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Our Necessary Shadow: The Nature and Meaning of Psychiatry
The first attempt in forty years to explain the full subject of psychiatry, from one of the world’s experts. In what will be a tour de force in the field of psychiatry in all its complexity and depth, this important new volume explores the essential paradox of psychiatry―and offers a balanced understanding of its history and development in the medical world. Much is written about psychiatry, but very little that describes psychiatry itself. Why should there be such a need? For good or ill, psychiatry is a polemical battleground, criticized on the one hand as an instrument of social control, while on the other the latest developments in neuroscience are trumpeted as lasting solutions to mental illness.
Which of these strikingly contrasting positions should we believe? This is the first attempt in a generation to explain the whole subject of psychiatry. in this deeply thoughtful, descriptive, and sympathetic book, Tom Burns reviews the historical development of psychiatry, throughout alert to where psychiatry helps, and where it is imperfect. What is clear is that mental illnesses are intimately tied to what makes us human in the first place. and the drive to relieve the suffering they cause is even more human.
Psychiatry, for all its flaws, currently represents our best attempt to discharge this most human of impulses. it is not something we can just ignore. it is our necessary shadow.
Which of these strikingly contrasting positions should we believe? This is the first attempt in a generation to explain the whole subject of psychiatry. in this deeply thoughtful, descriptive, and sympathetic book, Tom Burns reviews the historical development of psychiatry, throughout alert to where psychiatry helps, and where it is imperfect. What is clear is that mental illnesses are intimately tied to what makes us human in the first place. and the drive to relieve the suffering they cause is even more human.
Psychiatry, for all its flaws, currently represents our best attempt to discharge this most human of impulses. it is not something we can just ignore. it is our necessary shadow.
384 pages, Hardcover
First published June 6, 2013
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March 7, 2023
Our Necessary Shadow: The Nature and Meaning of Psychiatry is a history of psychiatry, a discussion of important issues in the field at the time of initial publication in 2013, and a professional memoir. In the introduction, Burns clearly sets out his intentions for the book. It is deliberately partial, based on his personal views after decades of professional experience, rather than trying to present a neutral synopsis. I appreciated this being stated up front. The writing style is accessible rather than academic; a selected bibliography is included rather than footnotes. I found it a very thought-provoking examination of mental illness and its treatment by doctors.
Initial chapters concern the historical origins of psychiatry, including the rise and fall of institutionalisation and of psychoanalysis. Burns does not hesitate to acknowledge the terrible cruelties perpetrated in the name of mental healthcare over the centuries, with particular reference to enabling mass murder of the mentally ill in Nazi Germany. For me the most informative part of this historical context concerned military psychiatry, which began during the First World War and adapted to the differing conditions in WWII and the Vietnam War. Another chapter that was particularly new to me concerned the interplay between psychiatry and the legal system. The effects of a shift to criteria-based diagnosis were also striking to discover.
The latter half of the book deals with contemporary issues for psychiatry, providing a perspective on mental health and illness that I haven't really come across before. As Burns mentions early on, most books by psychiatrists are intended for academic audiences or as self-help. This one attempts more of a demystification, while not downplaying the range of complexities, unknowns, and ambiguities inherent in the field. I was struck by how Burns defined mental illness as, 'individuals have become different from their 'normal' selves in some fairly recognisable way'. To my surprise, this doesn't mention distress or suffering. There is a strong tension between such a definition and the range of conditions routinely diagnosed by psychiatrists that aren't impermanent: autism, ADHD, and personality disorders. Burns discusses the latter particularly candidly:
Although popular discussion of mental health has moved on since Our Necessary Shadow: The Nature and Meaning of Psychiatry was first published a decade ago, it remains highly relevant. Burns mentions an NHS shortage of psychiatrists, which evidently continues. As far as I can tell, these days GPs do not refer anyone but the highest risk cases to a psychiatrist, instead offering medication, online CBT, and/or waiting lists for counselling to those presenting with mental health problems. Burns' musings on the future of psychiatry remain relevant and thought-provoking. The only parts to age notably badly are his comments on Chronic Fatigue Syndrome, which seem short-sighted in the era of Long Covid. Throughout, Burns argues that psychiatry has been justly critiqued, but is still valuable for its alleviation of mental suffering. He claims it is unique within medicine, yet states it should not be judged more harshly than other specialisms. I found his writing insightful throughout, whether I agreed with him or not. Our Necessary Shadow: The Nature and Meaning of Psychiatry provides a valuable perspective on psychiatry then and now.
