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Of Two Minds: The Growing Disorder in American Psychiatry

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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.

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.

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.

What do anthropologists do these days as the number of unstudied tribes in the wild has dwindled to something like zero? They practice urban anthropology as they study various "cultures" within the larger society. Here ethnographer, T. M. Luhrmann of the University of California, San Diego, takes a long look at the psychiatric profession and finds it split into two mind sets as it tumbles toward disorder. On the left side we have the traditionalists who believe in the efficacy of psychodynamic psychotherapy (mainly Freudian psychoanalysis), and on the right, "psychiatric science," the biomedical approach, characterized by the use of various psychopharmacological agents such as Prozac, lithium, clozapine, etc. This bicameralization of psychiatry, Luhrmann argues, is in part the direct result of the rise of the managed care industry which is threatening to put psychodynamic psychotherapy (the "talk" cure) out of business because the insurance companies increasingly won't pay for lengthy psychoanalysis. She sees the "psychopharm" cure, even though it is of limited effectiveness (with unknown long-term side effects) as taking over. Thus we have the "disorder" in psychiatry. Her conclusion is that psychotherapy and psychopharmacology together are the most effective method of treating mental illness.

In the course of her work, Luhrmann visited various mental health facilities where she observed their practices while she interviewed the doctors, the nurses, the staff and the patients. She constructed composites of some of the personalities, gave them fictitious names, and quoted them. Her style is lucid, and balanced almost to a fault. For example, on page 269 where she is discussing patient advocacy groups, she refers to a magazine called Dendron which seeks alternatives to what it calls "forced psychiatric drugging." In the next paragraph she presents the alternative point of view of The National Alliance for the Mentally Ill which believes that "mental illness is not the result of poor socialization and inadequate parenting but rather a medical condition in need of medical attention." On page 278 she writes, "...in the years of psychoanalytic dominance, the vulgarized psychoanalytic model was used to humiliate and insult the parents whose children suffered." On page 286 she counters, "The real dilemma...faced by our society...is whether we will allow the seductions of the vulgarized biomedical model to overcome our own responsible commitment to a complex view of human life." Thus one can see that Luhrmann has become of two minds herself!

She is not, however, an entirely an unbiased observer. As she points out in the Introduction, she got the idea for this study because she joined "an anthropology department known for its long tradition of psychological anthropology," a discipline that "grew out a tradition of using psychoanalytic ideas to make sense of cultural practices." (The Freudian paradigm making sense of New Guinea tribesmen? I think I'll just pass on THAT.) Luhrmann's father is a psychiatrist, and although she maintains that her background "was more cognitive" her experience in writing this book included attending lectures designed to teach "a clinical perspective on Freud and psychoanalysis" (p. 3). Consequently it is understandable that she supports the Freudian psychoanalytical approach. Even so, Luhrmann does not shy away from quoting authorities to the effect that psychoanalytic theory is without a firm scientific basis.

However I don't think she goes far enough. What really needs to be said is that the old Freudian psychoanalytic model in which the patient is psychoanalyzed for several years is no longer tenable. It's not just that the insurance companies won't pay for it. There have been many studies from Eysenck in 1952 to the present demonstrating the dubious effectiveness of psychotherapy, particularly in treating the heavyweights like schizophrenia and psychosis. Luhrmann cites studies both for and against this conclusion. She recalls the old "mantra" (p. 208) that "both psychotherapy and psychopharmacology have the same crude success rate: a third of the time they work well; a third of the time, they have some impact; a third of the time they don't work at all." She also makes the point that no one form of psychotherapy is superior to another, that it is the caring and the time spent with the therapist that helps, not the mode of therapy. This last point is really the crux of the matter. Luhrmann writes on page 202: "If the moral authority of the scientist derives from the knowledge he acquires, the moral authority of the analyst derives from the love he gives." On page 201 she quotes Elvin Semrad: "The most important thing, the thing that makes the difference, the thing that we as psychiatrists are dealing in, is love and humanity." It is NOT the Freudian mumble-jumble that helps patients (to the extent that they are helped), but it is the loving concern and care of the therapist.

If this is so, it raises the question, why do therapists need to go to medical school, need to study the now largely discredited Freudian mythology, need to spend years in psychoanalysis to be no more effective than a counselor from the local church? The answer is they don't. And this is part of the reason for the split and the crisis in psychiatry. What needs to be gotten rid of, and I don't think Luhrmann really sees this, is the Freudian baggage. Psychodynamic psychiatry really needs a framework and model more nearly consistent with the advances in knowledge about human beings that have occurred since the days of Freud. Those old ideas of "penis envy" and Oedipus complex, etc., as significant factors in mental illness must be scrapped. The revelations and the paradigms from cognitive psychology and evolutionary psychology need to replace the Freudian construct.

