Now, Shem (and the pseudonym's understandable, if not forgiveable) takes on the psychiatric establishment. Anybody who has worked in psychiatry, anywhere in the world, will find elements of truth in Mount Misery, and anyone who has fought against a lot of the stupidity and dogma portrayed so starkly in this book and carried on regardless, will find that the novel's central ethos, expressed particularly in the last few chapters, will get right up his or her nose. Shem tackles various theoretical viewpoints, artfully portrayed as the hero, Dr Roy Basch, whom many of us encountered in the first book, rotates through different placements in his first year as a psychiatric resident (equivalent in most respects to the senior house officer or SHO grade in Britain). The author systematically and vividly rips apart the thinking underlying the blind adherence of so many psychiatrists to two of the most pervasive doctrines, namely the psychodynamic (broadly, Freudian) and phenomenological (mainstream or Diagnostic and Statistical Manual (DSM)). He concludes that effective psychiatry consists of 'connecting' with the patient in a way that he leaves relatively undefined.

The strengths of this novel are its hilarious portrayal of modern psychiatric practice and its showing up of much psychotherapy as based on empirically dubious thinking, with the accompanying defensiveness and resistance to criticism that most of us have encountered in Freudian dogmatists. Pigeonholing people with regard to diagnosis and pig-headedly sticking to treatment protocols in books are obviously idiotic strategies. Where Mount Misery falls down, however, is in its acceptance of the ideology it seeks to refute, namely that 'mental illness' is a unitary term. Shem skirts over the subject of schizophrenia, and psychosis in general, briefly portraying a ward of people who are locked away and doped up with medication, and thereby ignores a group of patients who, according to the weight of current scientific evidence, have a serious neurological/psychiatric illness which does NOT respond to 'connection' alone (and I speak as a psychiatrist myself). Agreed, the medications available at present aren't perfect, and have potential side effects. So do the drugs for cancer, hypertension and arthritis. But in an imperfect world, they're the best we've got, and can alleviate the symptoms of conditions that cause untold misery to millions of people.

I recommend this novel as a work of art in itself, and as a caution to anyone who enters psychiatry (or is currently practising) with the view that the complexities of human thought, feeling and behaviour can be reduced to a menu in a textbook; but I'd warn against taking the book's own dogma as gospel, coming as it does from a doctor with his own experiences, prejudices and axe to grind.

For the British reader the novel provides a chilling insight into the working of an insurance based health care system, with the perpetual struggle of the medics trying to get funding for the care of particular from the apparatchiks at the Insurance company or the Health Maintenance Organisation who authorise the payement for their health care forming a recurrent theme. Since primary care groups are HMOs by another name, is this novel a warning of what those working in hospitals in England & Wales are going to have to face up to as the latest set of health service reforms start to bite?

This is an excellent book that should be read by everyone involved in training young doctors, young doctors in training (any specialty, not just psychiatry), in providing or managing health services or who might finish up needing to claim on their health insurance.