Initial chapters concern the historical origins of psychiatry, including the rise and fall of institutionalisation and of psychoanalysis. Burns does not hesitate to acknowledge the terrible cruelties perpetrated in the name of mental healthcare over the centuries, with particular reference to enabling mass murder of the mentally ill in Nazi Germany. For me the most informative part of this historical context concerned military psychiatry, which began during the First World War and adapted to the differing conditions in WWII and the Vietnam War. Another chapter that was particularly new to me concerned the interplay between psychiatry and the legal system. The effects of a shift to criteria-based diagnosis were also striking to discover.
The latter half of the book deals with contemporary issues for psychiatry, providing a perspective on mental health and illness that I haven't really come across before. As Burns mentions early on, most books by psychiatrists are intended for academic audiences or as self-help. This one attempts more of a demystification, while not downplaying the range of complexities, unknowns, and ambiguities inherent in the field. I was struck by how Burns defined mental illness as, 'individuals have become different from their 'normal' selves in some fairly recognisable way'. To my surprise, this doesn't mention distress or suffering. There is a strong tension between such a definition and the range of conditions routinely diagnosed by psychiatrists that aren't impermanent: autism, ADHD, and personality disorders. Burns discusses the latter particularly candidly:
But are personality disorders the same as mental illnesses? Is it proper to diagnose them? Does treatment work, and is there ever justification for compulsory treatment? In practise these questions only arise with the disruptive personality disorders. These are antisocial or psychopathic personality in men, which is associated with violence, and borderline personality in women, which is associated with self-harm. Both are regularly complicated by alcohol and drug misuse or by depression or anxiety so regularly come to psychiatrists. Most psychiatrists are reluctant to treat people compulsorily whose only diagnosis is personality disorder. Despite the claims of some enthusiasts, no-one really knows what to do for these very troublesome individuals, although governments and prisons are keen that we do so.
Psychiatrists are reluctant to treat people with personality disorders compulsorily for two reasons. First it seems illogical. We override personal autonomy in compulsory treatment on the grounds that someone is 'not their normal self', but a personality is the normal self, even if an unusual and distressed one. Second there is very little evidence that any of our treatments work, certainly no evidence that they work to change the personality itself.
Although popular discussion of mental health has moved on since Our Necessary Shadow: The Nature and Meaning of Psychiatry was first published a decade ago, it remains highly relevant. Burns mentions an NHS shortage of psychiatrists, which evidently continues. As far as I can tell, these days GPs do not refer anyone but the highest risk cases to a psychiatrist, instead offering medication, online CBT, and/or waiting lists for counselling to those presenting with mental health problems. Burns' musings on the future of psychiatry remain relevant and thought-provoking. The only parts to age notably badly are his comments on Chronic Fatigue Syndrome, which seem short-sighted in the era of Long Covid. Throughout, Burns argues that psychiatry has been justly critiqued, but is still valuable for its alleviation of mental suffering. He claims it is unique within medicine, yet states it should not be judged more harshly than other specialisms. I found his writing insightful throughout, whether I agreed with him or not. Our Necessary Shadow: The Nature and Meaning of Psychiatry provides a valuable perspective on psychiatry then and now.
July 21, 2018
A great book with powerful insights into life as a psychiatrist in the modern world. Tom states a very valid point about the state of psychiatry in the western world, informs the reader of its prominent rise into the sciences and its controversial history. He also describes what to expect if you are reading this book hoping to find some guidance when seeking psychiatric intervention and I was left feeling warmth, compassion and authenticity from his reasoning and personal accounts. This book is definetly not something you want to pick up if you fancy a humorous read, it's a very serious book with the point of explaining the current state of psychiatry from the perspective of a very respected professional in the field. It is in many ways I feel, a call to redefine psychiatry as a helping profession as apposed to a cure-all profession, or at least, that's the message I got from this book. Tom's realism, honesty and integrity shines through in this book and you kinda hope he's the psych you see if it all goes wrong! Seems like such a lovely guy! Good book!
