The following post is a book review by Jonathan Gadsby. If you would like to review a book or write a response to a book, please let us know. We have a list of great books to recommend, or perhaps you have one that you want to introduce to us.
Our list of books and reviews/responses is eventually going to become part of a project that will follow from the conference on the 9th of September. We would like to build a section on this website that students, tutors, practicing nurses and others can turn to for critical reading: books, articles, links, videos etc, especially critical writing about nursing.
Bonnie Burstow’s Psychiatry and the Business of Madness: An Ethical and Epistemological Accounting (Palgrave Macmillan, April 2015), is a significant addition to literature surrounding the evidence and practices of psychiatry in the 21st Century. An ‘Institutional Ethnography’, the nine chapters cover the history and culture of psychiatry, the evidence for psychiatric treatments, the cultures of the different mental health professionals, the formation and logic of the DSM and diagnosis, extensive discussion about the research, dissemination and actions of various psychiatric medications and ECT. The text is laced with feminist perspectives and survivor experiences. It is set in North America, but it is clear in the text just how strikingly similar the issues frequently are to the mental health scene in the UK.
This is not a book which picks apart aspects of mental health provision and makes suggestions for improvement. This is a book which describes psychiatry as a consequence of the state and a society driven by our fears, power and oppression, by the subjugation of women, non-whites, the rejections of all kinds of difference, the power of capital and machineries of misinformation which drench us in myths about progress. For Burstow, psychiatry cannot be understood as a branch of medicine or as any kind of science. She does not argue, as others have, that it is in need of a ‘paradigm shift’. Drawing on the influences of Thomas Szasz, RD Laing, Michel Foucault, Peter Breggin, Irving Goffman, David Healy and Robert Whitaker, this heavily referenced book is disturbing, personal and outrageous:
…what does “competence” even mean in a system such as this? How can we speak of competence when the entire industry is in the business of creating diseases and imbalance? Indeed, would anyone even be better off with a technically competent psychiatrist over a technically incompetent one? (p11)
What is new?
Some readers may feel that there is not very much here that is new, even while perhaps admiring the writing. Perhaps it is a little disingenuous to complain of this, for it is very clear that psychiatry, her subject, has been repeating old and discredited arguments for a long time. For me, there were several aspects which are, if not exactly new, then less familiar or which contained a fresh angle.
I had read before that psychiatry in the 20th Century was more widely interested with eugenics than might be generally known. Under Burstow, psychiatry and eugenics are long-time associates, and notions of heredity which pervade our thinking today originate there (p50). Psychiatry is described not as the unfortunate profession that was caught up in the fascist dogma of Nazism, but as the true architects of the Holocaust (p48), and neither was their influence limited to Germany, with concepts of degeneration and sterilisation widespread, especially in the USA. Burstow sees this not as a dark moment in psychiatry’s history, but intrinsic to the logic of distress attributed to biological origins:
Nazi Germany, according to its own postulates, was biocracy…. Psychiatry is in its own right a biocracy complete with incarceral capacities and police powers. In both instances, ruling is predicated on biological differences – real or imaginary. Indeed, what psychiatry is doing… is attributing physical difference to one segment of the population, then interpreting that difference as a mark of inferiority, warranting correction. Such a construction, I would argue, is itself a close relative of racism and indeed of all oppressions which locate inferiority in the body of “the other” (p71).
Also of great interest to me, as a nurse, was Burstow’s account of the ways in which psychiatry has been part of the disempowering and invisibilising of women’s knowledge (p31). From witches (whose main crime was the mixing of potions, more than ironic in the light of the chapter on psychopharmacology) to women healers, counsellors, midwives and abortionists, psychiatry is implicated as a key part of the framing of women’s knowledge as madness, disqualifying women from working with ‘the mad’ and the subsequent bringing of women to heel by men as ‘psychiatric nurses’, the ‘serviceable underling’ (p159). Burstow also critiques the professionalisation of mental health in ways which may strike a chord with many nurses, firstly as a means of marginalising competitors, and it additionally
“…cuts the professional off from authentic knowing and relating. It at once distances the professional from the “othered” person, nullifies the humanity of both, and subverts understanding, turning “help” into mini tasks, in which one can have “competencies” (p164).
