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Psychiatry and the Business of MadnessReview - Psychiatry and the Business of Madness
An Ethical and Epistemological Accounting
by Bonnie Burstow
Palgrave Macmillan, 2015
Review by Robert Scott Stewart, Ph.D.
Feb 14th 2017 (Volume 21, Issue 7)

Psychiatry and the Business of Madness is, Burstow says, "the culmination of decades of research" (16) in the field of 'anti-psychiatry'. Indeed, the Ontario Institute for Studies in Education (OISE) at the University of Toronto, where Burstow works, has recently created "The Bonnie Burstow Scholarship in Antipsychiatry," which is awarded annually to an OISE student conducting thesis research in the field of antipsychiatry. According to OISE's website, though antipsychiatry research has been conducted for a number of years, this is the first scholarship of its kind (

I have sympathy for this view. Contemporary psychiatry has a lot of problems and Burstow does a good job of explaining what many of these are. In Chapter 4 (73-100), she focuses on the problematic nature of the Diagnostic and Statistical Manual (DSM), particularly the third to the (current) fifth editions, which are supposed to be biologically rather than psychoanalytically based. For example, there are radical inconsistencies in the ways in which certain mental illnesses are categorized and described in different editions of the DSM. There are also, Burstow argues, factional wars at play in what behaviours get classified as mental illnesses, and how they get described thus making the content of the DSM a matter of political victories as much as a matter of scientific evidence. Chapter 7 (167-200) sets it sights on the troublesome connection between the pharmaceutical industry and psychiatric practice. Once again, a major component of this problem revolves around the DSM and the impact Big Pharma has in the construction of mental illnesses – which just happen to get treated by the drugs Big Pharma produces. Many of the people involved in the construction of new editions of the DSM have close financial ties with pharmaceutical industries. Compounding this problem is that pharmaceutical companies themselves sponsor research (and in some cases ghost write articles) on the drugs being investigated for safety and effectiveness – typically without revealing raw data from these studies – and such sponsored research typically 'shows' greater effectiveness and safety than non-Pharma sponsored research.

Burstow is not the first to point out problems of this sort in contemporary psychiatry, however. Indeed, such criticism extends back at least to such eminent figures as Thomas Szasz and R.D. Laing and today includes figures such as David Healey, Carl Elliott, and Peggy Kleinplatz to name just a few whose work I particularly like. What makes Burstow's position different and indeed revolutionary (in the Kuhnian sense of that term) is her belief that contemporary psychiatry is so completely flawed at such a deep level that we can't simply work to improve it; we must instead jettison it entirely and replace it with a different paradigm of therapy and 'mental illness' – a phrase and concept she contests. "[The book] demonstrates extensively, conclusively, and in a variety of different ways that psychiatry is untenable and unacceptable … the problems with the institution run so deep that what might be construed as 'improvement' is not and cannot be sufficient" (21). 

Burstow's arguments on this point involve the following points: (1) that the claims of psychiatry that it is progressive, liberatory and humane, as opposed to the brutality of pre-psychiatric views and 'treatments' of madness, are dubious at best and more likely simply false; (2) that despite the claims of psychiatry to be scientific, it is not. This is most clear, she argues, in psychiatric classification as it is detailed in the DSM. While the natural sciences and medicine have been able to locate a physical basis for their claims, psychiatry has been unable to do so: "no biological sign has ever been found for any 'mental disorder.' Correspondingly, there is no known physiological etiology" (75); (3) inter-rater reliability, which has been employed by psychiatry as evidence for DSM classifications, is inadequate (see 76ff). 

Burstow also devotes lots of space to what she thinks of as the coercive side of contemporary psychiatry. She focuses in particular on how easy it is for a person to be caught within the control of psychiatry, whether that be actual 'incarceration' as an involuntary mental health patient, or, more broadly, 'captured' within the structure of psychiatric classification and labelling with a concomitant drug therapy regimen and loss of autonomy (see, e.g., ch's 6 and 8).