July 7, 2014
A comprehensive, yet concise, and balanced summary of psychiatric/psychological history and development that highlights both the triumphs and pitfalls of the science.
June 18, 2021
The British Psychiatrist Tom Burns is a Professor Emerita of Social Psychiatry at the University of Oxford in the United Kingdom. I have taken a lot of courses on the social side of disabilities. I have not taken psychiatry courses so I read Tom Burns' 2014 book, Our Necessary Shadow: The Nature and Meaning of Psychiatry, to gain an introduction to psychiatry. I am glad I picked Burns’ book as an introduction to psychiatry. The book gives definitions of the field of psychiatry and of “mental illness” (xxix) in the “Introduction” (xi). The first section of the book is entitled, “What to expect if you are referred to a psychiatrist” (1). The second section provides a history of psychiatry as a medical field mainly in Western Europe and the United States. The last section is on topics and controversies in medical psychiatry in the early 21st Century. One of the interesting parts of the book I found was the history of community care in Italy, which had a different model of community care than in the United States or the United Kingdom (148-149). I felt like Burns’ was a very well-done introduction to the field of psychiatry in the United Kingdom and the United States in the early 21st Century.
May 7, 2022
A disappointing account, skims over the surface of real debate by caricaturing opposing views in order to make his own perspective seem much more simple and natural than it in fact is.
He talks about the reality of mental illness, but this is only meant relative to psychiatry as a means for psychiatrists to have "justified" power over other people. People are portrayed as victims of their illness, needing help from a medical industry they can trust, in a way that rings extremely hollow and disingenuous. He suggests that psychiatry will fight against and deal with big pharma, but I will believe that when I see it, not when a psychiatrist tells me to see it.
He paints a completely false picture of the past of people wholesale already having had their "rebellion" stage against psychiatry and needing to come back to it, by imagining that figures who were outcasts in their time, somehow represented the mainstream perspective of that time, such as figures like Foucault and Laing.
There perspectives may have now come to be accepted by more people and this may be difficult for those who want to enforce a psychiatric model on people, but there is no going back to old models of trust in psychiatric institutions. I suppose this book shows its age quickly due to how massively things have changed in our whole assessment of society since 2016. A dying call for the liberal consensus to return and be imposed on people that is simply going to fall on death ears, in an era when more and more people are finding alternate ways to embrace their "divergent" identities without running back to the safety of institutional care.
The only interesting part about this book is the title, but the actual book does not explore in any real or insightful way the notion of the shadow in our psyche, it reads as a politically motivated book by a psychiatry and institutional elite insider.
He talks about the reality of mental illness, but this is only meant relative to psychiatry as a means for psychiatrists to have "justified" power over other people. People are portrayed as victims of their illness, needing help from a medical industry they can trust, in a way that rings extremely hollow and disingenuous. He suggests that psychiatry will fight against and deal with big pharma, but I will believe that when I see it, not when a psychiatrist tells me to see it.
He paints a completely false picture of the past of people wholesale already having had their "rebellion" stage against psychiatry and needing to come back to it, by imagining that figures who were outcasts in their time, somehow represented the mainstream perspective of that time, such as figures like Foucault and Laing.
There perspectives may have now come to be accepted by more people and this may be difficult for those who want to enforce a psychiatric model on people, but there is no going back to old models of trust in psychiatric institutions. I suppose this book shows its age quickly due to how massively things have changed in our whole assessment of society since 2016. A dying call for the liberal consensus to return and be imposed on people that is simply going to fall on death ears, in an era when more and more people are finding alternate ways to embrace their "divergent" identities without running back to the safety of institutional care.
The only interesting part about this book is the title, but the actual book does not explore in any real or insightful way the notion of the shadow in our psyche, it reads as a politically motivated book by a psychiatry and institutional elite insider.
December 7, 2013
Interesting. A good overview of the field.
July 23, 2014
Excellent and highly readable.
