Ban ECT and junk the drugs. And whatever you do, don't follow the US example. Peter Breggin spells it out
Dr Peter Breggin has little time for biological psychiatry. When I asked him how he sees the state of psychiatry right now, he said: "It's bad. Psychiatry has dug itself into a biological hole, and it's one it finds very difficult to get out of. All the incentives on the side of the physician are in favour of making believe that spiritual and psychological suffering is medical in nature, which implies that they go on prescribing the drugs to patients which simply do not lead to healing."
"It's a very difficult situation here in the US, and there's been no slowdown in the use of ECT (electro-convulsive therapy) that I can see. It's very hard to achieve any change within psychiatry because psychiatrists are ill-equipped to earn a living within a spiritual, psychological or social model [of mental difficulty]," he said. Here he was referring to the fact that psychiatrists, especially in the United States, are trained only to diagnose 'illnesses' or 'diseases' or 'disorders' in accordance with a manual of symptoms. They are not required to have any training in psychology or in any form of psychotherapy or counselling — merely a general medical degree.
Breggin sees modern-day psychiatry as a "simple-minded application of physical treatment" which has its direct roots in the use of such methods originally in state mental hospitals. These methods, he says, were developed to subdue, but not cure, the unruly hospital population, largely made up of the poor, the old, the abandoned and the mentally disturbed. They were subjected to violent assault to contain their behaviour, peaking in the 1930s with the use of ECT, metrazole, insulin coma treatment and lobotomy.
"Now we have a transfer of this philosophy to the general public, the worst case in the US being our public schools. In them, a significant proportion of children is being treated as if they were in a mental hospital, and the drugs are used to control their behaviour." Among the results of this, he argues, is a significantly increased rate of cocaine addiction in later life, as stimulants such as Ritalin are known to cross-stimulate the desire for other such drugs.
But psychiatry won't admit that it is wrong, he says, and if a doctor speaks up against it the entire profession will turn on him or her. So how did this biomedical model come to dominate?
"Money," he says. "Money, money, money. The American
Psychiatric Association was going broke in the 1970s, and their own
Board minutes show they decided openly to go into partnership with the
drug companies. It wasn't a conspiracy, it was an open decision driven
by money. Psychiatrists at the time were not doing therapy, it was
being done by social workers, psychologists, family therapists. They
realised that they would have to impose on the entire system the idea
that even if you were seeing a counsellor for depression, say, you had
an underlying biological imbalance that requires a psychiatrist.
Not surprisingly, he believes it's high time for a change. And it's change he's been agitating for since the 1980s, but with little success. "Change will have to come by offering alternatives to which patients will turn instead of conventional psychiatry," Breggin believes, "because we're not going to change the psychiatrists of this generation. They don't know how to do therapy and their economic interests are totally bound up with dispensing drugs and shock treatment and locking people in hospitals."
This is where he issued a warning to Ireland and Europe: "Don't follow us. Europe usually ends up in lockstep with the United States in these areas, but on this one I warn you, don't do it. Where we are is a disaster. Don't follow us into the psychiatric hell. I'm very encouraged to hear there's the possibility of a change in direction in Ireland, and I implore you to go ahead and change direction, for the sake of everyone who ever needs help with their difficulties."
I explained to Dr Breggin how we had been using the metaphor of the 'crooked stick' and the 'straight stick' to illustrate the difference between the biomedical approach and the emotional, existential, person-centred approach advocated by The Wellbeing Foundation. He laughed at the thought, listening intently as I told him how Aine Tubridy saw the crooked stick as a support which was offered to patients but which was incapable of supporting them.
"I'd carry it a little further than Aine and say that the patient is actually beaten on the head with the crooked stick. It's no support whatever, the patient gets no guidance on how to walk, how to negotiate the world. I've seen patients who've been depressed for years and their psychiatrist had never once asked them whether they were unhappy in their marriage or at work — simply gave them antidepressants and never even tried to guide them in being happy in their marriage or job. The crooked stick is thus actually used as a weapon against the patient's brain and mind, in the hope of dulling their emotional responses rather than guiding the person in new directions."
