on 30 October 2013
As Burns observes in his introduction, there are few accessible accounts of psychiatry for the layman, and he's written a very lucid and helpful one. The opening chapters give a very good sense of how a thoughtful practitioner operates: nuanced, balancing common sense and fine judgement, showing that the familiar and shrill criticisms of the profession are caricatures of the reality. His historical summary is crisp and insightful, exposing the roots of psychiatry's overconfident biological assertions and showing that the profession has indelible origins in understanding the unconscious mind and the patient's experience, and treating the whole person rather than the diagnostic category.
In his account his job is not only, or even mostly, about doling out pills: talking, occupational and community therapies are at least as important. Whether the majority of his colleagues live up to this exacting and conscientious model is another question, but he is an admirable advertisement for his profession.
However, in soft-pedalling the 'medical model', he opens up the question of whether these conditions really are 'diseases' in the conventional medical sense: a question he addresses at several points but fails to fully answer. He caricatures the rejection of the medical model by presenting it only in its most polemical forms (Szasz, Foucault) and asserts (by definition without proof) that the neuroscience of the future will show he is right. As his history shows, however, this was what the likes of Henry Maudsley believed 150 years ago: since then generations of psychiatrists have awaited this revelation, and despite staggering quantities of recent research the etiology of the psychoses in particular remain entirely opaque: there is still no physical test, scan or measurement that can establish their presence or absence, let alone point to a cause or cure. It's time, perhaps, to consider a little more fully why this is so and what it might mean.
The second half of the book reflects calmly on the hot-button topics and trends that define psychiatry in the wider culture today; this feels a little more like series of newspaper columns, without quite the incisiveness of the early overview. But the text is exceptionally well edited throughout, with a first class index for quick navigation.
on 13 April 2015
I wasn't all that impressed with this book, but I gave it three rather than two stars because it wasn't as bad as I'd feared, knowing Tom Burns's reputation and having been deeply unimpressed with some of his media appearances, including him absolutely "losing it" with psychologist and former patient Rufus May in a debate about the best way to help voice-hearers, leaving me wondering who the mad ones really were. However, this is a critique of the book, not the person, so to be fair he does acknowledge that psychiatry and its disorders are not equivalent to other branches of medicine and disputes the validity of this claim, which is often made by psychiatrists and their auxiliaries. He is also humble enough to admit that he made a mistake in his influential recommendation of preventive community treatment orders, which later research showed to be ineffective (not to mention the unwarranted infringement of civil liberties they entailed). Having said that, I think the book ultimately fails to grasp the nettle presented in its subtitle. His examination of the dark side of psychiatry is, to my mind, an attempt to illustrate "the exception that proves the rule" principle so beloved of apologists of all kinds, and leaves the "dark centre" unexplored; he touches on the elision of psychiatry into neurology without discussing its implications for patients or society; he claims to have psychotherapeutic inclinations without fully exploring them or explaining them (unless I missed it), and without realising that this tends to undercut the confident biologism that has characterised psychiatry during his years of practice; he seems to perform the usual "divide and rule" manoeuvre common in psychiatry (in the NHS, at any rate) of dividing patients into the mad/not responsible/deserving (typified by 'schizophrenia') and the bad/responsible/undeserving ('personality disorders') without examining critically the aetiology or the clinical implications of these concepts; and while he presents a reasonably good summary of the history of psychiatry, his discussion of contemporary treatments is superficial and lacks context. You might reasonably argue that all these subjects deserve books in their own right, and that this is meant to be an overview of psychiatry's place in society; but as such, it reads less like a genuine philosophical examination of the topic (of which there are many excellent examples) and more like special pleading for a profession with an identity crisis. Considering this professor's eminence, I might have expected better.
on 26 March 2014
Started slowly but very helpful overview of putting psychiatry in perspective. Describes where its origins lay and how it has progressed with new directions taken. Is a kindly book whose author tries above all else to be transparent, engaging the reader not only on the role and place of psychiatry, but also giving insight into the unique individual doctor and patient transaction.
It is also a sharing book that is aimed to be enjoyed by both professional and lay reader alike. It does not shirk study of the mistakes along the way - but asks only that they be judged by the same critiques as due to other branches of medicine.
Overall it tries to de-mystify our recognition of the mind as a place mystery, and shed light on the way a psychiatrist tries to understand and care.
on 5 June 2013
Good and balanced, and covers the history in a sympathetic and economic way.
Interestingly in the fraught and key debate on causality, he seems to lean towards the results of long-term cohort studies (e.g. Dunedin) that show that early childhood experiences are key.
One issue he highlights well is that of getting good quality US and UK trainee doctors to choose psychiatry as their specialism; partly because psychiatrists position of professional power is so much weaker than that of physical health doctors (who are still dominant in their worlds).
