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on 8 October 2009
This book is packed with valuable information that will be of interest to a mental health professional and an interested layman alike. Based on a well-researched material, this book brings what could have been a boring subject to life, and makes for a very entertaining reading. It helped me to understand the development of the field before I committed myself to psychiatric training, and in some ways influenced my career choice. While Shorter certainly cannot be mistaken for a fan of psychoanalysis, he does present a well-balanced overview of the history of psychiatry (where psychoanalysis has an important, but not THE MOST important role). In fact, he accepts that organic psychiatry and psychoanalysis each have their place in the discipline, and some of the best minds in the history of psychiatry practised both as appropriate (e.g., Kuhn - the pioneer of imipramine and EEG in Switzerland - was also a trained analyst).

Now that history of psychiatry is examined in Paper 1 of MRCPsych, I think this book ought to be added to the official MRCPsych reading list. Highly recommend.

For those who, like myself, want to explore the subject in more detail, I recommend Dr Shorter's "From Paralysis to Fatigue" and "Shock Therapy" (the former describes the historical development of psychosomatic illness, the latter - the history of ECT).
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on 7 August 2011
Maybe I was wrong. When I reviewed Gemma Blok's history of anti-psychiatry in the Netherlands, I criticized her for interjecting her opinions, instead of sticking to reporting the facts. Perhaps that's not how historians see their role. Edward Shorter never even bothers to make a pretense of objectivity. I do admit that his unashamedly judgmental writing style makes for a stirring read. Let me be equally unashamedly judgmental about him.

For one thing, Shorter loves psychiatry. That's clear. For another, there's no mistaking what his favored model of psychiatry is. He lavishes praise on early German psychiatry which was well-funded by the state, enabling plenty of experimentation, as "the triumphs of science" add to the national prestige. He even goes so far as describing the structure within which Kraepelin worked as "majesty." On France of the same period he pours scorn for being "a second-rate psychiatric power," whereas in pitiful England, where teaching hospitals were dependent on charity, there was little science at all, according to Shorter.

Shorter credits Kraepelin, a neurologist according to him, with being the inventor of psychotherapy, although it wasn't called that at the time of course. Wealthy people loathed asylums, so they avoided them by pretending their personal problems were neurological diseases. That's why they became known as neuroses. Neurologists soon recognized the role of placebo treatments (which worked) for these non-diseases, although neurology is actually, according to Shorter, the science of unusual and incurable diseases of the central nervous system. The nerve doctors, poor things, didn't have much choice but to go along with doing psychotherapy and running resorts, as that is where the money was at the time, and they couldn't cure any of their real patients anyway.

The irony is that Kraepelin, whatever his real job title was, worked in asylums where people were taken involuntarily. He is today considered the discoverer of "schizophrenia," a supposedly brain-based disease.

Freud, too, was a neurologist, Shorter points out (this time correctly), though he has no sympathy for psychoanalysis. He juicily describes a lecture given by a German émigré to the U.S., which was so well received that "it brought the house down." "Respected by all and understood by none," the émigré had spoken in broken English about "penis envoy." Psychiatrists in the U.S. welcomed psychoanalysis as a means to escape the asylums. Why they would want to leave all that majesty, Shorter doesn't say.

The early treatments for people brought into the asylums were geared at making them physically sick. Patients would be administered emetics (drugs to make them vomit) or injected with blood from people who were ill with malaria and tuberculosis. These treatments worked, according to Shorter, as did prolonged narcosis (keeping people asleep with drugs), a successful therapy that might still exist today had not some of the patients messed it up by dying. Alcohol was another treatment tried. Pharmaceutical treatments were promising, but unfortunately, Swiss psychiatrist Jakob Klaesi who was doing drug research at Hoffmann-La Roche, was subject to manic-depressive personality swings, says Shorter, and became a nazi sympathizer.

One would think that Shorter, writing in a period that the works of Healy (who is mentioned by him) and Breggin (who is not) are well-known in the psychiatric community, might have connected the term narcosis to the modern term narcotics, which is what all psychiatric drugs are. But no, to him they are medicines, and bear no relation to the early efforts to cure whatever ailed people by making them sick or drowsy. Nor does he express any skepticism of the bombastic claims for the success of any biological treatments, whether the ones mentioned above or ECT, opposition to which he labels "hostility." Only about the curative capacity of lobotomy is Shorter less confident.

