Finally, here is a definitive discussion of the discipline of psychiatry, from an insider committed to the profession but who does not shy away from its profound difficulties. In Our Necessary Shadow: The Nature and Meaning of Psychiatry, Dr. Tom Burns reveals all even while insisting that at bottom “psychiatry is a major force for good.” Psychiatry is inherently controversial since it claims to know the psyche; but this touches, as he puts it, what “is most human in us,” our being, our “soul” which we cannot be neutral about. Psychiatry is a “hybrid” of “guided empathy” and detached cure—and the profession has swung wildly between them for years.

There is no unifying theory—“no –ology in psychiatry,” Burns concedes—only approaches that work for individual patients who are encouraged to take responsibility for themselves. Psychiatry itself is a medical discipline, one of the mind. It can prescribe medicines in the form of brain-altering chemicals, and recommend and sometimes perform surgery. It even has legal authority to decide when compulsory treatment is required. Psychiatrists normally utilize psychoanalysis (and psychological therapy generally) but these are also practiced by non-medical psychologists. Both treat mental diseases, normally classified as psychoses or neuroses. The former—schizophrenia, manic depression (bipolar disorder), paranoia—are more severe and were once labeled madness—with patients demonstrating very disturbed behavior and loss of contact with reality. The term neuroses is now somewhat unfashionable due to its over-diagnoses of normal depression but is different from manic depression in that the patient acknowledges a problem.

Mental illness has been with us since ancient times, treated by shamans, witch doctors, priests, fakes, hypnotists, and con men, many with wild theories and exaggerated promises of a cure. Medieval society basically left matters to families and some religious groups. It was not until what Michel Foucault called the “great confinement,” under the rationalizing influence of the 16^th century Divine Right monarchies, that officials sought to control madmen considered dangerous to society by incarcerating them in small units. The more enlightened thinking of the 19^th century produced warehousing asylums, the physician-mesmerizer Franz Mesmer, and the first professor of psychiatry in 1864, but with little measurable improvement. Burns concedes that “multiple personality” was invented by psychotherapists through the power of suggestion, and “recovered memory” (brainwashing) was routinely induced by doctors and social workers.

He observes that the field has “lurched widely,” being broadly biological, then almost exclusively psychoanalytic, then back to unapologetically biological today. At the beginning, ineffective surgery, limited drug success and treatment abuses tainted psychiatry. Sigmund Freud brought some respectability to the discipline but through psychoanalysis rather than medical psychiatry. Very different approaches to psychoanalysis were undertaken, by Freud himself, over time, and then by the other pioneers such as Alfred Adler and C.G. Jung. All had their proponents and achieved great popularity especially among intellectuals. Yet, by the close of the 20^th century, the fact that each began with different theories, utilized dissimilar treatments, and garnered equally poor results led to today’s emphasis on psychiatry and biology rather than psychoanalysis. Burns, while generally supportive of the new emphasis, insists psychotherapy is not an “add-on” but essential to the field since all mental illness ultimately is social rather than simply biological.

Medicated treatment—its four main types being antidepressants, antipsychotics, sedatives, and mood stabilizers—increasingly dominates the field. The first breakthrough was using malaria to cure late-stage syphilis in the late 1880s, then insulin for drug addicts during withdrawal and for schizophrenia, then treating psychosis with electric shock, and finally going beyond to brain surgery. Burns recognizes the abuses at each stage but even defends lobotomies and electrically induced epileptic fits by recounting the relief they give to very disturbed individuals, not to mention their families. He is fair to critics of the whole endeavor like Foucault, Erving Goffman, and the libertarian Thomas Szasz, but concludes they have no answers to the fact that mental illness is real and causes great harm.

Our author is a surgeon and argues for psychiatry’s firmer grounding in biology. He tries to distinguish between “illness” and “disorder,” psychoses and neuroses, biology and mind, psychiatry and psychoanalysis so as to devise some comprehensive orienting theme for his discipline. But he finally concludes that one can make legal but not medical distinctions, since medically each is useful in different circumstances. While questioning the concept of recovered memory, for example, he still finds some legitimacy in the idea of dissociation. There are psychological differences between psychosis and neurosis but he is reluctant to call the former scientific/medical and the latter merely requiring counseling. Chemical treatment and surgery may seem more scientific but after both are exhausted, social problems must be resolved for full recovery. So the lines sometimes blur, and in service of that point he notes that sympathetic counseling used by Quaker and religious nuns inspired early psychoanalysis. Also that treating folks patiently and decently is still the secret of success today.

Medicalizing all of life’s ordinary difficulties is our tendency today, and this concerns the author. Why not, he rhetorically asks, Prozac all the time for everyone? It would calm us all down; but at what cost to our humanity? Indeed he asks whether “psychiatry itself” isn’t “making us sicker?” He notes that in the United States, 10 percent of 10-year-old-boys are diagnosed with Attention Deficit Hyperactivity Disorder, which “surely cannot make sense,” and which in many cases is merely used to stop boys from being boys. He questions whether even alcoholism is a medical rather than a social disorder in most cases (although psychoanalysis can be helpful).

The fact that the psychiatric profession itself has expanded the number of mental illnesses from 106 in 1952 to 297 in 1994–an almost 300 percent increase—undermines its own claim to be a scientific discipline. “Of course,” he says “this does not mean that there are really hundreds more disorders” or that psychiatrists end up even using all of these categories.