Luhrmann compares and contrasts the biomedical and the psychodynamic in psychiatric training. The focus is compelling. The author starts from the assumption of medicine that these are illnesses. Service user diagnoses -- schizophrenics, borderlines -- replace the person; a family organizataion is described as a patient lobby, she notes that is clear to her that these are diseases and the medical model works. The last chapter tries to redress, and she has interviewed and quotes California clients John Hood, Vernon, and Howie, but she uses professional distancing jargon -- high-functioning and dysfunctional, .... I felt they were diminished. Missing is the model of managing and accommodating disability. Missing is the fuller context - where these psycho-science approaches fit when the spiritual and social dimension are included.

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.

Of Two Minds: The Growing Disorder in American Psychiatry By T. M. Luhrman

Managed care is drastically shortening the time in which the mentally ill can afford to be hospitalized, and making it harder for most people to afford outpatient psychotherapy. Drugs are cheaper and faster. But do they solve the underlying problems in people's lives, or merely mask symptoms? The growing distance between those who believe in medication and those who put their primary faith in therapy is one of the burning issues Luhrman explores in this excellent work. The author is an anthropologist who decided to study the training of American psychiatrists, and the result is a dense but not difficult book Anyone with an interest in mental health can find much that is useful, elucidating, and even intriguing here.

Am I my mind? Am I my illness? In a fascinating new book, T.M. Luhrmann makes a clear, concise argument that we cannot look upon the diseases of the mind in the same way that we look upon diseases of the body. This view is too simplistic, and allows healthcare companies to undertreat mental illness by paying for medication treatment, but discouraging talk therapy.

Luhrmann used her experience as an anthropologist and four years of field work to observe first-hand the training of mental health professionals. This part of the book is of interest to any patient who is affected by how their doctor's attitude toward patients was developed.

Lurhmann observes the situation and treatment of the mentally ill with a clear vision. The concerns she raises about the emphasis of the biomedical (chemical) model of mental illness over the psychodynamic (talk therapy) model are on target and worth serious consideration.

My lack of enthusiasm may be tempered by my bias, in that I am a senior medical student applying for residency in pscyhiatry. The book attempts to make the point that psychiatry has been lost to the pscyhopharamcologists and there remains at best little practice of psychotherapy or little incorporation of psychological theory in the field. I agree with this, and like the author, I would rather this were not the case. But...

1) I think the author could have made this point more strongly in about 30 pages.

2) I think the author doesn't provide enough open-minded discussion to the benefits of psychopharmacology, or to transferring the practice of psychotherapy mainly to mental health professionals other than psychiatrists

3) She oversimplifies the negatives

4) She spends much too little time providing investigative-reporting/detiled descriptions of her observations

5) instead of spending more time on her observations (which were the only powerful, interesting, elucidating parts of the book in my potentially short-sighted opinion) she spent time crafting rather unnecessarily verbose, confusing, and redundant arguments in a very subjective fashion. This greatly weakened her work. And bored this reader.

I felt sorry for her, that she spent four years doing this field work and then so much longer writing. I guess I say that because the book made psychiatry seem really boring, (which it is not by the way) and 4+ years is too long of a time to be so engrossed in something that is so dull. I am sure her fieldwork was actaully quite a rush. But you almost would never know it by reading this book. She doesn't really describe it too much, which is too bad, because that would be fun!

In the end, I could not bring myself to keep spending time on this book, so I gave up 40 pages or so from the end. Maybe that also contributes to any bias or shortsightedness I have.

I read this book on the basis of strong reviews from many different quarters. As a clinical psychologist with eclectic training, a fairly iconoclastic turn of mind and a research career in public health rather than mental health, I was hoping that at outsider to mental health practice could provide fresh insights. Instead, Luhrman has produced a work of lazy scholarship and self-serving pretense. The book proports to be balanced, but it is clear, throughout, that Luhrmann spends most of her time defending psychoanalytic therapy against biological approaches. Nonetheless, she never really defines what she means by psychoanalytic therapy and, in the process, rules out large chunks of that field, including contemporary variants like interpersonal psychotherapy. She reduces much serious work on psychopharamacology to being only about rhetoric and one wonders whether she ever tried to understand the what happens in the neurotransmitter systems (a topic that is more accessible than it sounds). Indeed, it appears that she developed rather little depth in either the biological or psychoanalytic perspective and she does grave injustice to both. Similarly, her insights about human interactions in her stint as a therapist-in-training suggest that qualitative interviewing is not her strength, either. Instead, we get a postmodern-lite analysis of what happens in clinical interviews and therapy. Indeed, the turgid prose and not-so subtle self-aggrandizing pose make this an altogether unsatisfying read.

Compared with past non-fiction accounts of mental health practice, the book lacks depth and the author's voice gets in the way rather than providing real insight. The book lacks the rigorous depth that has made for gripping, thought-provoking jounalistic accounts like Susan Sheehan's "Is There No Place For Me". It also lacks the depth of historical reviews of the field like Murray Levine's work. There is a need for a contemporary, close-to-the-front-line story of current mental health practice. Perhaps, someone will be inspired by the shortcomings of this pretentious effort to write such a book.