Reviewed in the United Kingdom 🇬🇧 on 9 August 2016
To cultural historian and literary critic Anna Schaffner, we live in an ‘age of exhaustion’ – she contends that the experience of exhaustion, both spiritual and physical, has an all-pervasive sway on our era. What she means by ‘exhaustion’ is rather vague and sweeping (she accepts herself there is no clear concept for exhaustion); its remit includes the retirement of a pope, political apathy, anxiety about climate change, reactions to capitalism, the Occupy Movement, clinical depression and ‘chronic fatigue syndrome’. Schaffner is right that the West is at a critical historical juncture, and that cultural pessimism may be part of this, but her attempt to extrapolate through the idea of ‘exhaustion’ is woolly – it offers a semblance of coherence, but is too broad to be meaningful. The diverse subjects she co-opts to support her thesis are often not examined in any real depth. Using such a loose approach, it might be equally plausible to suggest that this is the age of anxiety. Or globalisation. Or stupidity.
Schaffner sets out to understand shifts in the cultural perceptions of exhaustion over time, from ancient Greek theorists like Galen of Pergamum, through Earl Christian, Middle Ages and Renaissance thinkers, to the early 20th-century of Freud, and then on to the modern era – a time, she holds, when the idea of exhaustion is ubiquitous. The author is at her most fascinating when she examines the literary and medical writings of the past – Galen, Evagrius Ponticus, John Cassian, Dante, Marsilio Ficino, George Cheyne, Freud. From an anthropological perspective, it is certainly true, as Schaffner suggests, that human experience is mediated by discourses that are culturally and historically specific; and societal concerns can manifest as cultural metaphors. However, using books like Leader and Cornford’s Why Do People Get Ill? to develop her argument is unconvincing – a populist book that draws on Lacan and overstates the role of the psyche in physical illness.
Schaffner gets onto very shaky ground in the chapter on CFS or M.E. While extreme fatigue can be one symptom, M.E. is not ‘exhaustion’; Schaffner conflates chronic fatigue (burnout/stress) with chronic fatigue syndrome and M.E. (defined as a neurological disease by the WHO). Schaffner claims that in the late 20th-century, the cultural imagination became preoccupied by CFS, but provides no evidence to support this (eg no media analysis). Bizarrely, she interprets CFS or M.E. as a possible ‘cultural metaphor’; this will surprise the prestigious US Institute of Medicine, which last year evaluated 9000 scientific papers and concluded that ME/CFS was a complex, multi-system disease (not a psychological one or one perpetuated by psychological/behavioural factors). Schaffner refers to the idea that CFS could be a ‘fashionable illness’ in which unconscious processes manifest itself in ‘culturally legitimate’ ways; such an idea comes as a shock to ME patients, many of whom have faced years of being neglected, dismissed or even abused. I can’t think of a less ‘fashionable disease’ to get if you want legitimation by medics.
Although acknowledging that CFS or M.E. is a complex and controversial field, and although trying not to be over-definitive in her analysis, Schaffner effectively recycles a psychogenic or 'psychosocial' narrative about the illness. In Schaffner’s defence, I don’t think she appreciates what a minefield she has stumbled into or what is at stake. She cites literary historian Edward Shorter’s views of M.E. patients, acknowledging that these are unsympathetic – a better word would be contemptuous. She discusses psychiatrist Simon Wessely whom she considers misunderstood by M.E patients, his ideas being more nuanced than they think. Thus, she says, he holds that psychological illness is real not imaginary, and he has helped developed therapies like CBT/Graded Exercise which are at least ‘moderately effective’ in managing the chronic, debilitating illness. However, Schaffner doesn’t appreciate the complexity of the subject nor the politics involved. Patient charities and pressure groups are often more nuanced than she claims; they regularly state that psychological illness is real – they just don’t think the evidence supports the idea that M.E. is one; and the seminal US Institute of Medicine report last year affirms this view – it is highly surprising that Schaffner doesn’t even mention this. The benefits of CBT/Graded Exercise have often been overstated (by psychiatrists and media), accompanied with words like ‘recovery’, for which there is no evidence; and large-scale patient surveys report that Graded Exercise can harm – Wessely and his colleague refuse to take this on board. The conclusion of the flagship ‘PACE’ trial for CBT/GET (which was spun in the media) – that these therapies are moderately effective for some patients – has itself come under intense scrutiny. For instance, Ron Davis, Professor of Genetics and Biochemistry at Stanford University, has called PACE ‘the height of clinical amateurism’, while David Tuller, Professor of Journalism at UCL Berkeley, has written extensively about PACE’s methodological flaws (and I would recommend Schaffner read Tuller’s articles on Virology Blog if she wants to get to grip with the central issues here). Talking about the investigators of the PACE trial, Tuller recently said, ‘My interpretation is that they are used to saying exactly what they want about patients and they’re used to getting away with it, and not being challenged. And I think they were sort of gobsmacked by having something at this high level confronting them, and having top scientists from Columbia, Berkeley, Stanford, Harvard, wherever, saying publically and forcefully, ‘This study is a piece of crap.’’
