Our Necessary Shadow

Tom Burns, Our Necessary Shadow: The Nature and Meaning of Psychiatry

Allen Lane, 332pp, £20.00, ISBN 9781846144653

reviewed by Luke Brunning

Oncologists are rarely derided. Hospital wards are rarely shadowed by the taint of the discipline’s gamut of spurious interventions, mistakes, and oddities. Similarly, we seldom interrogate the motivations of orthopaedic surgeons. Nor do crowds gather on the streets to protest under the banners of the ‘anti-obstetrics’ movement.

Psychiatry, on the other hand, remains a source of fear, suspicion, and hostility – not to mention a source of colourful reformist advocates like the Alleged Lunatics’ Friends’ Society, established in 1845.

It is not hard to see why. Irrespective of the lengthy catalogue of specific – often highly egregious – abuses, I cannot envisage a more knotted disciplinary history, right from psychiatry’s inception to the present day. The intersection of individual personalities with the changing influences of social change, political reform and counter-reform, economic pressures, revolutions and crises, architectural ambitions, and cultural attitudes is complex enough. Then consider the above in the context of the two World Wars. Now add the conflict in Vietnam into the mix, then the Gulf War…

Psychiatry stands out from other areas of medicine because fundamental philosophical questions rest uneasily alongside continually and rapidly re-evaluated techniques and practices. We are still grappling with the very concept of mental illness, and the relationships between apparently disturbed forms of life and ‘ordinary’ forms of human experience. This struggle for traction strikes at the heart of psychiatry's identity as a specifically medical concern, for these issues predated Dr Johann Christian Reil’s coinage of the term in 1808. They will also post-date psychiatry as a specifically medical discipline, if its anticipated demise comes to pass.

Although many people are unmoved by these questions in the abstract, they resonate very deeply in contemporary society – perhaps more so than any other form of thought about human nature. Public debate surrounding the mental health of Anders Breivik, James Holmes, or Ian Brady is intense, involved, and illustrates the political and legal impact of psychiatric assessment. It is easy to be ambivalent in the face of these issues. On the one hand, perhaps they have been faking psychosis all along, as Brady recently attempted to argue. That is troubling if possible, but if they were then these people can be jailed with mens rea safely in evidence. What some find harder to consider is that violent criminals really are mentally ill. It can be hard to find a place for the unique horror of their actions within a punitive system that depends on establishing malicious intent.

Tom Burns steps calmly into this maelstrom of complexity, suspicion, and emotional investment. Our Necessary Shadow is a clear-headed, and deeply personal, statement about the nature and value of psychiatry from the perspective of a renowned academic. The book would make an admirable introduction to the discipline. I also suspect its virtues reflect those of Burns himself. The text is patient, retains comprehensiveness without losing focus, is knowledgeable yet communicative, and blends personal judgement with objective and self-aware acknowledgement of differing opinion or uncertainty.

The book is divided into two parts: part one surveys the historical antecedents of contemporary psychiatry; the shorter part two examines the interplay between questions internal to psychiatric thinking and broader issues about human nature. Yet prior to both these sections Burns tackles the question of what psychiatry is, and then clearly describes what happens when a doctor undertakes a psychiatric assessment. He argues that psychiatry is best thought of as a medical speciality, not a more encompassing discipline, nor something to be eventually folded into neuroscience.

That said, psychiatry can, and should, accommodate a diverse range of insights. Burns is clear that ‘when we describe the psychopathology of patients we attempt to describe what is going on in their minds and what they are experiencing, not just list the obvious symptoms that indicate it.’ Being able to describe different forms of experience requires empathic understanding, and an ear for the meaning and symbolic resonance of various symptoms within the context of a patient’s life.

This processes begins in the initial consultation. Part of what makes Our Necessary Shadow so accessible is Burns’ efforts to explain what exactly takes place when someone is referred to a psychiatrist. ‘Depression,’ he tells us, ‘will be responsible for more early deaths and lost years of good-quality life than any other illness.’ So obfuscating myths can be fatal, and dispelling them is vital. Often people who are distressed, depressed, or otherwise feeling out of step with the usual course of their mental life fear they will be described as ‘abnormal’, but Burns suggests the opposite is the case: psychiatrists – used to the breadth of human experience – are more sanguine about making such judgements. However, he is also clear that for many distressed and unwell people, a psychiatric diagnosis – with its often revisable or tentative character – is welcome, and allows the recent changes in their experience to be viewed without excessive blame or self-recrimination. The following sentence encapsulates the tone and nature of the whole book:

No psychiatric diagnosis – none – can be confidently made on the basis of a single symptom or sign. The diagnosis of a mental illness, as repeatedly stressed in this book, reflects a judgment, albeit often imperfect, that individuals have become different from their ‘normal’ selves in some fairly recognisable way. It is not that they are different from us, or that they are socially deviant, but that they are different from what we and they usually understand as their normal selves.