December 27, 2019
One of the books that made me want to study medicine.
October 15, 2020
This is a must-read if you're working in or interested in Psychiatry. I also recommend it if you're an inquisitive sort, like history and are curious about mental illness and health.
I read it after 'Shrinks: the untold history of psychiatry' (https://www.goodreads.com/book/show/2...) as preparation for my imminent fellowship exam.
But I wish I'd come across it earlier. I felt a sense of contentment suffuse me as I realised he was exploring questions about humanity, human nature, our quest to understand it and serve it - the search for answers which had driven me to join Psychiatry in the first place. Aside from the depth and breadth of landscape traversed, it was also a pleasure to read the book's elegance of written expression.
The first part covering the fascinating history of psychiatry has left me with a contextualised sense of our era of practice, realising how young models of practice I've been 'raised in' are. It was interesting noting how two different authors approached this, with each book giving varied limelight to alternative parts of Psychiatry's history (of which I found this one more rounded). Observing the evolution of Psychiatry from the prevailing practices of our predecessors, leaves me wondering about the paradigms we proclaim today. The second part of the book is where Prof Burns delves into these more philosophical and pragmatic mysteries. He didn't resolve them for me as I was initially hoping - I'm left with more questions than when I started but they're more defined and nuanced now.
In our epoch where any illness can (should?) be elucidated 'biopsychosocioculturally' how do you distinguish a 'mental' illness? When does suffering become pathological? How does a transmuting self and self-control feature in its definition (e.g. Depression vs. OCD vs. Addiction)? Is the province of Psychiatry really bounded by mental illness or do we aspire towards 'wellness'? Contemporary Psychiatry treats people with 'mental disorders', where the appreciable illness has crossed the threshold into significant distress and dysfunction. Yet I wanted to have a dialogue or debate with Prof Burns on many of the positions he takes e.g. on military psychiatry, ADHD, whether substance use and personality disorders are mental illnesses, the 'medicalization of everyday life'. I found myself tempted towards rating a 4.5 due to being cognizant that lay readers might just accept these stances, rather than recognise the heterogeneity of the research literature and alternative conceptualisations. However, the refreshing thing about this book (and part of the reason why I found it more sophisticated than 'Shrinks') is his candour, with the disclaimer at the outset and littered throughout encouraging readers to investigate for themselves.
At the same time, points of contention contributed to lingering ambiguities and complexities, which serve as gauntlets thrown down for all of us involved in creating contemporary and prospective Psychiatry. There are some questions, which he cogently illustrates may never be answered, and yet I feel more inspired than ever to try.
I read it after 'Shrinks: the untold history of psychiatry' (https://www.goodreads.com/book/show/2...) as preparation for my imminent fellowship exam.
But I wish I'd come across it earlier. I felt a sense of contentment suffuse me as I realised he was exploring questions about humanity, human nature, our quest to understand it and serve it - the search for answers which had driven me to join Psychiatry in the first place. Aside from the depth and breadth of landscape traversed, it was also a pleasure to read the book's elegance of written expression.
The first part covering the fascinating history of psychiatry has left me with a contextualised sense of our era of practice, realising how young models of practice I've been 'raised in' are. It was interesting noting how two different authors approached this, with each book giving varied limelight to alternative parts of Psychiatry's history (of which I found this one more rounded). Observing the evolution of Psychiatry from the prevailing practices of our predecessors, leaves me wondering about the paradigms we proclaim today. The second part of the book is where Prof Burns delves into these more philosophical and pragmatic mysteries. He didn't resolve them for me as I was initially hoping - I'm left with more questions than when I started but they're more defined and nuanced now.