His couple of pages on psychoanalysis (research shows is ineffective, now not offered in US or UK health system, but both analysts and patient enjoy it) reflect fairly typical view within the NHS and effectiveness-based worlds.
I very much hope in future he can focus on the now emerging movement towards prevention; he just finger-tip touches in this book. Our outcomes in mental illness treatment are still very poor; as mental illness causes a large and increasing share of human disability (c.23% now) and suffering (we should include collateral suffering of family and friends also), prevention programmes (such as parenting/attachment skills training and use of pre-emptive CBT) are desperately needed; but these need to come from public health, not psychiatry.
on 27 July 2013
This is a warts-and-all view of psychiatry from the inside. There is a lot of contemporary debate, particularly online, about the validity of "mental illness" and the "medical model" used to treat it. The pragmatic reality however is that if people with mental health problems are to be assisted by the health services, then doctors are needed to pronounce illness and sort according to diagnosis, however imperfect the labels themselves may be. Professor Burns is very clear in the book about his opinion that psychiatry is not just another medical specialty, just as depression is something different in quality from a chest infection. Psychiatrists and patients alike are aware of these differences whether they admit it or not, and it can make psychiatry a complicated and uncertain business. Nevertheless, anyone who has worked as a doctor in this field will have seen people being helped enormously despite all the difficult dilemmas, and the book conveys this also. I would recommend it to anyone considering entering psychiatric training, and from my own point of view I found it a useful and enjoyable refresher on the history of my profession.
on 24 July 2013
"I wrote this book to give an understanding of what psychiatry is, what it can do and what it cannot do." With this explanation the author starts his introduction. He goes on to acknowledge that zillions of books have already been written on the subject representing a broad spectrum of views for and against psychiatry. "[W]hich should you believe? Should you believe either? Is it perhaps possible to believe both?...I hope to clarify some of these contradictions so you can decide for yourself. ... I hope I have succeeded in conveying both sides of the debate." Yet the reader knows what Burns wants him to conclude before opening the book: we need psychiatry. The title says so.
Why do we need psychiatry? Because, according to Burns, it works. He repeats this sentiment in a variety of wordings scores of times throughout the book. How it works, how often it works, and how its efficacy is determined he mentions nowhere. "I made a decision to keep this book free of references" he states in the acknowledgments even ahead of the introduction. Fair enough. A reference makes a statement look scholarly but doesn't make it true. However if you're going to rest your entire case on this one claim, expecting the reader to accept it on faith won't do. In fact I don't. Psychiatry does not work, ever. Nobody gets better from it, only worse. My source for this is the testimony of my own eyes and ears.
"Establishing and sustaining a trusting relationship with a troubled and suspicious patient is a skill," he posits, suggesting that psychiatrists have this skill. "It is simply not the case that psychiatrists only focus on symptoms and prescribing pills." This is not fact, it is propaganda. In my country some psychiatrists never even meet the "patient" but rather base their opinions about him/her on discussions with the nursing staff and social workers. When there is actual contact between psychiatrist and "patient" it more likely adversarial than "trusting".
This type of propaganda continues in Chapter 1, entitled "What to expect if you are referred to a psychiatrist" in which Burns makes all sorts of claims for psychiatrists' skills and abilities such as "intuition" and "see[ing] through ... emotional understatement" being "slow to pass judgment" and "feel[ing]" when someone is depressed. He sums up with "I think psychiatrists as a group tend to be warmer, more approachable and more understanding than most doctors."
Chapter 2, The origins of institutional psychiatry, presents some history and ends with more propaganda: "a mini-revolution with the introduction of new and dramatically effective specific interventions."
In Chapter 3, The discovery of the unconscious, he states "Mesmer's methods seem like so much hocus-pocus today but they were a radical break with a superstitious past." Is hocus-pocus not superstitious? "The magnetizers ... established that we have ideas and memories of which we are not conscious." They didn't establish that, they claimed it. Such claims justify the psychiatrist attributing to his "patient" thoughts and memories that he does not have. Thoughts and memories are by definition consciousness. Unconsciousness is precisely the absence of thought and memory such as during a coma or general anesthesia. "[T]he reality of an unconscious mind has been accepted by most professionals working in the field." That doesn't make it exist.
"The rise and fall of psychoanalysis" occupies Chapter 4, the fall being brought about by "effective antipsychotics and antidepressants." It is true that some people manage to hang on to their ordinary lives for many years while taking antidepressants -- which are synthetic cocaine -- just as other people manage to do so while taking real cocaine (for instance Sigmund Freud and popular Washington DC mayor Marion Barry). But "antipsychotics"? I have yet to meet someone on these drugs whose life is not utterly destroyed.