Burns’ voice throughout is resoundingly humane. Part one of the book charts the various currents of psychiatry that led to this point of view. Things were not always thus. It is impossible to justly survey every historical influence here, but the main themes are clear. The history of psychiatry emerges as a history of over-extensions and conservative retrenchments.

Take asylums, for example. Burns charts the complex relationship between the conception of the asylum as a place of safety and respite for the mentally distressed and suffering, and the increasing political desire to manage various unpredictable and purportedly unsavoury sections of society. Expansive asylum programmes quickly diluted the goals of the early Quaker pioneers, for instance, with their emphasis on rest, calm, humane treatment, and the absence of restraints in their ‘moral cure’. But asylums were also sites of innovation. They offered opportunities to observe and describe conditions, and catalysed much psychoanalytic reflection and insight. The influence of the Burghölzli, for example, cannot be underestimated. Eugen Bleuler, Carl Jung, Karl Abraham and several other influential analysts worked there. Indirectly, the over-expansion and resultant abuses within the asylum system – an infrastructure that has now given way to community care in the most part – contributed to the productive critique of anti-psychiatrists like Erving Goffman. Our Necessary Shadow presents us with a qualified defence of psychiatry that is sensitive to, and accommodating of, legitimate concerns.

Other historical points of focus include the upsurge in psychiatric thinking in response to the vast suffering in wartime; the impact of psychoanalytic reflection on the influence and meaning of unconscious thought processes, with the attendant focus on changes to a patient’s psychic experiences and not just their symptoms; the relationship between pharmacological innovation and new diagnostic categories; the origins of community care in the context of large political reforms such as the Marxian Psichiatria Democratica which effectively closed mental hospitals in Italy, and so on. A review cannot sustain the weight of the themes canvassed, but part one of the book leaves the reader well acquainted with the interlocking influences that shaped the modern discipline.

These themes are extended and challenged in the book’s second part. Burns soberly catalogues the abuses of psychiatry, from psychiatric collaboration with the Nazis, the Soviet Union, and the CIA; unethical experiments with aversion therapy and LSD; attempts at fragrant charlatanism; through to the general neglect and abuse of women (which is arguably on-going). His defence of the disciple is stronger precisely because it confronts the legitimate reasons for people to be concerned about the unique opportunities for abuse or unethical behaviour within psychiatric practice.

The force of Burns’ advocacy is also revealed in this context. His driving comparison between psychiatry and other branches of medicine. Prompts us to see psychiatry as a medical endeavour like any other: that is, as a process that until very recently was largely based on the practical skills of its practitioners. Randomised controlled trials are very recent innovations. Moreover, Burns reminds us that many mental illnesses have physical symptoms (he describes witnessing patients in India being treated for depression purely on the basis of physical symptoms), whilst many physical illnesses impact upon psychological life.

Thus Burns mollifies the natural impulse to think that the ‘mental’ differs radically from what is paradigmatically ‘physical’; things are more complicated than that. Burns repeatedly stresses the intrasubjective and often social aspects of mental illnesses. They arise because we need others, and because the meanings of the experiences we undergo are finely mediated by the idiomatic character of our localised standing in social space.

The comparison with other medical illnesses also helps frame the real suffering many people experience. Those influenced by anti-psychiatry, myself included, are often sceptical about diagnoses of mental illnesses, especially insofar as the very act of diagnosis seems to have unpredictable cultural effects, as Ian Hacking has suggested. But Burns is surely right to stress that for many, a diagnosis is a source of comfort. Unknown and painful physical ailments interrupt the passage of ordinary life, and destabilise our implicit trust in our bodies. But this is equally the case, if not more so, with mental illnesses. Burns never turns a blind eye to suffering.

This makes for some occasionally difficult reading, none more so than Burns’ description and advocacy of electroconvulsive therapy (ECT), in which a localised epileptic fit is induced in a patient under anaesthetic in order to treat severe cases of depression. ECT usually results in the loss of some concrete memories, and can cause disorientation. It is a treatment of last resort. Depictions of the treatment in the popular media portray it as a barbaric process, but they frequently fail to acknowledge that the treatment is carried out only when the patient is not conscious. Undoubtedly the treatment has historically been used in awful ways, and its side-effects mean that it is the most controversial prevalent psychiatric treatment. It is also, though, the most effective. In heeding these points Burns poses a challenge for the reader, ‘the crudity of ECT does little for psychiatry’s self-image. However, it seems arrogant in the extreme to deny a highly effective treatment in such an awful illness because it offends our aesthetic or philosophical sensibilities.’

There is every chance this book can change attitudes towards psychiatry and positively influence the way readers approach their own mental distress, or that of people they know. This is not least because Burns’ is prepared to accommodate some of the intra-subjective emphases of psychoanalytic thinking, which has increasingly recognised the importance of careful attention to the wider meaning of a patient’s symptoms. Burns succeeds in presenting a vision of psychiatry which allies pharmacological innovation and ongoing research with humane and attentive forms of interaction. While he argues that human society will always live under the shadow of the need for psychiatric help, the light Burns sheds on his discipline may at least begin to dispel the penumbra of fear and suspicion that often surrounds it.