In our epoch where any illness can (should?) be elucidated 'biopsychosocioculturally' how do you distinguish a 'mental' illness? When does suffering become pathological? How does a transmuting self and self-control feature in its definition (e.g. Depression vs. OCD vs. Addiction)? Is the province of Psychiatry really bounded by mental illness or do we aspire towards 'wellness'? Contemporary Psychiatry treats people with 'mental disorders', where the appreciable illness has crossed the threshold into significant distress and dysfunction. Yet I wanted to have a dialogue or debate with Prof Burns on many of the positions he takes e.g. on military psychiatry, ADHD, whether substance use and personality disorders are mental illnesses, the 'medicalization of everyday life'. I found myself tempted towards rating a 4.5 due to being cognizant that lay readers might just accept these stances, rather than recognise the heterogeneity of the research literature and alternative conceptualisations. However, the refreshing thing about this book (and part of the reason why I found it more sophisticated than 'Shrinks') is his candour, with the disclaimer at the outset and littered throughout encouraging readers to investigate for themselves.
At the same time, points of contention contributed to lingering ambiguities and complexities, which serve as gauntlets thrown down for all of us involved in creating contemporary and prospective Psychiatry. There are some questions, which he cogently illustrates may never be answered, and yet I feel more inspired than ever to try.
May 11, 2022
My friend is a psychiatrist so I thought reading this book might give me some insights, which it did. The first half of the book is a history of psychiatry, which I loved. I'd give it 5 stars easily. I thought the history of mental hospitals (asylums) and the closing of them was illuminating. It was strange how in the past people deemed mentally ill had the right to free room and board and medical care (this was before there was any kind of social safety net) but now they often live on the street (and this is supposed to be a huge improvement). I also thought the trend first to psychoanalysis and then from "talking therapy" to medical psychiatry was fascinating. The second half of the book ("The questions psychiatry asks about us and the questions we ask of it") was more like 4 stars for me. Yes, the questions are really interesting, but Part Two of the book felt a lot like a British psychiatrist's musings on philosophical subjects. For questions like, "Are we over-medicating young boys so they fit into school settings?", I'd like to see more science and less opinions of one (admittedly very thoughtful) man. Also, while the author seems very knowledgeable of the U.S. health system, and tries to cover it well, it is not central to the book. That's not a bad thing, but less useful to me. The author states in the introduction, "I worry that I may have devoted too much of this book to psychiatry's mistakes and controversies". I concur, but I agree with him that it was a good idea in the sense that although modern psychiatry tries to make their medical view akin to other diseases, there is a huge perceived difference between a broken bone and the various mental illnesses. Also, a lot of these controversies, like closing the asylums, have direct impact on our personal lives.
March 10, 2025
Having personally met with the author I can honestly say that I feel that he is an embarrassment to the medical profession he is incompetent, negligent , rude and haughty.
His views are outdated and he is out of touch with patients needs and requirements so much so he comes across abstractly psychotic in his views on mental health.
Sadly despite his many publications and qualifications and years of experience in psychiatry he is a good example of why the NHS mental health system is so dysfunctional and broken in England.
As a person he is a callous presumptuous man and a danger to service users who would do best to avoid him at all costs .
This book isn't worth the paper its printed on and I entirely agree with the other gentlemen who left a 1 star review for this book in his views on the matters he mentioned. this book isn't even worth 1 star to be frank
His views are outdated and he is out of touch with patients needs and requirements so much so he comes across abstractly psychotic in his views on mental health.
Sadly despite his many publications and qualifications and years of experience in psychiatry he is a good example of why the NHS mental health system is so dysfunctional and broken in England.
As a person he is a callous presumptuous man and a danger to service users who would do best to avoid him at all costs .
This book isn't worth the paper its printed on and I entirely agree with the other gentlemen who left a 1 star review for this book in his views on the matters he mentioned. this book isn't even worth 1 star to be frank
November 26, 2020
Great book on psychiatry - captures everything that psychiatry should be about. The reason I only give it four stars is this - I greatly liked the argument Burns makes in his Very Short Introduction to Psychiatry. I picked up this book looking for more, but I didn't find it added much. The historical account which makes up the rest of the book is one I personally have read about five times over recently so it wasn't that riveting. However, he's got a great empathy for the patient and understanding of the tensions in psychiatry. He suggests psychiatrists have got to face these tensions, not hide behind doctorly omnipotence and drugs.
April 18, 2023
I learned a lot from this book, which means I should at least give it a 3.5, I suppose.