This is a big, bold book and requires a lengthy and critical analysis, which, unfortunately, isn't possible within a short review of this sort. But I hope such critical analyses appear shortly since I believe that despite my sympathy for some of the positions Burstow takes, I think that her arguments for the complete rejection of the current psychiatric paradigm are vastly overstated. Moreover, I believe her alternative paradigm, which she develops in Ch. 9 (229-264), lacks any of the empirical, evidentiary support she claims is missing from contemporary psychiatry. I discuss some of this below beginning with a few passages from Burstow about the nature of her new paradigm.

"In the world that I am suggesting we need to strive for, no one would be living luxuriously, but everyone would have enough to eat, would have adequate shelter, would be attentive to the environment; and everyone would be an integral part of the decision-making process…. Agriculture would take the form of subsistence farming… Equality would replace hierarchy. Mutual cooperation would largely replace competition…. [J]ails as we know them and psychiatric institutions would be but a distant memory. (233)

"[E]ducation would be liberated and liberating, experiential, more open, oriented to the skills most useful in navigating life. … [I]stead of slaving over such subjects as trigonometry, which few will ever encounter again, children will be introduced to such vital skills as active listening, the giving and receiving of empathy, facilitating, conflict resolution, surviving in the wilderness, thinking outside the box, dealing with crises, peace-making." (235)

There would be a "commoning" of what are today called mental health services. These, according to Burstow, would be "provided by the community at large, not professionals, with everyone taking their turn as "befrienders" – with those particularly gifted in this line of work perhaps making it their major contribution." (241).

To help clarify the notion of a befriender and what "help" in the future might look like, Burstow offers an example taken from her own background as a therapist. The case deals with 'Mark' who has just called a community helpline complaining that someone is strangling him, and that this has been going on for hours. Instead of dealing with it by sending out experts of various sorts – an emergency medical team, the police, and so on, Burstow has us imagine a "befriender" (who is not an expert), dealing with the issue. As Burstow relates this occurrence, she quickly recognized that Mark was not being choked by someone else but that he was choking himself. He was, according to Burstow's "hunch," incorporating aspects of his father, that just as his father hurt him, he was hurting himself now, but he was doing so at least on some level unaware" (247). By getting Mark to breathe deeply and flexing his free?hand, she was able to get Mark to remove his other hand, which was choking him. Her hunch was right and all worked out remarkably well, though we are not told what 'therapy,' if any, Mark engaged in after this crisis.

Let's first consider the chances of a mostly untrained "befriender" having the correct hunch about the source of Mark's problem in this case. Or, having had the right hunch, was also sufficiently aware to engage in dialogue with Mark correctly and to persuade him to stop choking himself. I realize that in Burstow's "eutopia" that everyone will be educated in some of the skills we currently associate with trained therapists – from psychiatrists to psychologists and social workers. But that just raises more issues. Why should we assume that everyone wants to be educated in "befriending?" This is a particularly tricky issue for Burstow's paradigm since  education in Burstow's eutopia will have no mandatory curriculum: rather, students will pick their own. Some, perhaps the vast majority of people, would hate the sort of education required to be a befriender. And some might actually like math, which is a good thing if we want to be able to do things like build bridges, and invent and manufacture things like smart phones and computers. Furthermore, we surely want to have some sort of evidence that the 'help' being provided by befrienders  is actually helping. But Burstow requires little than anecdotal evidence to support her views in this chapter.  

Psychiatry and the Business of Madness will appeal to a number of people predisposed to her point of view. However, I don't think she has come close to her goal of convincing others to jettison psychiatry and the field of mental health entirely.


© 2017 Robert Scott Stewart


Robert Scott Stewart, Ph.D., is a Professor of Philosophy at Cape Breton University. His most recent book, Philosophizing About Sex, was co-written with Laurie Shrage and published by Broadview in 2015.


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