Of Two Minds: The Growing Disorder in American Psychiatry [Hardcover]

T.M. Luhrmann (Author)

Book Description

ISBN-10: 0679421912 | ISBN-13: 978-0679421917 | Publication Date: April 4, 2000 | Edition: 1

In this groundbreaking book, Tanya Luhrmann -- among the most admired of young American anthropologists -- brings her acute intelligence and her sophisticated powers of observation to bear on the world of psychiatry. On the basis of extensive interviews with patients and doctors, as well as day-to-day investigative fieldwork in residency programs, private psychiatric hospitals, and state hospitals, Luhrmann shows us how psychiatrists are trained, how they develop their particular way of seeing and listening to their patients, what makes a psychiatrist successful, and how the enormous ambiguities in the field affect its practitioners and patients.

How do psychiatrists learn to do what they do? What is it like for psychiatrists to deal with people who are in emotional extremity? How does the choice between drug therapy and talk therapy, each of which requires very different skills, affect the way psychiatrists understand their patients?  Boldly and with sharp insight, Luhrmann takes the reader into the world of young doctors in training.

At a time when mood-altering drugs have revolutionized the treatment of the mentally ill and HMOs are forcing caregivers to take the pharmacological route, Luhrmann places us at the heart of the struggle -- do we treat people's brains or their minds? -- and allows us to see exactly what is at stake.

Editorial Reviews

Amazon.com Review

Is the fight between cures worse than the disease? The fairly comfortable truce between psychotherapy and drug treatment for mental illness started eroding a few years ago, when the latter's bottom-line efficiency made it the preferred option for HMOs and many other health care providers. The often-sharp division between these two methods is highlighted in Of Two Minds, an insightful anthropological assessment of psychiatric training in America by University of California-San Diego's T.M. Luhrmann. She studied with psychiatrists in training, visited inpatient and outpatient facilities, and interviewed scores of doctors and patients to reveal the craft of a strange and misunderstood profession. Neither opponents nor defenders of the mental health establishment will find unqualified support from the author's careful evaluation. While she states from experience that she believes mental illness is real and in many cases of biological origin, she also despairs at the divide between research and treatment.

Luhrmann is strongly sympathetic with her subjects, whether physicians, patients, or instructors. She paints a portrait of harrowing training for young doctors and hellish experiences before, during, and after treatment for those seeking relief. She does find much to recommend both drug and talk therapies, though current research suggests that combining them is more effective for more patients than either one alone. In closing, Luhrmann warns that we are in danger of dehumanizing the mentally ill by emphasizing cost-effective pharmaceutical management of symptoms over interpersonal relationships. Of Two Minds has the depth and complexity necessary to match its subject and the warmth to reach its readers. It's essential reading for anyone involved or interested in mental health. --Rob Lightner

From Publishers Weekly

Cultural anthropologist Luhrmann puts the psychiatric profession on the couch, with devastating results. Psychopharmacology has become "the great, silent dominatrix of contemporary psychiatry," she reports, as a combination of ideology and socioeconomic forces favors treatment via prescription drugs and drives talk therapies out of the marketplace. In the new climate of managed care, doctors have very little time to evaluate patients, psychotherapy is not deemed cost-effective and psychiatrists in hospitals and clinics are pushed into management roles. A professor at the UC-San Diego, Luhrmann spent more than four years in psychiatric hospitals, attending classes and interviewing psychiatrists and administrators. Though she writes in a rather academic style, her valuable report offers an uncensored look at the new biological psychiatry. Luhrmann found that medications often do not work, that most patients are on more than one medicine and that unwanted interactions between drugs are common. In the classroom, discussion of Freud or of the scientific literature on emotion and human development is extremely cursory. Moreover, biomedically oriented doctors are trained to see psychiatric illness as a medical disease, which tends to eliminate ambiguity and nuance in diagnosis. Luhrmann's own view is that the evidence indicates a combination of talk therapy and psychopharmacology works best for most patients. She concludes with a look inside the mental health patient advocacy movement, which, like the profession itself, is sharply divided between lobbies for biomedicine and groups opposed to mandated psychiatric medication. Agent: Jill Kneerim, Palmer and Dodge Agency. (Apr.)
Copyright 2000 Reed Business Information, Inc.

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Product Details

• Hardcover: 337 pages
• Publisher: Knopf; 1 edition (April 4, 2000)
• Language: English
• ISBN-10: 0679421912
• ISBN-13: 978-0679421917
• Product Dimensions: 9.4 x 5.5 x 1.3 inches
• Shipping Weight: 1.6 pounds
• Average Customer Review: 3.9 out of 5 stars  See all reviews (14 customer reviews)
• Amazon Best Sellers Rank: #407,165 in Books (See Top 100 in Books)

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Customer Reviews

Most Helpful Customer Reviews

36 of 37 people found the following review helpful:

5.0 out of 5 stars Freud, Prozac, and managed care, June 5, 2000

By A Customer

This review is from: Of Two Minds: The Growing Disorder in American Psychiatry (Hardcover)

This most recent book by T. M. Luhrmann distills the results of four years' observation, interviewing and experiencing the theory and practice of American psychiatry, in venues ranging from one of the last private psychoanalytic residential centers to neuroscience labs, psychiatric conferences, and elite biomedically oriented hospitals. Her previous books dealt with how people make sense of their worlds: Persuasions of the Witch's Craft showed how witches in modern England come to believe in astrology and magic; and _The Good Parsi_ examined the Parsis' reaction to their fall from grace as India's colonial elite. Now she turns her attentions to some of the great existential questions of modern society: what is mental health? how can we intervene in people's lives when we only have imperfect knowledge? and what does it mean to be a person?