Chapter 5 deals with a variety of (mis)treatments introduced during the interwar period, such as malaria, insulin shock and ECT. Burns believes in the efficacy of ECT and plugs it several times throughout the book. About insulin shock he states, "The apparently wonderful earlier outcomes are now thought to be due to unintentional selection of patients most likely to recover and optimistic attitudes of the staff caring for them." More likely reports on "wonderful outcomes" were based on wishful thinking, as are the wonderful outcomes Burns himself reports in his book. Such untruths are the mainstay of psychiatry.
Chapter 6 deals with The impact of war, and contains some valid observations. "Big personalities have always had a disproportionate effect on the course of psychiatric advances." If the word advances is changed to practices that is certainly true.
Chapter 7 deals with the transition from coercion in large institutions to coercion "in the community" made possible according to Burns (and other psychiatrists) by the "drug revolution." He neglects to mention that budget cuts, not drugs, emptied the institutions. He calls this shift "our strongest assurance against the abuse and poor practice that have disfigured periods of our history." Were this but true. For the unwanted, battered, and homeless "in the community" means that they are now denied the one service that they ever really needed: shelter. Furthermore shooting people up with depot neuroleptics (misleadingly called antipsychotics) and not sticking around to watch them deteriorate helps blind psychiatrists and psychiatric nurses to the harm they do. Poisoning people and subsequently leaving them on their own and helpless in this condition is no less abuse and poor practice than what went on in the institutions of yore (and still goes on).
In the chapter exploring psychiatry's legitimacy Burns discusses some of its best-known critics, Foucault, Goffman, Szasz, and Laing. (There were and still are many others.) Although he heads this section "The rise of anti-psychiatry" he acknowledges that none of these critics considered themselves anti-psychiatrists, nor were they part of a coordinated movement, but rather each was highly individualistic. That's a refreshing improvement compared to other authors who sweep all of these names under the same carpet. Ten points for Burns. He credits them with "leaving a lasting legacy both within the profession and in our wider understanding of the human condition." He is least enamored of Szasz, although I am impressed that contrary to many other opponents of Szasz, Burns has actually read at least some of his books and made an honest attempt to understand his point of view. He states "I find him deliberately simplistic." That is true and Szasz was aware of it. He called it his "shorthand". Burns further finds fault with Szasz for rigidly adhering to the view that there can be no "real illness" in the absence of an identifiable physical cause. Here too Burns has a valid point. When we don't know the cause of a strange behavior, and we usually don't, it is just as wrong to assume the absence of a physical cause as it is to assume the presence of a physical cause. But then Burns pulls a fast one on us. He asks rhetorically "What would Szasz have made of the accumulating evidence of relative over- and under-activity of neurotransmitters in various psychiatric disorders?" We don't have to wonder, we know exactly what Szasz made of it. What do you make of the fact that no such evidence exists? There isn't even a method for determining the activity of neurotransmitters in human beings. Burns has already admitted in Chapter 1 that the only lab tests done in psychiatry are to monitor the effects of the chronic poisoning. The role of neurotransmitters is theory and conjecture, not fact, promoted by the pharmaceutical industries to justify selling their products. Burns then continues to criticize Scientologists for their controversial therapies as though Szasz were somehow responsible for them. Although Szasz agreed to lend his name to Scientology's offshoot Citizens' Commission on Human Rights, he was not a Scientologist and didn't believe in Scientology.
Next comes a chapter in which Burns attempts to expose some of what he considers the sins of psychiatry. He is to be commended for mentioning the T-4 program, albeit briefly. Most psychiatrists know nothing about it. Under the header "Psychotherapy oversteps the line" he states about certain non-mainstream therapies "Having submitted yourself to something that is gruelling and unpleasant there is a strong incentive to believe it works." Why would this be true for alternative psychotherapies and not for ECT?
In a chapter dealing with psychiatry and the law he makes some fair points. "[C]ourts want all the help they can get." The contribution of psychiatrists in perverting the course of justice is mentioned in a different chapter in the discussion of recovered memory syndrome, but could have been mentioned here too. Even if somebody really is crazy, that does not prove he committed the crime in question. "Psychiatry seems to be safer when it restricts itself to 'abnormalities' or differences that are obvious even to the layperson." In other words, lay people can judge that someone is crazy just as well. A very valid point regarding law he makes in a later chapter. "The wording in [compulsory treatment] legislation is convoluted and, frankly, rarely bears careful scrutiny." In other words, the content of coercion laws is irrelevant, as neither psychiatrists nor judges respect the safeguards for human rights. They don't have to. They aren't accountable to anybody.