Psychoanalysis is especially liable to abuse. Two-thirds of patients are women despite that mental illness, generally, seems roughly equal between the sexes. Even with increasing public criticism of over-diagnosis, demand for psychoanalysis remains high, especially if third parties or government bear the cost. People like a shoulder for comfort. Yet the “extreme dependency” of the patient in such settings and the profession’s skepticism of customary moral taboos makes such sessions open to abuse. A few therapists even justify close sexual relationships with patients. Beyond that, ill patients are often not able to make decisions and these must be turned over to families. Mothers tend to stick with the patient but many family members simply want the situation solved no matter the nature of the treatment or the risk to the patient.

Government is inevitably involved in such situations. “Compulsory community treatment” orders for a year or two are the current favorite but are expensive and have the obvious Catch 22, says Burns, that whether the patient improves or not, additional treatment is offered as the solution.

In the end, he writes, psychology is simply the “practical response to the reality of mental illness.” The fact of limited success is balanced against the real anguish of patients, parents, relatives, and friends. The mind is so complex there are no cut and dried solutions—but society still demands them. Psychological evaluations are required by legislators and judges to help them keep order and make distinctions between “mad and bad.” It is governmental officials and society more than psychiatrists who insist on medical support for compulsion. Even though Burns’ own study of compulsory treatment orders in Britain found “absolutely no effect” on recovery, he finds that compulsion is “inevitable” since few will accept Szasz’s solution of treating the mentally ill the same as ordinary criminals. Neuropsychology and gene research promise refinement of diagnosis in the future but Burns confesses to being “unaware of any philosophical breakthrough in understanding the mystery of consciousness and identity.”

Refinement certainly does not characterize how the totalitarians addressed this issue. Between 1939 and 1945, 200,000 people were diagnosed as incurably mentally ill and ordered medically euthanized by the Nazi Committee for the Scientific Treatment of Severe, Genetically Determined Illnesses. The Soviet Union routinely classified political dissidents as mentally ill, certified by the appropriate psychiatric physicians. Burns adds that it was not only the bad guys:

The systematic extermination of the mentally ill was a terrible consequence of more long-standing eugenic ideas which had been gaining strength in Europe, the UK and the USA for decades. “Social Darwinism,” and a moral panic that the unfit were “breeding” faster than the educated and able, had become a preoccupation at the turn of the 20^th Century. It is never far from the surface, even now.

Forward-thinking Sweden sterilized over 60,000. The “enhanced interrogation” undertaken by the U.S. government after the attacks of September 11, 2001 was supervised by psychiatric physicians.

Reflecting on the Nazi abuses, Burns asks: “How could such a terrible thing happen and why was there no effective opposition from psychiatry? For there was none.” The only opposition was from some families and the church. After all, it was “scientific.” Even in the United States, the American poet Ezra Pound was confined to Saint Elizabeth’s Hospital in Washington, D.C. as “unbalanced” but mainly for being an open fascist sympathizer. Burns notes the “witch hunts” claiming child abuse from “recovered memory” children in the United States during the 1980s and 1990s. He is concerned about the “current dangers” of “commercial and social pressures.” Still, he expresses himself “relatively hopeful that psychiatry is unlikely to be such an obviously unwitting tool of state oppression again. We have learned our lesson and the profession is now more open and international.”

Two “errors” of early psychiatry highlighted by Burns suggest the difficulties that remain, and the profession’s enduring temptation to bend to public or elite opinion. Until 1973, homosexuality was listed by psychiatry as a mental illness. Today, it is considered normal and those who oppose it are labeled homophobic. Discrimination against homosexuals today is often punished by legal authorities and homophobia has even been recognized by professionals as a contributing factor to mental illness. Some states forbid psychiatric treatment to “reverse” homosexuality. It took the profession 40 years to turn homosexuality from a serious disorder to now requiring government to protect it.

Burns is also disturbed by early psychiatry’s treating women as mentally different from men, somewhat as inferior beings. But while noting many more women demand psychotherapy, he is careful not to blame either them or therapists. “Who is influencing whom can be debated,” he writes. He is ambivalent as to whether there actually is a mental difference between the sexes. One suspects that there would be no more opposition to the currently “correct” decision from the American Psychiatric Association today than there was back in the early 20^th century.

The author’s warning that eugenics and Social Darwinism are “never far from the surface, even now” cannot be ignored. He makes very clear that psychiatry has no single view of human nature. There is no theory. It is empirical, relative to a given situation. So what is to keep it within limits? Ewen Cameron earned the presidency of the American and the international psychiatric associations claiming that the brain was simply a computer. He worked for the CIA and the Canadian government in the 1950s to change usually unwilling patients’ minds by applying electroshock twice a day (versus the norm of three times a week) to break all “incorrect” brain pathways and create “correct” patterns. The project was carried on by Canada’s McGill University into the 1960s, with no opposition from government, the academy, or the profession.

The fundamental problem is that Burns’ more traditional view that mind and brain are not the same is a minority opinion in government, in the academy, and in psychiatry. For Darwin there was no “mind,” only the evolved animal brain. Burns has done a great service in highlighting the dilemma that it is not really easier now to cure mental illness, to distinguish “mad” from “bad,” or to limit compulsion. Compulsion and not-fully-informed patients are inherent in the discipline—indeed have produced its most important advances. While he is right to defend psychiatry’s positive achievements, it is questionable whether a field of endeavor that has no theory to guide it has learned or ever can learn its lesson.