds of antidepressant prescriptions and ECT treatments are for women) in the hands of biopsychiatry. However, as the latter itself represents extreme male values, he finds this trend (particularly in relation to elderly women), very worrying, as the woman, more often than not, ends up experiencing the same kind of oppression - this time at the hands of psychiatry.

In the final chapter of Part 4, Dr Breggin delivers a scathing attack on what he refers to as the 'Psycho-Pharmaceutical Complex' in the U.S.A. - that is

the giant combine similar to the military-industrial complex and involving the psychiatric profession (The American Psychiatric Association (APA)), government (National Institute of Mental Health (NIMH)) and the Food and Drug Administration (FDA), private industry (drug companies and health insurers), education (medical schools) and organizations representing the parents of patients (National Association for the Mentally Ill (NAMI) and other family groups) (page 451).

It was as a result of NAMI lodging a formal complaint with the Maryland Commission on Medical Discipline which eventually exonerated Dr Breggin and expunged the complaint from the record -following an appearance on the Oprah Winfrey show in 1987 - that a new inspiration was brought to his reform work culminating in the writing of Toxic Psychiatry. In this rather complicated complex the profit motive is uppermost and the APA functions not so much as a scientific body but as a "political advocate for the advancement of psychiatric and pharmaceutical business interests". Continually reiterated is the conviction that "only a medical or biological image can enable psychiatry to compete economically" (page 437). Dr Breggin highlights all of the above by a detailed description of the way in which the Upjohn Co., manufacturers of Xanax, one of the latest fad minor tranquillisers, managed to influence American psychiatry to get FDA approval in 1991 for its use as the first drug specifically for 'panic disorder' - this in spite of the fact that the experimental trial for the drug was relatively small in numbers and the positive effects short-lived. It helped that one of the main promoters of the drug was a prominent psychiatrist in the company's pay roll. But the point that Breggin wishes to make in all this is not only that this sort of undue influence and conflict of interest occurs, but that the American public is lulled into believing that any treatment which has FDA approval is efficacious and safe.

In the last part of the book, Part 5 ('Psycho Social Alternatives') Dr Breggin reviews the literature relating to the efficacy of psychosocial treatments and outlines his own approach to psychotherapy which he sees as potentially a caring, understanding relationship made safe by professional ethics and restraint. This notion resonates very much with his first experience as a freshman volunteer in a Massachusetts State Mental Hospital, in which he and several other fellow students worked toward helping a number of 'chronic' patients leave the ward - just by being friendly, supportive and understanding. He cites several good quality research studies to support the notion that psychosocial approaches are efficacious, validating a roughly 70% improvement for people in psychotherapy, (regardless of the therapist's school of orientation). This efficacy applies even with severely hospitalized so-called 'psychotic' patients (here he refers to the work of Bertram Karon et al in Michigan). Several outstanding individual residential projects - Soteria House in San Francisco, set up by former NIMH director of schizophrenia research, Dr Loren Mosher who made use of nonprofessional therapists, and Birch House in Littleton, New Hampshire run by psychotherapist David Goldblatt (both projects very much inspired by the work of R.D. Laing) are also described in very positive terms. Yet biopsychiatry remains sceptical - primarily, he believes, because medical school is such a poor breeding ground for psychotherapists. Thus, unlike his friend and colleague Jeff Masson, but certainly cognizant of some of the latter's cogent criticisms, Dr Breggin is not for the wholesale jettisoning of the profession of psychotherapy, but feels it should be freed (at least in the States) from the restriction of State Licensure and opened up to many more people who, with several years training, could become good therapists.

But the main hope for Dr Breggin vis-a-vis the psychosocial alternatives and at the heart of the reform movement are the survivors themselves - those people who have been through the psychiatric system, who know what it is like and want to see better non-medical alternatives set up. He gives moving accounts of the lives of two American survivors - Judi Chamberlain, who has a long involvement in the survivors movement in the States and set up the Ruby Rogers Center in Cambridge, Mass., (a survivor-controlled day centre) and Rae Unzicker the co-ordinator for the National Association of Psychiatric Survivors (NAPS). The psychiatric survivor network still has a long way to go as far as becoming service providers but with their emphasis on self-help and self-advocacy bring a lot that is positive in any future reform in the psychosocial arena.

All in all then Toxic Psychiatry represents the brave attempt of one lone psychiatrist to put forward a condemning critique of his own profession. His argument is not that medical psychiatry should be abolished but that somehow it needs to take stock of itself and be made more publicly accountable. (I know of no equivalent book re: UK psychiatry, although Lucy Johnson's Users and Abusers of Psychiatry might be a good place to start.) In any case, the book should be an inspiration to anyone approaching the mental health field with a critical frame of mind, and is accessible to both professional and layperson. It is especially recommended to those who are frontline prescribers (GP's etc) as a reminder of Hippocrates' great dictum viz Primum Noli Nocere i.e. In the first place do no harm. Steve Ticktin

Steve Ticktin