For a book boldly named "A History of Psychiatry," reference to the psychiatric obscenities in Germany leading up to and during WWII is surprisingly brief. Not delving deeply into the facts, as though this were a minor sidestep in the history of psychiatry, Shorter condemns these events in no uncertain terms, manic-depressive personality swings or not. "Academic medicine in Germany on the whole stood waist-deep in the Nazi sewer" he asserts, suddenly forgetting about the glories of state funding and experimentation, which were the hallmarks of nazi medicine even more than of the earlier regime so praised by Shorter. Strangely, he ascribes the events under the nazis only to the theory of degeneration, not to the theory of heredity, even though degeneration rested on heredity.

Degeneration, Shorter laments, was seized upon by the eugenicists (so there was nothing wrong with the theory itself?). Later in the book Francis Galton is credited with proposing twin studies, about which Shorter is enthusiastic, without any mention of Galton being the founder of the eugenics movement, and twin children being the infamous Mengele's favorite victims. Mengele isn't mentioned in the book either. Instead, Shorter says defensively, "There was nothing intrinsically racist about the technique of twin studies in psychiatric genetics. ... Indeed, the next major contributions to the field came form Jewish scholars." Shorter misunderstands the meaning of the word racism in the nazi context, and implies that whatever any Jew does cannot be racist. He but regrets the influence of nazism on psychiatry because it imposed taboos on the discussion of biology and heredity in psychiatric disease for decades to come.

Advances in drug therapy were fortunately not held up too much by the nazi sewer, and by May 1952, Delay and Deniker's patients were all doing great on chlorpromazine, according to Shorter. It even cured "patient number one, Giovanni A., a 57-year-old laborer" of his propensity for "making improvised political speeches in cafés ... and ... preaching his love of liberty."

To his credit, although I'm not sure his heart is in it, Shorter isn't totally oblivious to the aggressive expansion of psychiatric territory. He notes regarding "Tom-Sawyer-esque enthusiasm ... the natural spirits of ladhood, [that] in the 1960s and after a whole series of psychological diagnoses arrived to define such behavior as pathological" and "[Such programs as] Mental Illness Awareness Week encourage doctors to diagnose depression. ... the ultimate effect is psychiatric empire-building against other kinds of care." He also mentions some of the various influence groups which affected the content of the DSM (apparently only in the past).

As I started this review with a reference to Gemma Blok, let me not leave out Shorter's section on antipsychiatry movements. They flourished, he claims, throughout the nineteenth century, then apparently mysteriously disappeared for a while. In the 1960s they were reborn, with books published by Michel Foucault, Thomas Szasz, and Erving Goffman. But what really caused the movement to flair up was a novel by Ken Kesey, One Flew Over the Cuckoo's Nest. The movie made from it swept the academy awards of that year, winning all five main Oscars, Shorter relates. That none of these authors considered themselves antipsychiatrists is apparently beside the point. Like Blok, he pronounces this movement a failure.

Shorter ends the book with a justification for the existence of psychiatry. "Whereas the average consultation in internal medicine or obstetrics lasts only around 10 minutes, the average in psychiatry lasts over 40. Within this 40 minutes, psychiatrists do essentially two things that their competitors on either side - the psychologists on the one side, the neurologists on the other - do not do. Psychiatrists offer psychotherapy, which the neurologists generally speaking do not... And psychiatrists prescribe medication, which the nonmedical competition is not permitted to do. This combination of psychotherapy plus medication represents the most effective of all approaches in dealing with disorders of the brain and mind."

Conspicuous by their absence from this justification for the existence of a field of medicine so hated by many of its supposed benefactors, are words like cure, improvement, and customer satisfaction.

There's a snapshot of Shorter on the dust cover. He's quite good looking. If you happen to see him somewhere - turn around and run!

