Pilling FG - June 23 16 Correspondence Address: Merrick Daniel Pilling, School of Social Work, York University, 4700 Keele St., Toronto, ON, M3J 1P3; Email: mpilling@yorku.ca ISSN: 1911-4788 Volume 10, Issue 1, 177-179, 2016 Book Review Psychiatry and the Business of Madness: An Ethical and Epistemological Accounting Burstow, Bonnie. (2015). New York: Palgrave Macmillan US. ISBN 9781137503831 (cloth) US$95.00; ISBN 9781137503848 (paper) US$40.00; ISBN 9781137503848 (eBook) US$29.99. xi + 302 pages MERRICK DANIEL PILLING York University, Canada Psychiatry and the Business of Madness is a critique of psychiatry and “all that surrounds it, makes it possible” (Burstow, 2015, p. 3). Following Szasz (1961) and others, Burstow sees “mental disorders” as “problems in living” that are tragically mismanaged and exacerbated by a system that medicalizes distress and pathologizes human behaviour (p. 227). To be clear, this book is neither an appraisal of the proficiency of individual psychiatrists nor a call for the field as a whole to improve. In fact, Burstow’s work suggests that in doing their job “well,” mental health practitioners are actually inflicting harm, rendering the question of competence irrelevant. She asks, “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?” (p. 11). Burstow uses institutional ethnography and critical discourse analysis to illuminate the function, purpose, and impact of psychiatry as a complex system of social control. Burstow’s goal is ambitious; she aims to “map” the institution of psychiatry as a whole in order to provide a “multifaceted” and “holistic” picture (p. 20). Her focus is therefore quite broad and covers a wide range of topics including the history of psychiatry, an analysis of the Diagnostic and Statistic Manual of Mental Disorder (DSM), the role of the state, the inner workings of mental health service provision, and the iatrogenic effects of psychiatric drugs and electroshock. The breadth of Burstow’s approach is impressive, and is one of the contributions of her Merrick Daniel Pilling Studies in Social Justice, Volume 10, Issue 1, 177-179, 2016 178 work. Her methodology is another; she presents a thorough and meticulous example of institutional ethnography. Primary data sources include institutional texts, professional observations at the Ontario Consent and Capacity Board, and qualitative interviews (n=119) she conducted with various stakeholders including psychiatric survivors and psychiatrists. Burstow draws on a number of theoretical frameworks, but antipsychiatry and second wave feminism are the most evident. One of the most compelling chapters addresses the interlocking nature of psychiatry and the state in which Burstow argues that psychiatry is a “textually mediated regime of ruling” (p. 100). She examines the legislation in Ontario that allows people to be hospitalized involuntarily and treated against their will (Mental Health Act and Health Care Consent Act), psychiatric charts, police apprehension, hospitalization, Community Treatment Orders, and Consent and Capacity Board hearings. She points to some of the underlying default assumptions that characterize people in distress as a danger to themselves and others as a justification for completely stripping people of all agency. She demonstrates a number of alarming realities including the conflation of decision making capacity with treatment compliance. In other words, being assessed as capable of making one’s own treatment decisions hinges on the acceptance of psychiatric medications. The larger implications regarding the power of psychiatry as an agent of the state capable of denying bodily autonomy are chilling. Burstow’s ultimate conclusion is to do away with psychiatry altogether, an abolitionist stance that will not appeal to everyone, but one that makes sense within the context of her overall argument. Critiques of any dominant institution are often met with an imperative to provide “the answer,” an alternative that will solve all of the problems with the current system, a daunting task for any one individual. Burstow courageously takes this on in her final chapter in which she imagines a radically different society, one that does not include professionalization, the culture of experts, positivism, proceduralism, corporatization, hierarchy, or state power. As she states, “working outside the system offers a greater measure of protection. The hope lies in the movements of people – not states, not any part of the industrial complex” (p. 257). She suggests community-based strategies emphasizing collectivity, agency, and treating people in distress “as subjects, not objects” (p. 243). One powerful example is “mad literacy.” This involves communities becoming more knowledgeable about the meaning of behaviours that currently get dismissed as irrational and incoherent by learning about madness from mad people and becoming aware of “different ways of processing and/or expressing thoughts and feelings” (p. 238). While this final chapter is full of interesting ideas about how things could be done differently, some of them rely on ideas that appropriate Indigenous beliefs. Indeed, the book as a whole could benefit from a stronger anti-racist analysis. Burstow sees one of the contributions of her work as the ways in which her analysis is informed by her positionality as a woman, an activist, Book Review Studies in Social Justice, Volume 10, Issue 1, 177-179, 2016 179 and someone who is connected with psychiatric survivors personally and professionally. As she points out, the field is dominated by White men and more perspectives are needed, particularly from those who privilege the expertise of the people most intimately affected by psychiatry and the mental health system. However, Burstow perhaps minimizes the extent to which gender binarism and Whiteness shape her focus and the assumptions that inform her analysis. There is limited acknowledgement of the racialization of psychiatric violence, the role of psychiatry in colonization, the embeddedness of racism and gender binarism within the foundational concepts of psychiatry, and the current context of violence against trans people and people of colour. Burstow also uses some language that could be problematized from an anti-racist perspective including the term “genital mutilation” (p. 239), the colloquial use of “slaving” (p. 235), and the use of “colonized” to refer to psychiatry’s influence on related health disciplines throughout the book. Likewise, her use of “transgendered” and decontextualized use of “pre-operative male to female transgender” show a lack of awareness about trans culture and respectful language (p. 239). Burstow reveals a binary and sometimes essentialist approach to gender in casual phrases such as “geared at the ‘everyman’ and ‘everywoman’ in all of us” (p. 21), and the use of universal pronouns “she” and “he” throughout, which genders the content in telling ways. Her gender analysis is a singular focus on sexism as it pertains to cisgender women, rather than a trans- inclusive approach acknowledging transmisogyny and the psychiatrization of trans people, queer people, and gender dissidence. Overall, Psychiatry and the Business of Madness is engaging and highly readable. Given the current overwhelming predominance of the biomedical model of mental illness, critiques of psychiatry and the concept of “mental disorder” are often characterized as unsound, at best. As Burstow states, such perspectives are seen by those working within the system as “perplexing, plain wrong, bizarre” (p. 163). For this reason Burstow’s work might appeal most to those who already have some grounding in similar critiques, whether through academia, activism, or lived experience. While this work will certainly be interesting and informative for many, it is especially important for those most invested in the current system to seriously consider the value of Burstow’s critique. Indeed, Burstow’s work stands as an important contribution to ongoing challenges to psychiatry and the biomedical model of mental illness. References Szasz, T. S. (1961). The myth of mental illness: Foundations of a theory of personal conduct. New York: Harper & Row.