‘Psychiatry is an irregular-shaped human endeavour’ says Tom Burns at the beginning of his book, which examines the profession's place in the modern world. His compelling and far-reaching effort certainly has many angles and makes no attempt to gloss over the many imperfections that characterise the profession and its history. Burns reckons many hundreds of books about aspects of psychiatry are published but that very few of them consider the professional endeavour as a whole; he cites David Stafford Clark's 1951, Psychiatry Today and Anthony Clare's 1976, Psychiatry in Dissent as worthy predecessors. It is a pity that its publication coincided with that of DSM-5, and has thus been lumped, to some extent, with the many recent critiques of that endeavour; this book offers so much more.

The first chapter of the book is entitled ‘What To Expect If You Are Referred to a Psychiatrist’. Here Burns gives a useful account of the types of things a psychiatrist might be interested in as well as providing a good deal of his own opinions on the process. For example, he thinks that psychiatrists should conduct all initial assessments and argues that the ‘medical model’ should be thought of as extending far beyond diagnosing and prescribing medicines. He also reveals that he does not continue to see people with severe personality disorders ‘even if they value it and want it’ on grounds that it is misleading with regard to what psychiatry can offer. One of the primary pleasures of the book for me was these forthright opinions, some of which I strongly disagreed with, setalongside his impressive grasp of the history, philosophy and place in modern society of psychiatry.

The bulk of the book is devoted to the history of the profession, from ancient times, through the asylum era, psychoanalysis and into the modern era. Burns has an excellent grasp of his material, particularly psychoanalysis, war psychiatry, misogyny in the profession and the move to community care. He considers that the work of Mesmer and de Puységur constituted a ‘paradigm shift’ (notwithstanding that their work was based on pseudoscientific theories), in that they removed supernatural beliefs from the process of dealing with neuroticism, which he believes paved the way to the discovery of the unconscious. Interestingly, Burns includes some of psychotherapy's excesses, such as Janov's primal scream therapy and recovered memory therapies, alongside the more egregious historical scandals of psychiatry such as Henry Cotton, Walter Freeman and the profession's shameful facilitation of Nazi goals. He devotes some time to the achievements of Wilfred Bion, Michael Foulkes and Tom Main and has a tendency throughout to be more positive about British psychiatry: ‘The French, like most continental Europeans, admire intellectual sophistication for its own sake’. Thomas Szasz is described as having been ‘deliberately simplistic and slippery’ while R.D. Laing had ‘a remarkable facility for engaging with profoundly disturbed, psychotic individuals’.

Burns goes on in the second half of the book to consider many of the dilemmas facing psychiatry today. He readily dismisses past psychiatric treatments and theories as ‘hocus pocus’, but is rather less inclined to do the same for some of their modern variants: ‘Undoubtedly too many antidepressants and tranquilisers are prescribed, but is this too high a price to pay for ready access to effective treatments?’ Over-diagnosis and over-treatment and their relationship to DSM-3 and its successors are rather softly criticised, as are the roles that psychiatrists have taken on in the courts. He bemoans the medicalisation of everyday life but sees this as extending way beyond psychiatry. Controversially, Burns sees little role for psychiatrists in the treatment of addictions and regards society's approach to smoking cessation as a more appropriate model. Bravely he states his view that chronic fatigue syndrome is akin to a dissociative disorder. ‘Role blurring’ is held partly responsible for recruitment difficulties in psychiatry. Burns is firmly against Community Treatment Orders and he cites his own research in support of his view. He is gloomy about the prospective impact of developments in neuroscience on what psychiatrists do. He even allows himself to mourn the loss of psychiatric hospitals where the ‘slower pace… allowed for more reflection, the necessary time for a more detailed examination of complex problems. Time also to develop and respect relationships and to appreciate the place of illness in each patient's personal narrative rather than a technological focus on fragmented episodes of care’. In fairness though, he catches himself, and acknowledges the awful experiences that many patients had in asylums.

This is a passionate, ambitious and deeply impressive book. Tom Burns has a nice clear writing style and he has managed to cover a vast amount without being dull or over-inclusive. There is an excellent glossary and index. It is very opinionated and no psychiatrist will agree with all of it, but that is also its great strength. At a time when most writing in psychiatry is partisan, highly specialised and narrowly focused, it is refreshing to read such a thoughtful, wide reaching, broad minded and earnest book. I thoroughly recommend this book to all psychiatrists and anyone else interested in psychiatry.