So what's the straight stick?
"The straight stick — what people need is spiritual and psychological revival, which may come via therapy, or philosophy, or religion, or even chance, such as a better situation at work, or meeting someone who becomes a loved one and gives them hope.
"Depression, you see, is one of the easiest conditions to deal with, as long as you're an enthusiastic and hopeful therapist willing to provide new insights, new understanding, and new directions."
Breggin turns his ire on psychiatry once more: "Psychiatrists actually treat human unhappiness, though most of them would deny this because they know that the question that arises is 'what power should psychiatrists have in such a vast and complex arena as human suffering?' So they try to redefine [this suffering] as 'damaged brains', but ironically the only damaged brains most psychiatrists see are the ones they're damaging themselves."
He knows whereof he speaks: Breggin's evidence has been crucial in winning landmark cases against drug companies in the US, brought by people damaged by their products and who have proved it in court.
I didn't now expect a positive answer to my next question, and I didn't get one: "Do you have any sense that we are near a 'tipping point' which will involve a wholesale paradigm shift from the crooked stick to the straight stick?"
"In the US, the avalanche is still coming down the hill and anyone who stands in the way of biological psychiatry gets rolled under it. No, we're nowhere near a tipping point in the US."
But the campaigning doctor is well aware of the differences with Europe, and is more hopeful for us: "I am very hopeful. I think it would be wonderful if Ireland is able to shift the paradigm and move in a new direction. The old way just doesn't work."
I pointed out that national health services in Europe like to see some return from the money they pay out for treatments, and that as the most-prescribed drugs, the SSRIs, had no greater effectiveness than placebo, their use is coming under scrutiny.
"Yes," said Breggin, "they're a complete waste of money. And what people haven't looked at yet is the amount of disability these drugs are causing. It's just enormous, but it's not recognised because usually when a patient has, say, a manic episode caused by a SSRI, they diagnose it as a manic episode rather than an adverse drug reaction."
He had no doubt that when the economic cost of the side effects of the drugs come to be quantified, they will be enormous, perhaps even more damaging financially than the costs of alcohol abuse.
So what do we do now? What is Breggin's concept of the straight stick?
"We have to completely junk the medical model. We have to completely junk using drugs and ECT to change people's lives, and we have to get down to the basics of what people struggle with. We have to deal with the whole arena — a spiritual, philosophical, economic and social understanding . Every person coming to us is a human being struggling in the world — we have to find out what that struggle is about, what their suffering is about, what changes are required. And you know, that often doesn't even fit the simple psychotherapy model. For example, I often end up working with families when I treat a person, because if you teach families how to help each other then they grow in a much more independent and full way. And there's healing. So, and I suppose not many psychotherapists would like me saying this, but we need to think, dare I say, about deprofessionalising even psychotherapy, being more flexible and trying many approaches."
For many years Dr Breggin had defended the need to have ECT available as a last-resort treatment, not because he believed it was effective, but because of his libertarian instincts which told him that if there is informed consent by the patient than he could not interfere with or deny them their choice. But then he turned against it.
"ECT makes as much sense as having a horse kick the patient in the head," he says. "ECT works by damaging the brain, so the person is temporarily so delirious, so dysfunctional, that they can't be depressed. The patient temporarily becomes unable to know themselves anymore because they are so injured, so they stop complaining. This shows in doctors' reports, with two-word notes such as 'less complaints' or ' no complaints'. There's also 'mood elevated', which is a euphoria of brain injury — and they call these improvements. It's very hard when you have people willing to do that (ECT) and a whole profession willing to countenance it."
ECT should definitely be banned, he says: "There's no way that doctors can provide truly informed consent for ECT, or only suicidal patients would take it. Who would take ECT if they were aware of all the large animal studies which show brain cell death and haemorrhages? So, because of the impossibility of informed consent I finally came to the conclusion that we need to ban it. And it would be wonderful to see ECT banned in Ireland.
