Violence: Reflections on Our Deadliest Epidemic By James Gilligan. London: Jessica Kingsley. 1999. 306 pp. £12.95 (pb). ISBN 1 85302 8428

This book is a tour de force. The author - a respected forensic psychiatrist and psychotherapist - proposes that we approach violence and its prevention in a naturalistic, non-moralistic way, “as a problem of public health and preventative medicine, thinking of violence as a symptom of life-threatening (and often lethal) pathology, which like all forms of illness, has an aetiology or cause, a pathogen”. Elsewhere, Gilligan (2000) has written,

“A consensus on the causes and prevention of violence has been emerging over the past few decades among investigators of this subject from virtually every branch of the behavioural sciences. All specialities, independent of each other, have identified a pathogen that seems to be a necessary but not sufficient cause of violent behaviour, just as specifically as exposure to the tubercle bacillus is necessary but not sufficient for the development of tuberculosis. The difference is that in the case of violence the pathogen is an emotion, not a microbe - namely, the experience of overwhelming shame and humiliation. And just as people's vulnerability to tuberculosis is influenced by the state of their body's defence mechanisms, so their vulnerability to violence is influenced by the state of their psychological defence mechanisms”.

Disarmingly, but convincingly, Gilligan argues that it is really quite clear that we can prevent violence and clear, too, how we can do so, if we are sufficiently motivated. He cites compellingly the accepted data of the enormous differences in individual and collective violence in different societies around the world. His especial target is his own country, the USA, which is massively more violent than any other democracy and every other economically developed nation (its prison population is over 2 million - nearly 1% of the population), and just happens to be by far the singular dominant nation of the world in economic and material terms. He quotes Currie (1985): “we have the level of criminal violence we do because we have arranged our social and economic life (as we have)…the brutality and violence of American life are a signal that there are profound social costs to maintain these arrangements”. We have decided that we prefer this to a far less violent alternative.

Central to Gilligan's radical thesis is that violence springs from psychopathological roots of hidden shame and that our societal systems of response are iterative in causing further shame and shaming - thus creating a circle of causation. This is an important, and I believe, considerable claim, which is especially significant at a time of moralism and righteousness. There are huge clinical and pragmatic consequences. Experience of shame is antithetical to thought and breeds crude defensive reactions, such as ‘macho’ attitudes and even violence, it is related phenomenologically to paranoia. ‘Guilt’, on the other hand, is often the secret that demands to be spoken (hence, confession and psychotherapy).

The origins of this book lie in the relative microcosm of 25 years of clinical forensic practice in a maximum secure state hospital and the Massachusetts prison system and crystallise in an impressive conceptual sweep that sets Gilligan's theories within cultural and sociological arenas.

For example, there is an excellent clinical chapter, ‘Violent action as symbolic language’, in which Gilligan addresses the common central clinical problem that,

“Understanding violence requires understanding what thought or fantasy the violent behaviour symbolically represents. Doing this is especially difficult in the case of most violent people, because they are so oriented toward expressing their thoughts in the form of actions rather than words. Their verbal inarticulateness prevents them from telling us in words the thought their behaviour symbolically expresses”.

This is partly derived from Hanna Segal's work on symbol formulation and its failure in concretisation of thought. It is familiar territory in forensic psychiatry and psychotherapy - and is addressed, for example, by Fonagy & Target (1996) as failure of “ reflective self-function” - but Gilligan expresses it particularly well. Quoting the philosopher and literary critic Kenneth Burke's belief that in order to understand literature we must learn to interpret language as symbolic action, Gilligan suggests that in order to understand violence we must reverse that procedure and learn to interpret action as symbolic language with a ‘symbolic logic’ of its own.

Gilligan argues that we have neglected shame and shaming as a root cause of our endemic violence and, instead, have been too preoccupied with edifices erected around the concept of guilt, both psychologically speaking and within the ‘crime and punishment’ approach of the criminal justice system.

In later chapters Gilligan analyses the biology of violence and gender differences, and addresses more fully the sociology of violence. He considers economics, class and race, taking as his cue Gandhi's observation that the deadliest form of violence is poverty. He argues that what he calls ‘structural violence’ within our societal systems - for example the increased rates of death and disability suffered by those who occupy the bottom rungs of society - far outweighs as a public health problem the ‘behavioural violence’ (or unnatural deaths caused by individuals) with which we are more familiar as health professionals, and with which the media are preoccupied. He writes, “Where violence is defined as criminal, many people see it and care about it. When it is simply a by-product of our social and economic structure, many do not see it; and it is hard to care about something one cannot see”.

I am sympathetic to the notion that as professionals we have neglected shame as a profound experience and cause of violence for the very reason that Gilligan gives: “nothing is more shameful (or painful) than to feel ashamed;…violent man would (literally) rather die”. Further, I am sympathetic to the notion that as a society we are more comfortable with guilt than with shame and that psychoanalysis in particular may have done a disservice by emphasising the one at the expense of the other. My imagination will hardly extend, however, to a possible future society where we eschew the retributive/crime and punishment model. We seem to be programmed to such a system, whether we like it or not. Is this really (merely) the consequence of our Judaeo-Christian societal origins, and therefore mutable, as Gilligan suggests?

There are many gems in this volume and I give as an example Gilligan's interpretation of the depressing and professionally demoralising rhetoric of ‘law and order’ and control common to the politics of the main parties in the USA and UK. It is in the political interest of the party that represents the rich (or middle classes) to foster and to publicise (by alarmist headlines and speeches) perceptions of high rates of crime. The more people are worried about crime and violence, the more will the middle classes focus anger and fear on the poor and members of certain minority groups (who are responsible for most of what is labelled crime). When crime is at its maximum, the party of the rich can represent itself as the saviour of everybody, by promising to ‘get tough on crime’ and by declaring its ‘war on crime’ (which is really a war on the poor).

The style of writing is clear and the examples always wonderfully vivid. A book for the generalist to savour, for clinicians to ponder and for policy-makers to worry about.