Luhrmann began by following the training process of a group of new psychiatric residents, to see how medical students become psychiatrists, and how they negotiate between the two, often antagonistic, models of psychiatry: biomedical and psychodynamic. The book contains great descriptions of patients and residents, of the quirks of different kinds of programs, and of how neither the psychoanalysts nor the biomedical specialists really believe in most of the DSM categories per se, but use them empirically and pragmatically as a means to treating the problems they represent. Luhrmann is sympathetic to the position of psychiatrists, but fair. She makes the point quite strongly that both biomedicine and analysis have their down sides, that both have internal theoretical and practical problems, but that they're addressing an absolutely real need. The dichotomy between the two, according to Luhrmann, is a false one which grew out of historical differences (namely the near-monopoly of psychoanalysis in the 1950s and 1960s) and which has been prevented from a reconciliation by the perceptions and policies of managed care, probably to the detriment of both patients and of the financial bottom line.

The book is extremely readable, which is welcome in the field of medical writing, which is often either thinly disguised politics or thickly layered jargon. Luhrmann manages to range from William Styron's autobiography to budget cuts in a state psychiatric clinic to debates between Hume and Kant over the nature of personhood without once losing her readers. She also has written a book which would be almost impossible for one of the insiders to write, because most psychiatric professionals are thoroughly socialized into the assumptions and habits of medicine long before they come to psychiatry. And so she does what a good anthropologist is supposed to do -- to give us a new perspective on our own lives. I highly recommend this book to anyone interested in American psychiatry, the effects of managed care, or the profound challenges posed by the paradoxes of mental illness.

15 of 16 people found the following review helpful:

4.0 out of 5 stars Well done!, January 27, 2001

By 

Greg Sazima - See all my reviews

This review is from: Of Two Minds: The Growing Disorder in American Psychiatry (Hardcover)

I'm a practicing psychiatrist, with the requisite 10 years in to (in theory) know what I'm doing. I'm grateful to Dr. Luhrmann for the thoroughness of her experiential research and the humanity of her expression. The book evoked memories of powerful, sometimes painful experience for me as I read her descriptions of internship and psychiatric residency; her accounts are realistic and carefully written. Her description of the profession-threatening impact of market forces should be required reading for anyone interested in the future of mental healthcare.

My only real trouble with the book is in its mutually excluding premise of "either/or"; that one's perspective on human behavior and its tragedies must be viewed either objectively, in reductionistic biomolecular ("nature") terms, or intuitively, through the subjective lens of psychodynamics("nurture"). I, too, was weaned in a psychdynamic orientation, then later yanked by the both the shock of witnessing severe illness and the expediency of managed care psychiatry to a more medical model. I ultimately have been disappointed by the pure biologic orientation. It usually provides a mere pharmacologic "band-aid", insufficient for lasting change unless the patient's experience of the world is also addressed - something no pill can achieve but the "heavy lifting" of psychodynamic psychotherapy can.

My own conclusion is that neither model stands up fully on its own, either diagnostically or in treatment. I suspect the best path is in integrating the perspectives. And why not? We know, for instance, that the scarring of witnessing/experiencing trauma in early life commonly leads to the extreme suffering of PTSD - a syndrome that, though fully "situational" as opposed to genetic, appears, and is, "hard-wired" and responsive to medication intervention. Yet we also know that some who experience similar trauma don't become cursed with insomnia, night terrors and hypervigilence - suggesting a component of a biological nature. We trust so in the dogma of the double-blind study, but even that gets tarnished when recent studies show 80% or more of supposed blinded subjects can guess whether they are on active drug or placebo - potentially casting at least a little doubt on a generation of pharmacology research, not to mention an entire industry. Frankly, we really still know so little! That Dr. Lurmann preferentially interviewed either babes-in-the-woods(with an understandibly shaky perspectival foundation) or academic attendings (who are commonly where they are via a narcissistic confidence in the camp he or she cast his or her fate) - may account for the intellectual myopia inherent in insisting primacy of one of the two stances.

Only in attempting to integrate the two and understanding the field within a wider philosophical and spiritual perspective have I found an inhabitable worldview. My own study has reached outside the usual to philosophy, anthropology and spirituality (I recommend reading Hegel, Aurobindo and especially Ken Wilber in attempting to understand how to integrate this complex matter). Nevertheless, this book is a wonderful piece on how things are in the polarized climate of the psychiatric profession; I recommend it.

12 of 14 people found the following review helpful:

5.0 out of 5 stars psychiatry today, May 24, 2000

By A Customer

This review is from: Of Two Minds: The Growing Disorder in American Psychiatry (Hardcover)

Of Two Minds is destined to become a classic. Luhrmann writes with style and verve about more than three 3 years of participant observation of the modern world of psychiatry. Her book is rich in quotes and observations about the daily life of psychiatrists. The main thesis of Luhrmann's book is that the world of psychiatry is currently split between two different therapeutic models, the biological and the psychodynamic, and, at this point, the big battalions belong to the biological camp. Luhrmann succeeds in describing what this actually means with respect to human life - the lives of both patients and psychiatrists. Luhrmann's book takes on one of the major problems of modern society. The book is a good read, the illustrations are gripping, and the treatment is always balanced and far-sighted. She is sensitive to the moral dimension of human life and the great underlying American conflict between doing things the efficient way versus the moral way.