"It's time to turn around this notion that damaging the brain with psychiatric treatment, whether ECT or drugs, is a solution to life's unhappiness, stress, and suffering."
From that standpoint, he sees the 'Healing Depression'
conference on 21 October as a "marvellous opportunity". And he urged
everyone who attends to take it as such and make the most of it.
— Basil Miller
More critical thinking in psychiatry. And let's ally with patients and voluntary groups, says Pat Bracken
Dr Pat Bracken knows his way around critical psychiatry circles. His articles and editorials in the British Medical Journal have found a wide readership and always stir debate, his books cover many themes including the notion of ‘postpsychiatry’, and he hasn’t been afraid to stick his head above the parapet since returning to Ireland. So how does he feel about psychiatry now?
“I believe that there are both good and bad developments at present. On the positive side, the rise of the service-user movement has given rise to enormous possibilities. The French philosopher and historian, Michel Foucault, maintained that since its origins ‘the language of psychiatry (has been) a monologue of reason about madness’. I believe that the rise of the user movement has meant that there are now some real possibilities for dialogue in the area of mental health. Within psychiatry itself, I see many psychiatrists becoming interested in this dialogue and genuinely making efforts to establish a different sort of relationship between the profession and those on the receiving end of its interventions. There are forward thinking people in the Royal College of Psychiatrists in Britain, and also groups like the Critical Psychiatry Network (http://www.critpsynet.freeuk.com) who are willing to interrogate some of the fundamental assumptions of psychiatric theory and practice.”
Anyone familiar with his writings will know he is heavily critical of biological psychiatry, so I asked him his views on the dominance of the biomedical model and how it came about: “A coalition of the pharmaceutical industry and some prominent academic psychiatrists [created this dominance]. It has also been influenced by the way in which medical interventions are reimbursed by health insurance agencies in the USA. These will only pay a doctor if he or she makes a medical diagnosis. When it comes to people who are depressed, making a diagnosis tends to strip the person’s problems from the personal, social and cultural context from which they often arise. Patients often feel as though they have been ‘put into a box’ when they receive such a diagnostic label.”
Surely it’s time to change this radically?
“Very much so, and change is very much overdue. In the book I published recently with my colleague Phil Thomas, Postpsychiatry: Mental Health in a Postmodern World, we argued for a ‘paradigm shift’ in the field of mental health. Many individuals and organisations have already made this shift but psychiatry remains committed to a narrow perspective. The idea of ‘postpsychiatry’ involves imagining a different way in which medicine can relate to states of madness, distress and alienation. We believe that medicine (not just in terms of drugs) has a vital role to play in helping people who are struggling with such states of mind. But we need a different way of conceptualising this role.”
Dr Bracken hadn’t pondered the metaphor of the crooked stick and the striaght stick sufficiently to give any sort of verdict on it, but he did say that to create any kind of alternative to the present state of affairs would require a strong critical psychiatry movement in Ireland, linked to patients groups and advocacy networks.
On this, he feels very positive. “There’s a shift within psychiatry itself in Ireland. Many doctors are becoming a bit wary of the stranglehold of the pharmaceutical industry and are beginning to look more sceptically at some of the claims made for the biomedical paradigm. I also think quite a lot of psychiatrists are becoming more open to working as allies of service users and less wary of the service user movement as such. So, even within psychiatry there are grounds to be hopeful.
“Outside the profession there are huge grounds for hope. There’s an emerging voluntary sector that’s playing a more important part in the conceptualisation of mental health and in the delivery of services, and that sector is open to very different ways of looking at mental health, how to understand it, how to respond to it.
“The rise of the service user movement is the single most important development ever in the field of mental health here, and it’s fantastic to be around when that has happened. I think, from speaking to the Minister and senior officials in the Department of Health, that there’s a very positive approach to mental health and to the involvement of service users, and there’s a healthy scepticism towards the claims of academic psychiatry.”