Burns does a lot in a little amount of space: explicate both the Christian and Enlightenment roots of psychiatry, tangle in the weeds of all manner of hot-button psychiatric debates still ongoing, explain what might happen if you do schedule a visit with a psychiatrist. Burns does a fairly good apologia of his profession and does not play down its abuses and faults.
Still, I left the book wanting. The writing is terse and clinical, which makes sense for his purpose but does not fit his subject matter which concerns all the highs and lows, nooks and crannies of human experience.
Burns does a lot in a little amount of space: explicate both the Christian and Enlightenment roots of psychiatry, tangle in the weeds of all manner of hot-button psychiatric debates still ongoing, explain what might happen if you do schedule a visit with a psychiatrist. Burns does a fairly good apologia of his profession and does not play down its abuses and faults.
Still, I left the book wanting. The writing is terse and clinical, which makes sense for his purpose but does not fit his subject matter which concerns all the highs and lows, nooks and crannies of human experience.
will-never-read
February 12, 2024i checked this out at the library and read a couple pages and i really loved it but i just don't think i'll end up checking it out again. if i do, i know i will be pleasantly surprised, but i am indifferent to any other outcome.
March 11, 2025
Utter tripe , I suppose it could have a use as emergency toilet paper though if you run out so its worth 1 star
August 19, 2014
2.75 stars. I became bored in the middle of this book, and so skimmed a lot of that. The end was more interesting to me, as was the beginning. The title about says it all as far as the author's premise.
Quotes I liked:
page 217: If we accept that people's personalities are the result of neglect or early abuse, how fair is it to hold them responsible for their actions? Should a court consider these early experiences when sentencing; in short how much allowance can be made for an individual's personality? In the end the courts and all of us have to strike a balance. People have to be held accountable for their actions; otherwise civil society is simply unworkable. However, sometimes it is glaringly obvious that this person or that person is so very different that some allowance just has to be made. Psychiatry would be entering dangerous territory here if it suggested that human behaviour is entirely determined or predictable. Psychiatry does not insist that certain classes of individuals must be exempt from the legal process. It is not the case that psychiatry pushes itself forward to plead for these troubled individuals; most psychiatrists feel relatively unsure in this arena. It is more that the courts want all the help they can get.
page 267: USA ethicists and lawyers despair at the intrusiveness and paternalism of European psychiatrists. European ethicists and psychiatrists in their tun despair at perceived clinical neglect justified as respect for autonomy - 'dying with your rights on'.
page 270: By the time this book is published my own RCT of CTOs will be published. We have randomized over 300 patients and followed them up for a year. There is absolutely no effect. The CTOs neither reduce relapse and readmission to hospital, nor appear to confer any real benefits in terms of symptoms or general wellbeing. So three studies have failed to find an advantage, despite substantial curtailment of patients' liberties. A salutary experience for me as I have been a strong advocate for twenty years. But I was clearly wrong. Will practice change dramatically in the light of these results? I think it should (otherwise why spend years doing the research?) but I doubt if it will...we cannot continue to insist that coercion in the community reduces relapse and readmission. [CTO = Community Treatment Orders; RCT = randomized controlled trial]
page 273: The luxury we do not have is to declare ourselves unsatisfied with current thinking and to tell our patients to go away and come back some years hence when we have the answers.
pages 278-9: Almost invariably the model put forward for the mind as brain is some form of analogy with computers. If we are no more than a computer that processes inputs according to a series of set algorithms, then where do choice and responsibility lie? How can we hold people morally accountable for their behaviour? Each new psychological experiment conducted within this paradigm confirms our predictability. Yet somehow this just does not fit with how we understand ourselves, nor with how we conduct our lives. As human beings we seem to have to believe in our own free will, otherwise everything...becomes impossible. Even faiths based on predetermination or fate hold their members personally accountable for their day-to-day behaviour.