We're nearing the end. The next chapter is "A diagnosis for everything." Most psychiatrists agree that the DSM, a thick catalog of diagnoses, goes over the top. But few campaign for abandoning it, and neither does Burns. He would be happy to shrink it. Like so many others authors in the field, he has his pet (non)diseases. "I have never come across a diagnosis of caffeine-induced insomnia." Burns would also like to see addictions and personality disorders tossed out, not because they don't exist but because the people who answer to these criteria are annoying and psychiatrists don't know how to deal with them. He's rather naive to imagine that abolishing categories from the DSM will change anything. Psychiatrists will simply resume labeling annoying people schizophrenic like they did before the DSM introduced special categories to accommodate them. And psychiatrists will continue drugging them into oblivion like they do everyone else. He continues "One in ten of ten-year-old boys in the USA ... is currently prescribed stimulants for ADHD. Now, wherever the threshold should lie ... this level surely cannot make sense." What should USA child-psychiatrists do, apply some sort of scale, and prescribe stimulants only to the top (or bottom) percentage that makes sense to Burns? If "One in ten cannot make clinical sense" then what doesn't make sense is the clinic (diagnosis and treatment).
The last chapter (except for a brief epilogue) is the apparently obligatory prediction of the future, which he calls "The rise of neuroscience." I will not fault the author for it as such chapters always contain nonsense -- nobody can predict the future. Thankfully he does have some very welcome news for us. "The main threat to psychiatry's survival may ... be ... a dramatic fall in the number of doctors choosing to go into it. ... Most doctors coming into psychiatry in [the USA and UK] are foreign graduates ... who are often disappointed by not being able to get surgical or medical jobs." I haven't noticed this influx of foreign graduates in the Netherlands but that could be because they don't speak Dutch. Nonetheless we too have a supposed shortage of psychiatrists. Perhaps fewer physicians are willing to spend their careers making and keeping people sick and disabled by poisoning them. If this shortage does herald the end of psychiatry, it is a terrible pity that it is taking so long.
Copyright © MeTZelf
on 30 August 2013
A one-star reviewer, who says he couldn't read this book, asks why anyone would want to. People forget, or perhaps are not fully aware, that the 20th century will go down as the Age of Psychiatry. That is enough of an answer to the one-star protester. I am a lay reader and a voracious one and 'Our Necessary Shadow' is one of the best books I have read over the past year, because it gives us such a clear perspective of this Age in which I grew up, and a framework within which we can delve deeper should we want to. When the psychologists and psychiatrists came into our lives they influenced everything for good and bad. The 20th century was the time people began really to talk to one another and to unburden themselves and to communicate in a way that was simply not done before, even by husband and wife. Psychologists also took hold of the whole consumer revolution of course, propelling it forward. And most important - which is the area Burns looks at so well - the psychiatrists began to look at mental patients with humanity. Asylums had been a cross between prisons and zoos, with 'patients' often chained in cells and on show to the fee-paying public; the asylums then became hospitals; and an ever clearer understanding of mental illness and its treatment released many who should never have been patients in the first place (imagine what their lives had been like!) back into the community; and ordinary people's attitudes changed too. The theories of Freud, Jung and others are ingrained into our language and into our culture now. It is essential that every so often a man like Burns comes forward and says, 'This is the state of play; this is where we are at with this psychiatry thing.' It is a question of books like this being necessary to our cultural evolution, how we perceive things and each other, that the insights of this science closest to the arts be apprehended and made ever more relevant to day-to-day life.
on 9 July 2013
I would highly recommend this book - it is very interesting, and very well-written - I started reading it and ended up staying awake to finish it. A clear and thought-provoking survey of the history of psychiatry, including its many errors, and the controversies facing it today.
on 4 March 2016
Great, and delivered quickly :-)
on 1 November 2013
Professor Tom Burns has received payments for lectures and consultancies from the pharmaceutical companies Eli Lilly and Janssen and Otsuka....like many psychiatrists who speak up on behalf of pills publicly, he does not report this conflict of interest. For evidence of this conflict see: [...]
Moving on, this so-called critique of psychiatry pretends to address the main problems facing psychiatry in the 21st century. It does not. What it actually does is further anaesthetize the psychiatric community to how perilous its situation is, insofar as psychiatry's very low outcomes are a result of the very 'treatments' it administers; treatments that research now suggests are compounding many patients' problems. This attempt at critique, offered by a member of the establishment, might mean a few more psychiatrists will nestle further into the status quo, but it won't help patients. Apart from a suggestion that there should be more therapy (his wife is a therapist), it does nothing other than actually maintain the current state of affairs in the name of critique. From the standpoint of the conventional psychiatrist it is`balanced' account, from the standpoint of any conscientious observer it is simply more of the same....more of the medical model, with its requisite drugs and diagnoses. Doesn't get my vote I'm afraid....