He mentioned what he felt was an important development in Britain which also gives cause for hope: “While I was there, the Royal College of Psychiatrists moved substantially towards close collaboration with service users, and to valuing this collaboration.” All the same, he said, “there’s more of a gap” between the profession and the voluntary sector in Ireland, and so “there’s a bit more wariness from psychiatrists towards voluntary sector organisations and the service user movement. But I think that will change and that we will be able to move forward.”
On whether we are near some kind of tipping point which will see a radical change in outlook, he said he didn’t know, that it was hard to say for sure: “But I’d like to think we are at a point where we can go forward; I think the forces lining up behind the need for a paradigm shift are becoming increasingly powerful and solid. All the same, I wouldn’t like to underestimate the financial resources available to the ‘other side’, and I wouldn’t like to underestimate how canny they are in terms of shifting the goalposts.
“For example, we see the pharmaceutical industry increasingly funding service user initiatives and I think that’s a very pernicious development — but it’s happening. However, the plus side is that their credibility with service users is at a low and dropping.”
Dr Bracken strongly believes in the role of critical psychiatry in changing the profession: “Psychiatry is still a vital element in the whole approach to mental health, and the challenge for me is how to engage psychiatry with critical thinking. We have to see that many service users have experienced psychiatry as oppressive and disempowering — to me that is simply a fact that you have to accept, as you accept that the sun rises in the morning. If you start from that, you must ask ‘how is it that this has happened?’. Most people in the profession have tried to do their job and help people, but yet that help — and not just the coercive side of it — has been experienced by many people negatively. So we need to develop this capacity to reflect critically on our theories, on our history, on our assumptions and interventions. I think that if we genuinely did that, we could lead medicine.
“We need to train our professionals in a somewhat different way, and I think that critical thinking and the ability to reflect critically have to be promoted over the next ten years or so. I think we can actually do it in Ireland. In contrast, in the United States the biomedical outlook has taken over so completely that there’s virtually no room for manoeuvre. But here we do have that space and we should use it to good advantage.”
We moved on to ECT: “I guess I am not as radically anti-ECT as some other critical psychiatrists. If a patient requests ECT (perhaps because they feel that it has helped in the past) I don’t think I should deny them access to this treatment. I will explain about the possible side effects and be clear that it is a controversial treatment. I have been working in Bantry for the past two and a half years. We haven’t actually given ECT in the sector where I work during this time and we have recently decided to get rid of the machine from the hospital. However, I have made arrangements for two patients to have the treatment in a neighbouring service at their request. I do believe that ECT is overused in many mental health services and like most psychiatric interventions (such as drugs and psychotherapy) can produce some very negative effects.
“So, do I think it should be banned? Honestly, at this moment, I just don’t know!”
And our conference? Did he think it is timely?
“Yes. I think there is so much propaganda around about depression being an illness or a disease that can be easily treated with drugs. There is a need for a strong counter-blast! Drug companies have huge amounts of money to promote the biomedical model and they do so in many different ways; some very subtle and some not so subtle. I think we have to struggle to resist their efforts in many different ways. Conferences such as this are of great importance in this struggle.
“At this one, we have four professionals speaking on this theme, and I think what that shows, what your Foundation is trying to show by organising it in this way, is that there is a different view, a solid view supported by people who have been writing and thinking, who are practitioners. We’re not from another planet, we actually engage with the same kind of people with the same kind of problems as anyone else does — but we’re trying to think about these problems in a different way. So, yes, I’d like to see many of my fellow professionals and other workers in the sector attending.”
And what outcome would he like to see as a result of the conference? “I would like to see the emergence of a critical mental health movement in Ireland. I hope that this will be an alliance of service-users, carers, professionals and lay-people. Perhaps this conference will be the event that leads to the development of such a movement.”
— Basil Miller