Quotes I liked:
page 217: If we accept that people's personalities are the result of neglect or early abuse, how fair is it to hold them responsible for their actions? Should a court consider these early experiences when sentencing; in short how much allowance can be made for an individual's personality? In the end the courts and all of us have to strike a balance. People have to be held accountable for their actions; otherwise civil society is simply unworkable. However, sometimes it is glaringly obvious that this person or that person is so very different that some allowance just has to be made. Psychiatry would be entering dangerous territory here if it suggested that human behaviour is entirely determined or predictable. Psychiatry does not insist that certain classes of individuals must be exempt from the legal process. It is not the case that psychiatry pushes itself forward to plead for these troubled individuals; most psychiatrists feel relatively unsure in this arena. It is more that the courts want all the help they can get.
page 267: USA ethicists and lawyers despair at the intrusiveness and paternalism of European psychiatrists. European ethicists and psychiatrists in their tun despair at perceived clinical neglect justified as respect for autonomy - 'dying with your rights on'.
page 270: By the time this book is published my own RCT of CTOs will be published. We have randomized over 300 patients and followed them up for a year. There is absolutely no effect. The CTOs neither reduce relapse and readmission to hospital, nor appear to confer any real benefits in terms of symptoms or general wellbeing. So three studies have failed to find an advantage, despite substantial curtailment of patients' liberties. A salutary experience for me as I have been a strong advocate for twenty years. But I was clearly wrong. Will practice change dramatically in the light of these results? I think it should (otherwise why spend years doing the research?) but I doubt if it will...we cannot continue to insist that coercion in the community reduces relapse and readmission. [CTO = Community Treatment Orders; RCT = randomized controlled trial]
page 273: The luxury we do not have is to declare ourselves unsatisfied with current thinking and to tell our patients to go away and come back some years hence when we have the answers.
pages 278-9: Almost invariably the model put forward for the mind as brain is some form of analogy with computers. If we are no more than a computer that processes inputs according to a series of set algorithms, then where do choice and responsibility lie? How can we hold people morally accountable for their behaviour? Each new psychological experiment conducted within this paradigm confirms our predictability. Yet somehow this just does not fit with how we understand ourselves, nor with how we conduct our lives. As human beings we seem to have to believe in our own free will, otherwise everything...becomes impossible. Even faiths based on predetermination or fate hold their members personally accountable for their day-to-day behaviour.
December 29, 2015
I read this book as a counter weight to Richard Bentall's 'Doctoring the Mind', which Burns references several times himself as a counterpoint. I must admit, even though Burns' observations about the necessary limitations of psychiatric theory given the age of the discipline did somewhat mitigate the effect of Bentall's excoriating critique, I still thought that Bentall gets the better of this exchange. The major conceptual problems he identifies (defining mental illness, finding a uniting paradigm to discuss mental illness, etc) are left more or less untouched by Burns, who seeks instead to defend the record of psychiatric practice historically rather than philosophically.
This defence of the historical conduct of psychiatrists does little to assuage the conceptual discomfort that must attend the reading of Bentall's work: amongst other claims, he alleges that patients with identified psychiatric illnesses typically recover at much higher rates in developing countries in which no treatment is available, because the medications prescribed in the west and the treatment regimes used are at best ineffective and at worst counter-productive, that the basic conceptual building blocks of psychiatric diagnosis (i.e. the defined psychiatric conditions) are hopelessly out of date, based on observations of mental patients made more than 100 years ago, and ignoring significant evidence of overlap between conditions, but also that the symptoms of said conditions are in fact widely distributed in the more general population. Thus, Bentall claims that it may be the case that what psychiatrists identify as mental illnesses are collections of psychological characteristics which occur in isolation in the wider population, existing in groups in those with psychiatric illnesses. He also argues that the rate of diagnostic agreement between psychiatrists is so low that it is very difficult to believe that psychiatric illnesses are accurately identified, even if one grants that they exist as defined at present. Most pressingly, Bentall draws attention to the complete lack of any detailed explanatory framework which would make psychiatric diagnoses make sense; there is no theory with which psychiatric illness can be described or explained in global terms, no posited account of what has gone wrong, in broad terms, when someone is mentally ill.
Burns does not really address these fundamental issues, instead he meekly insists that psychiatry is a relatively new branch of medicine, and it is simply proceeding to use the treatments that, through trial and error, it has found to work, without having developed any governing theory as yet. If Bentall's claims about treatment in developing countries (or the lack thereof) are correct, this is a less than convincing defence.