Copyright © MeTZelf
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on 7 December 2010
Reading a book describing the history of your own discipline may not only be interesting and informative, but helpful too. Helpful meaning putting contemporary psychiatric practice in perspective and all the relevant context, which in turn enables one to understand one's place in the society better.
The author begins his story at the end of 18th century and continues with it more or less chronologically, changing specific subjects of interest from chapter to chapter. Generally narration is fluent and makes the book easily readable.
Nevertheless, as I was reading through the book, my misgivings were steadily growing. The author quickly turns out to be biologically-minded, and he doesn't hide it. That wouldn't be fault in itself (I'm also a biological psychiatrist), weren't he acting as a historian rather than ideologist. It results in the unfolding events or people responsible for them being either praised or mocked, depending on whether they are rooted in biological thinking or not, respectively. The author is clearly anti-psychoanalytical and it surfaces now and then. He generally blames psychoanalysis for seriously hampering the development of psychiatry. It's of course clear, now, that psychoanalysis has proved dead end, but such a unilateral account isn't what I expect from historical account of psychiatry.
The book can boast many a positive features, too. Above all it reads well, is enganging and quite thorough.
The last, but most important thing for me - the book has 'history of psychiatry' in it's title, but it doesn't mention 'ICD' even once and you can't find it in the index. That's why I won't give it more than three stars.
Not mentioning 'ICD' the author seriously undermines his authority and makes me not to count this book as authoritative. It's interesting but only partialy helpful.
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on 6 October 1997
I loved this book. Terrific. Over and over it tied together and made sense of things that had puzzled me.
To get personal: in the fifties, my father spent a small fortune on traditional Freudian psychoanalysis. And it did him a lot of good. For years, I believed Freudian psycyoanalysis was scientific. For one things, it just _had_ to be. No charlatan could go to the effort and expense of getting an MD, then board certification in psychiatry, then undergo psychoanalysis, just in order to con people.
Yet in some way that I didn't quite understand, I became aware than nowadays Freudian psychoanalysis is considered to be a pseudoscience, on about the same level as orgone boxes or homeopathy or Christian science.
How _could_ my parents have fallen for it? How _could_ the medical community?
Well, Shorter explains what happened in a way that makes sense, seems clear, and (to my mind) is really quite sympathetic to the psychoanalytic community and its clients.
Along the way he ties up a lot of loose ends. All through the book I kept saying to myself things like, "Oh, so _that's_ what 'neurasthenia' was" (people in novels written early in the century often had it). "Wow, so that's what the word 'degenerate' is really referring to."
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on 2 March 1998
Highly intelligent, principled writing. Not opinionated, but has opinions, argues for them, convinces the reader. Informative but does not aequalize between imporatent and unimportant. Brilliant style, most amusing.
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on 21 January 2015
Book arrived but was kinked in the middle.
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on 12 June 2012
The usual triumphalist, Whiggish interpretation of one of the single most ethically challenged professions in the history of mankind, and a testament to the inhumanity of your average psychotyrant. Throughout the book he studiously avoids anything that might let the ugly reality of human suffering into his carefully manufactured narrative.

In the preface, full of nauseating (for me), elating (for him) phrases extolling the profession's current status, he tries to elevate his own own ostensible history above others with the granidose claim that it is his that represents what actually happened, making for an ignominious spectacle of unwarranted psychiatric hubris. He tries to give off the impression that the people who have written the critical histories of psychiatry are just squabbling infants using the history of his sacred profession as a vehicle for their own ideologies, which just seems like a paradigmatic example of the human proclivity to attribute our own motives, desires and impulses to our opponents. It is hardly surprising that for the next few hundred pages, he scrupulously avoids writing anything that could by perceived by his pals as neglecting his duty to tow the party line wherever possible.

He asserts at a number of points in the book that mental illness is real, as if a concept whose referent can't even be located in space can be said with confidence to be ill. A man has persistent hallucinations of diseases that aren't actually there; we call him a psychiatrist. A man thinks human beings are wicked and are out to get him; he has a mental illness. He imperiously proclaims in the preface that 'one may no longer argue that schizophrenia and depression are social constructs lacking a basis in flesh and blood', as if doing so would be lese majeste. I'll argue what the hell I want, Mr Shorter, regardless of the edicts of despotic quacks who believe that the fictive substances that we call mental illnesses are real. If you are so confident of this, if you can so confidently assert that there is a biological correlate or cause, why hasn't a laboratory test been implemented so that a proper diagnosis of the patient can be made? It also seems to escape him that a physical illness is a physical illness, whose treatment doesn't fall within the purview of the psychiatrist.

He says, self-incriminatingly, that the account he makes is not apologetic, but only 'semi-apologetic'. He who excuses himself, accuses himself, in this case.

