Review from the Canadian Journal of Disability Studies, Vol 5, No 1

Burstow, B. (2015). Psychiatry and the Business of Madness: An Ethical and Epistemological Accounting. New York: Palgrave MacMillan.
ISBN: 978-1-137-50384-8.

Reviewed by Jennifer Poole, Zachary Sera Grant & Katherina Yerro
School of Social Work, Ryerson University
jpoole [at] ryerson [dot] ca

Original Article: http://cjds.uwaterloo.ca/index.php/cjds/article/view/260/474

It is rare to come across a scholarly book that one cannot put down. It is rare to come across a book that unequivocally demands we step “outside the circle of certainty” (2) around “mental” “illness” and “care.” This is such a book, and in it we have a clear argument for what psychiatry has become, what it is capable of, and how this all came to pass.

We have heard echoes of this argument from scholars situated in the fields of anti-psychiatry, critical mental health, and Mad studies. Yet, for us, three social work scholars at various stages of our careers, the breadth and depth of Burstow’s accounting is not only spectacular but new. In a clear and accessible way, Burstow takes us through personal, historical, narrative, institutional, economic, political, and discursive landscapes. She shows us how each is a part of her particular “study of psychiatry” (1) and “all that surrounds it” including governments, the legal system and “mechanisms of enforcement” (2). Importantly, she shows us what the consequences of it all have been on our friends, family members, colleagues, and ourselves. Burstow is not afraid to question the whole mental health system, and how it has come to be that “people believe what medical doctors state and what medicinal doctors recommend” (3). Boldly, she asks, “what if this were not legitimate medicine…what if psychiatry’s fundamental tenets and conceptualizations were inherently faulty? Indeed, what if – despite some helpful practitioners – it does far more harm than good” (1)?

We have long suspected the same, and so we welcomed Burstow’s accounting. With such a book there is much to be made of all her arguments, but for us, certain sections stand out more than others. Of note were Chapters 2 and 3 which we see as difficult but mandatory reading for those interested in the history of psychiatry, “mental health,” and “helping.” In the former, Burstow takes us back to classical times, to witch hunts, to the power of the Catholic Church, the birth of psychiatry and its terminology and classification system. We enjoyed Burstow’s take on Pinel, usually presented as a hero for unchaining the mad. She writes, “what we have with Pinel, in other words, is not the end to brutality as professed but a more subtle form of brutality” (35) and one tied up in “confinement on an unprecedented scale” (44). Chapter 3 is a terrifying tour of modernity, as well as the challenge of psychoanalysis, psychiatry’s role in eugenics, the Holocaust and of course the pharmaceutical revolution. As Burstow notes in her conclusions, images from these chapters continued to haunt us long after we closed the book.

We must also commend Burstow’s detailed discussion of the DSM in Chapter 4, and the utility of her demonstration of how “things” come to be included or not in this oh so powerful text: “Criteria sets pathologize the everyday [e.g., General Anxiety Disorder] and … routinely pathologize deviance [see Oppositional Defiant Disorder, Schizophrenia, Borderline Personality Disorder], they are blatantly sexist, racist, classist, transphobic” (92). In this chapter, we are also gratefully reminded that, “No biological sign has ever been found for any ‘mental disorder.’ Correspondingly, there is no known physiological etiology” (75).

Similarly, Chapter 5 on the “beast” that is psychiatric “care” had personal resonance for us as did Chapter 6 on the co-option and “hooking” of the professional. We nodded in recognition at what professionals tell themselves to rationalize clinical decisions and the nursing interviewee who admitted, “I can’t do this anymore…I tried to speak up, but the power of the script is too big for me” (143). And then there are the chapters on “pharmageddon” (Chapter 7) and electroshock (Chapter 8). Even for those of us who might be familiar with this content through multiple encounters with the “system,” these are troubling chapters, for they detail how these “treatments” come to be approved and how they “work,” including the cherry picking that goes on in clinical trials, the silencing of adverse effects, the lack of testing on ECTand the admission that ECT produces results similar to brain injury.

We must also note that Burstow has created one of the best examples we know of institutional ethnography (IE). “A culmination of decades of research” (16), the book is based on 119 interviews as well as analysis of hundreds of documents and observations (p. 16). Although she also includes other forms of research such as critical discourse analysis, after reading this book we have the sense that this is how we “should” be doing IE. Citing Smith (2005, 2006) and staying true to the language and process of IE (i.e. regime, problematic, boss text), Burstow offers the reader many a “point of disjuncture” (3), showing us how to then go “where the documents point” (10).