This defence of the historical conduct of psychiatrists does little to assuage the conceptual discomfort that must attend the reading of Bentall's work: amongst other claims, he alleges that patients with identified psychiatric illnesses typically recover at much higher rates in developing countries in which no treatment is available, because the medications prescribed in the west and the treatment regimes used are at best ineffective and at worst counter-productive, that the basic conceptual building blocks of psychiatric diagnosis (i.e. the defined psychiatric conditions) are hopelessly out of date, based on observations of mental patients made more than 100 years ago, and ignoring significant evidence of overlap between conditions, but also that the symptoms of said conditions are in fact widely distributed in the more general population. Thus, Bentall claims that it may be the case that what psychiatrists identify as mental illnesses are collections of psychological characteristics which occur in isolation in the wider population, existing in groups in those with psychiatric illnesses. He also argues that the rate of diagnostic agreement between psychiatrists is so low that it is very difficult to believe that psychiatric illnesses are accurately identified, even if one grants that they exist as defined at present. Most pressingly, Bentall draws attention to the complete lack of any detailed explanatory framework which would make psychiatric diagnoses make sense; there is no theory with which psychiatric illness can be described or explained in global terms, no posited account of what has gone wrong, in broad terms, when someone is mentally ill.
Burns does not really address these fundamental issues, instead he meekly insists that psychiatry is a relatively new branch of medicine, and it is simply proceeding to use the treatments that, through trial and error, it has found to work, without having developed any governing theory as yet. If Bentall's claims about treatment in developing countries (or the lack thereof) are correct, this is a less than convincing defence.
February 21, 2015
cool title, ok book. Sort of a once-over-lightly of historical and contemporary issues for the field. Didn't seem to do any original scholarship. I agreed with most of his opinions so in that sense it was an easy enough journey through the chapters, but if you're familiar with mental health care at all I'm not sure how much new you would learn.
ECT scares people but has its place for severe treatment-resistant depression. Some believe ADHD is overdiagnosed these days. Insanity defense is complicated. That neuroscience is awfully big these days. Etc. etc. etc.
He comes across as a good and wise clinician himself and I guess wanted to cap his career with an exposition of his take on most major topics in his profession. If you're very interested in any one of these issues, though, probably other sources would be preferable.
ECT scares people but has its place for severe treatment-resistant depression. Some believe ADHD is overdiagnosed these days. Insanity defense is complicated. That neuroscience is awfully big these days. Etc. etc. etc.
He comes across as a good and wise clinician himself and I guess wanted to cap his career with an exposition of his take on most major topics in his profession. If you're very interested in any one of these issues, though, probably other sources would be preferable.
October 7, 2016
I loved every page of this fascinating case for Psychiatry, from the sweeping history of Anton Mesmer's hypnotic shows through the foreboding city-size asylums of Long Island and right through to fMRI neuroscience. Charcot, Janet. Freud and Jung get irresistable mini-bios. The author doesn't hold back on a worts 'n all exposure of the science and its relation to psychology and psychotherapy. Big Pharma and the global spread of the US diagnostic model via DSM IV and V are all here. As is the influence of media from movies and books. Tom Burns psychoanalyses psychiatry in these pages. There's nowhere to hide. A considered, enlightening and courageous yet sensitive review of an old and controversial craft, where the author always declares his position and opinion.
I have a paperback copy going spare, if you want it.
I have a paperback copy going spare, if you want it.
triedtoread
December 29, 2014I was enjoying this, and it made a nice counterpart to the books I read last year about how psychiatry is "de-normalizing" us. It's due back at the library though and I'm surrounded by fiction I'd rather read.
August 12, 2015
Didn't read the whole book, but this seems like a very good overview of psychiatry in general. It would be a good book for someone considering majoring in psychology who wants to understand what psychiatrists do.
December 28, 2024
A fantastic overview of the psychiatric system in the UK. Tom Burns writes with compassion and nuance sharing both the strengths and limitations of the psychiatric system. This is a necessary read for anyone wanting to understand the mental health system in the UK.
December 16, 2014
Actually 2.5
December 31, 2015
A very lucid introduction to this most misunderstood field...
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