As I made clear earlier, Shorter claims in the preface that, 'this is what actually happened.' How he reconciles this to his avoidance of discussion of the defining characteristic in psychiatric history, coercion, I really don't know. Maybe this is because it doesn't harmonise with his view of the psychiatrist as a medical professional, treating diseases just like any other diseases, patients, just like any other patients, in hospitals, just like any other hospitals. As Thomas Szasz says in 'Coercion as Cure': 'I regard psychiatry as the theory and practice of coercion, rationalized as the diagnosis of mental illness and justified as medical treatment aimed at protecting the patient from himself and society from the patient.' I agree. Coercive relations between indivduals are always inherently political, and this is the truth that perhaps Mr Shorter finds unpalatable.

At one point he asserts : 'Having a partly biological and genetic nature, psychiatric illness is as old as the human condition.' This is just an ipse dixit.

His triumphalist interpretation of the PR fraud that was the 'pharmacological revolution' is just plain offensive, especially for someone like me who, at 28, would say that all the most insufferable, terrifying experiences of my life, came whilst on psychiatric drugs, some of which I was forced to take. It all attests to the man's indifference to the reality of patients, who he treats as if we were unpeople, people dispensable in the pursuit of a mental health utopia. Like some sort of base historical alchemist, he turns excrement into gold, a plague of iatrogenic illness into a golden age for his beloved profession, even though the demonstrable damage done by psychiatric drugs far outweighs in quantity that of the damage done by the preceding brain-damaging treatments put together. Maybe if he experienced the horror of neuroleptic malignant syndrome (something not mentioned in the book, something I have experienced, and something that according to one study might be responsible for over 100,000 lives, at the least tens of thousands), maybe this would cure, to put it in psychiatric pseudo-medical language, his Moral Deficient Disorder.

With the advantages accruing to historical distance from an event, most can now see that lobotomy was a fraud. Only in hindsight will the generality of people see that the cruel hoax that was the 'pharmacological revolution' was actually a revolution in how we torture our fellow human beings, in this case in the name of therapy.

He, revealingly, gives the medical catastrophe that is the Tardive Dyskinesia epidemic short shrift, only mentioning it once in passing, an implicitly obscene mockery of the suffering people have and are going through because of the 'therapeutic' impositions of psychiatrists. No mention is made of the egregious irresponsibility of sadists like E Fuller Torrey in telling people that the neuroleptics are amongst the safest and most effective drugs in common usage, a falsehood promoted by many, to the detriment of many.

The whole debacle functioned as a microcosm of the whole self-serving nature of the profession. The forces of obscurantism had their way for decades before the APA was finally forced to reveal that the drugs the profession had been raping people with were causing a neurological disease, which only serves to compound the evil of psychiatric coercion. We are talking of tens of millions of people here, yet these drugs are still being forcibly administered to patients, and the elective blindness of society constitutes a widespread conspiracy of silence even worse than the willful ignorance of the German populace vis a vis the the persecution of the Jews in Nazi Germany, because modern society affords us far greater latitude. Of course, the herd are too preoccupied imbibing the cretinising pleasures and thrills offered by the mass audio-visual media to have time for this.

Shorter reserves little space for the systematised killing of mental patients in Nazi Germany, which he views as an aberration, and I view as showing how therapeutic rhetoric acts as a euphemistic-camouflage concealing the abuse, control and extermination of political opponents and society's unwanted. Our use of pseudo-medical rhetoric to stigmatise, punish, control and destroy certain segments of the population betrays the legacy of Nazi Germany, although to make such a link is obviously taboo. It also showed how when you appeal to the health, the good or the flourishing of the community, any crime against humanity is permissable. Mr Shorter's position depends on his not recognising this legacy.

As has already been said in another review, Shorter, in commenting on the 'antipsychiatry movement', subsumes a group of disparate voices to the one childish, disparaging noun. He accuses 'it' of perpetuating the deinstitutionalisation process, anything to escape culpability for its egregious disregard for the institutionalised patient, most of them actually being shipped to other 'custodial' institutions where they were treated just as badly.

Now I'm off to read something less offensive, like the diary of Joseph Goebbels.
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on 24 May 1999
This book is a one-sided polemic. The author clearly believes that only the "biological" approach to psychiatry is worth anything, but instead of presenting his case as an honest argument, he gives us a weighted, colored, and biased view of history. I was very disappointed.
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