Psychiatry and the business of madness: an ethical and epistemological accounting

Burstow’s Psychiatry and the Business of Madness: An Ethical and Epistemological Accounting provides a systematic and thorough deconstruction of the foundations of psychiatry. Questioning the fundamental principles upon which psychiatry rests, Burstow critiques the medical model of mental illness, challenging its hegemony in light of its precarious evidence base. Writing from a ‘Western’ perspective, Burstow interrogates the biomedical model, which individualises and pathologises behaviour, revealing how ‘treatment’ is a form of social control. Consequently, Burstow calls for the abolition of psychiatry, asserting that the ‘regime as a whole is epistemologically flawed and ethically unacceptable’ (227).

Burstow utilises institutional ethnography and critical discourse analysis to provide a robust empirical base to support the proposition that ‘psychiatry is untenable and unacceptable’ (21). This book is based upon data which include an impressive 119 interviews with survivors, families, psychiatrists, and mental health advocates amongst others, alongside document analysis and professional observations. The strength of this book lies in its depth of evidence, which not only provides a powerful and convincing critique of psychiatry, but also brings lived experience to the forefront through interview narratives.

The book begins with a history of madness from classical times through to modernity. Burstow problematises historical accounts that depict pre-psychiatry as cruel and archaic and psychiatry as progressive and humane. Further discussion focuses on psychoanalysis, eugenics, shock treatment and lobotomies, the establishment of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the advent of the pharmaceutical industry, and the ‘aggressive marketing of mind-altering drugs for illnesses that do not in fact exist’ (60; original emphasis).

A credible challenge is provided to the romanticised view of current psychiatric practice, drawing attention to the process by which medical discourse has been utilised to secure legitimacy, despite there being an insufficient evidence base to support this. However, the argument that there is no biological basis for mental illness fails to unpack the complex relationship between the biological, social, and psychological. As Tew (2011) demonstrates, the biomedical model can be rejected whilst acknowledging that social and environmental factors can cause a physiological imprint.

Chapter four covers established ground, critiquing the DSM, highlighting the exponential growth of classified disorders despite the lack of evidence on aetiology and biological pathways. The subjective nature of diagnosis and inherent problems with the DSM are discussed, including distress being individualised, cultural differences being ignored, and behaviours outside of normative expectations being labelled as mental illness. Chapter five is particularly impressive, evaluating the use of texts such as mental health law, assessment forms, and the DSM for the administration of hospital and community-based compulsory treatment. Attention is brought to the ‘tick box’ culture and related failure to explore the context and circumstances surrounding mental distress. Furthermore, the role of families in monitoring and surveillance of those subjected to compulsory measures is highlighted. Chapter six focuses on the interdisciplinary mental health team and the associated hierarchy with psychiatrists and the medical model taking centre stage.

Chapter seven provides a critique of psychopharmacy. It examines conflicts of interest and the manipulation of evidence in the drug approval process, before unpacking how psychotropic drugs function and their iatrogenic effects. Contrary to biomedical understandings of the causes of ‘mental illness’, Burstow asserts that chemical imbalance does not in fact exist until drugs are administered; the subsequent damage caused by medication creates the therapeutic effect as opposed to correcting any pre-existing chemical imbalance. Building on this, chapter eight deconstructs the research process in relation to electroshock and highlights the associated brain-damaging effects that are often concealed by pharmaceutical companies.

In the final chapter, Burstow sets out her idea of a good society, based on small communities with ‘communal commons’ and participatory governance (233). Education on mad literacy would take place to encourage understanding and compassion, replacing pathologising and coercive treatments. Burstow argues that societies where people are encouraged to be themselves, along with greater connectedness with nature, would help to reduce the levels of mental distress experienced. Whilst this book offers a persuasive critique of psychiatry, the proposed solution weakens its overall effect. Burstow’s vision for the future requires further development, particularly on how to transition from globalised and neoliberal societies to what is described as ‘Not a make-believe land, but a possible land’ (256; original emphasis). Ironically, whilst the book makes the case for the abolition of psychiatry, there is insufficient detail on how to achieve this.

There are several other issues that require further exploration. The proposition that liberty should only be over-ridden in situations where individuals pose harm to others, and not themselves, neglects the temporal and fluctuating nature of mental distress and that people often retrospectively agree with intervention, including where they have opposed treatment initially. Burstow also recommends that anyone attempting to withdraw from psychotropic medication should ensure that they have 24-hour support from people they trust not to hospitalise them. However, this assumes that people have such networks of support and resources available to them and fails to consider that some people are socially isolated. Furthermore, calling for the abolition of psychiatry undermines the experience of those who feel their subjective well-being has been improved by psychiatric intervention. The critique of psychiatry may well be convincing, yet the solution presented does not stack up.

Despite a number of questions remaining, Psychiatry and the Business of Madness is a provocative and interesting, yet accessible, book, which would appeal to students, activists, and practitioners alike with an interest in Mad Studies, sociology, and social policy.

Aisha Macgregor
Strathclyde Centre for Disability Research, School of Social and Political Sciences University of Glasgow, Glasgow, UK
[email protected]
© 2017 Aisha Macgregor
https://doi.org/10.1080/09687599.2017.1321240