Indeed, this book is a detailed IE account of the strangle-hold psychiatry has on so many. We believe this text should be core reading for anyone in the helping professions who is unaware of or has forgotten how psychiatry controls and manipulates those under its authority. As service users, we appreciated being able to relate to stories of other survivors included in the text. As educators and students, we appreciated all the effort that Burstow has put into this brilliant new text.

However, we do have questions.

While we believe this book to be a much needed compilation of the intersectional oppression of psychiatry, some of us struggled with a general lack of suggestions for our own critical mental health work. If, as Burstow asks, there must be a better way, we need more details on what that way is. Agreed, compassion is central, as is listening, believing, and working together in “the commons,” but how do we get there? How do we start on that path? Who can make this happen?

Secondly, after reading this book some of us are also troubled by an even greater fear of psychiatry. In the words of one interviewee in the book, “we have seen psychologists mysteriously disappear… there is a real fear of saying anything against the grain, let alone coming out against a treatment” (156). When do we speak up against psychiatry? How do we speak up? Can we, as Burstow notes, take down the system a la “Trojan horse”? It is far easier for those with tenure, with social and educational capital, with stable housing and white privilege to ask the questions than those starting out in this work, living with debt and precarity, as well as with oppressions such as transphobia, heteronormativity and racism.

We also had questions about how Burstow problematizes so much psychiatric language in the book but, in Chapter 5, does not do the same with “eating disorders.” To write “like many a young woman in this society, she is anorexic” (135) is not only counter-productive but demonstrates the author’s own “institutional capture” (another IE term). While we do not believe Burstow intended to make an overarching judgment about women in society, we do believe it to be an excellent example of how psychiatry functions, when a leading anti-psychiatry activist, in a book about psychiatry as a means of social control, can themselves make a statement which perpetuates, in her words, the “misogyny” (95) ever present in theDSM.

As well, many readers of this book may be left wondering about Burstow’s focus “on the west” (22) and the inadvertent centering of all things western, including whiteness. Although there are sections where race and racism are taken up (see Chapter 2 for instance), there is very minimal attention given to colonialism and “all that surrounds it” vis-a-vis psychiatry. Although Burstow takes up what she calls “Aboriginal worldviews” in her final chapter envisioning a “eutopian” world, it is a cursory mention, without credit to any particular scholar, elder, teacher, or nation. And at this time, in this place, we see this exclusion, this de-centering, as colonialism once more. Cannot settlers, even expressly anti-psychiatry settlers, do better?

Finally, we are left with a question of what does this book offer disability scholars? While there is no mention of critical disability studies per se, Burstow does cite and include multiple references to scholars important to disability work and especially that which takes a critical look at “mental disability.” LeFrancois, co-editor of the Canadian Mad Studies collection Mad Matters is both interviewed for the book as well as cited as a scholar, as is Chris Chapman and Irit Shimrat. Burstow also locates her work in a tradition of critical scholars such as Szaz, Foucault, and Fanon “committed to revealing what might be called the hidden face of psychiatry” (20). To this list she adds feminist scholars Chesler, Showalter, and Caplan, as well as Erick Fabris (2011). But it is Peter Breggin (1983, 1979) and David Healy (2009) who are especially referenced throughout. Clearly, this situates Burstow’s argument alongside a more classic canon rather than a contemporary Crip commentary. And we could not help but wonder what scholars such as China Mills, scholars troubling psychiatry and colonialism, might make of this particular orientation.

Struggles and questions aside, this is an important book. It made us question a good deal of what we “know”; personally and professionally, and we have already recommended it to colleagues, friends, and students. Gratefully, we are left with even more questions about the system, about those who find psychiatry helpful, and about what is next, both for Burstow, and for us.

References

• Breggin, P. (1979). Electroshock: Its brain-disabling effects. New York: Springer
• Breggin, P. (1983). Psychiatric drugs: Hazards to the brain. New York: Springer
• Fabris, E. (2011). Tranquil prisons. Toronto: University of Toronto Press.
• Healy, D. (2009). Psychiatric drugs explained. London: Elsevier.
• Lefrancois, B., Menzies, R. and Reaume, G. (2013). Mad matters: A critical reader in Canadian mad studies. Toronto: Canadian Scholars Press.
• Smith, D. (2005). Institutional ethnography: A sociology for the people. Landham, MD: Altamira Press.
• Smith, D. (2006). Institutional ethnography as practice: Landham, MD: Rowman and Littlefield.