Schaffner uses literature to try to illuminate the ‘perceptions’ of M.E. patients. She cites several long passages from Nasim Marie Jafry’s funny, poignant novel The State of Me – an excellent book that many patients relate to. ‘One of the many strengths of literary works,’ observes Schaffner, ‘is that they give us access to the minds, experiences and perceptions of others.’ A noble sentiment and she clearly has respect for Jafry as a writer, commenting warmly about the emotional arc of the story, for instance. But Schaffner fails to understand what Jafry is really saying in her novel. Rather, in a coercive reading, the fictional character Helen Fleet – as well as Jafry herself (whose blog is quoted) – is co-opted into Schaffner’s overly psychological narrative about M.E. patients, including their alleged ‘irrational hostility’ to psychiatry. Schaffner quotes selectively from the novel, failing to mention that what she calls Helen’s ‘anti-psychiatry or anti-psychoanalytic rhetoric’ is based in part on how Helen is being treated by a consultant neurologist – he assures her that she has a physical illness and gives her plasma exchange and immune-suppressants. This echoes Jafry’s experience; she was diagnosed and treated by Professor Behan, who approached the illness in a biomedical manner. Schaffner doesn’t acknowledge that there might be legitimate grounds for criticizing, or feeling angry about, the role of psychiatry in M.E – the possible misrepresentation of the illness, the possible harm done by three decades of research along an arguably misguided path. Rather, in a reactionary reading, Schaffner interprets criticism and anger as the possible consequence of psychological defence mechanisms or mental health problems. Isn’t this getting into dubious waters, especially given the very real power relationship that exists between M.E patients and the psychiatrists? I think Schaffner would identify herself as a progressive thinker, but where is the space for legitimate questioning? Wessely et al have long conflated legitimate criticism of their ideas and methods with ‘harassment’. Anger at the psychiatrists might have sometimes been expressed by fringe members of the M.E. community in unacceptable ways (I am not talking about Jafry here), but Schaffner doesn’t take on board that patients have legitimate grounds for complaint.
As a novelist and a blogger, Jafry has been keen to educate people about the experience of M.E. But Schaffner co-opts Jafry’s words, and those of her fictional character, to support the very psychogenic ideas that Jafry believes have misrepresented M.E. patients and compounded their suffering. Isn’t that contentious, if not politically suspect? In a manner that I found troubling, Schaffner also offers a (albeit tentative) psychoanalytic reading of Helen Fleet and her illness, and by inference, of Jafry herself – that is, she is not physically ill but has unresolved childhood issues. Based on a short sentence of what is a fictional character, this reading is insensitive at best; it reveals more about the lens Schaffner brings to her reading than about Jafry herself (or her fictional character); it also denies Jafry any self-awareness. Schaffer, after all, is not a qualified psychotherapist. I’d contend that Schaffner’s reading of Jafry verges on the unethical.
How Schaffner interprets Jafry echoes the way psychiatrists arguably treat M.E. patients – the refusal to listen dressed up as empathy, the denial of lived experience dressed up as ‘we have more insight into your experience than you do’, the silencing of voices dressed up in the get-out clause, ‘We know there is some doubt, but this is the best theory we have.’ Power and priviledge are key to this – to literary critics or psychiatrists defining the realities of patients and then labelling as aberrant any resistance to this.
If someone in distress is not listened to again and again, it can harm them mentally – if M.E. patients show signs of mental distress when responding to psychiatric rhetoric, it is precisely because they repeatedly don’t feel listened to.
Psychogenic or biopsychosocial theories are not the ‘best we have’. The criticism of the PACE trial, the publication of the Institute of Medicine report and the increasing momentum of biomedical research in the US, mean that, internationally, the psychogenic or biopsychosocial school of CFS is losing the scientific argument. Interesting, then, that at this very historical moment, the attempt to shore up the psychogenic narrative seems to have shifted to the cultural arena; Schaffner’s is one of several books that have come out recently supporting the psychogenic view. I’m not saying this process is conscious or deliberate; Schaffner’s isn’t part of any conspiracy. But it is curious these books are shoring up what is, in scientific terms, a sinking ship. Given Schaffner’s interest in projection and the cultural unconscious, maybe she would reflect on this.
Given that I like the work of cultural historians like Marina Warner, I hoped to enjoy at least parts of this book. While there is fascinating material in earlier chapters, the chapter on M.E. should never have been included - it made me deeply uncomfortable. As Schaffner seems to identify as a progressive thinker, I would also strongly recommend her to look at George Faulkner’s pamphlet, ‘In the Expectation of Recovery: Misleading Medical Research and Welfare Reform’ (by the Centre for Welfare Reform), which examines the links between certain UK CFS psychiatrists of the biopsychosocial school and the attacks on the sick and disabled - the disability denial – by the UK government.