However, it was in reading Burstow’s analysis of her interviews with psychiatrists that I felt most convicted as a nurse. That psychiatrists today are found with the same self-serving stories of being on the cusp of a new scientific and humanitarian age as they have repeated for the last two centuries is seen as comical (were it not for the power wielded by these credulous hopefuls) (p152). However, at that moment I saw the nursing story, working to change the system from within, a story that I have allowed myself to be recruited into, and I confess I still do not know what to do with that realisation. Burstow concludes that often well-meaning people are perpetuating the stories they need to hide their violence, and that their doing so amounts to “bad faith” (164). Not much middle ground is left.
Burstow’s examination of the DSM (referred to in her Institutional Ethnography as a ‘boss text’) is a particularly memorable chapter (p73 – 100), and while I have read arguments about validity and reliability many times, there did seem to be something incisive here in that Burstow argues that the purpose of the DSM is to couch reliability as validity (giving an analogy about identifying Martians!) (p78). Additionally, the chapter which concerns research and ‘evidence’ is essential reading, frightening though it is. While Burstow’s position appears extreme, Peter Gøtzsche of the Cochrane Collaboration has been producing similar analyses.
Are there limitations?
This book might be said to share (in parts) a problem with some of Robert Whitaker’s writing. Both writers refuse the simplistic manner in which psychiatry may paint experiences as secondary to biology, a simple arrow of causation from brain to person, and in doing so they stand on very established ground. However, when describing the damage caused by psychiatric drugs, they seem much happier to then re-explain experience as secondary to this damage, without the non-reductionist understandings for which they convincingly argued minutes before. That said, the discussion of the damage caused by psychiatric drugs makes for alarming reading, and, although I am no neuroscientist, does tally very well with experiences I have witnessed first hand (and with the work of Joanna Moncrieff, for example).
Realisations I do not know what to do with, an approach which views psychiatry as part of state power and the common human practice of ‘othering’, dramatically argued chapters about the illegitimacy and corruption of psychiatric treatments and their deliberately damaging effects: one can see that to read this book is to be caught in a meta-narrative of urgent and global consequences, of moral polarisation and imperative. It is a book written in such a way as to produce two possible outcomes – to create revolution or to be ignored. Therein lies its great difficulty, and depending on what you feel about psychiatry – perhaps what you already feel before you pick the book up – you will likely either see the two options as a problem which is located in Burstow’s head (leading to an dismissal of the text, which is uncomfortable given her credentials and the highly referenced and logically-argued nature of much of it), or a problem located in psychiatry and society (leading to the sense of great unrest and urgency she would endorse). As such, one could argue that Burstow has very faithfully presented the world (and critical mental health discourse) as it is.
This problem is crystallised in the final chapter, entitled Dusting Ourselves Off and Starting Anew. If one views the problem of psychiatry as being part of a grand narrative about power, if the problem is on a global scale, then the solutions one has to propose must be too. The result is an enormously idealistic closing chapter, and, just as before, depending on your point of view you may see it as essential, brave and perhaps even prophetic, or else naive, opinionated and utopian. You may feel that in widening the discussion to war, gender inequality and the environment Burstow is going ‘off-topic’, or else you may feel that she is finally getting the the heart of the matter. With subheadings such as Daring to Dream and A Better World, I would imagine that Burstow would be aware of this, saying that it is a matter for professional to “decide whose side they are on” (262). There are some sections on trauma I will certainly return to. My own feeling is that your point of view is likely to be shaped by your experience of power: if you have it, it is generally hard to see what all the fuss is about. It would be wrong to conclude that this book is somehow all just a matter of strong opinion to either like or dislike. The mainstream and more accepted face of mental health services is obviously no less caught in a narrative: one which raises certain ideas to high prominence while sweeping huge problems (bad science, corruption, discrimination, harm, history) under the carpet. Those who reject the central arguments of this book will probably find it very difficult to explain why. And that suggests that it is crucial reading.