Of Two Minds: The Growing Disorder in American Psychiatry

A funny thing happened to T. M. Luhrmann when, in order to sharpen her psychological skills as a new assistant professor of anthropology, she began attending a series of lectures on clinical psychiatry at San Jose State Hospital in California. Responding to a suggestion from one of the psychiatric residents also attending the lectures, she turned her anthropological eye on the tribe of psychiatrists. She undertook what became a four-year study, conducted in a number of hospitals and training institutions, of how young psychiatrists become enculturated, how they learn to see and do in a not-at-all-romantic, hard, and difficult profession.

From the beginning of the book the author makes her main contentions clear. She believes that the profession of psychiatry is being dangerously split between two models, the biomedical and the psychotherapeutic, and that these models differ profoundly both practically and philosophically. She fears that "a combination of socioeconomic factors and ideology are driving psychotherapy out of psychiatry." This trend is bad for patients suffering from mental illness, as evidence is accumulating that an approach featuring both appropriate medication and psychotherapy is more effective than either alone.

Treatment limited to drugs and management is also demoralizing to many psychiatrists. It carries with it a dehumanizing connotation that the sorrows of life are states that are "curable" and imposed from outside, rather than embedded within the human condition.

Dr. Luhrmann's concentration on this central point, however, is not the whole value of this book. She has also produced a cogent and well-written account of the present state of psychiatric training and of the profession itself (although she does not have much to say about practicing, nonhospital-connected psychiatrists). Her account draws many interesting generalizations, such as the observation that a bad personal reputation is more damaging to a psychoanalyst than to a psychiatric scientist. She also provides case accounts and discussions with well-known psychiatrists.

What powered the trajectory of psychoanalysis from the glory days of Freud and its dominance in the 1950s to its present parlous state? From the cure by love to the cure by medication? From the guruhood of the psychoanalyst to that of the psychiatric scientist? Dr. Luhrmann enumerates the factors: psychoanalytic arrogance and even greed, treatment failure, more effective treatment with drugs, a more objective and "scientific" approach to evaluation of results, the impact of the atheoretical DSM, the signal Osheroff case, and, finally, the climactic and still reverberating impact of managed care. In her discussion of the latter, Dr. Luhrmann tries to be fair as she describes the excesses—principally financial—that needed correction, but her heart is clearly with the anguished and angry outcries of psychiatrists as they experience an escalation from reasonable correction of abuses to what seems to be a crescendo of cost cutting, with disastrous effects on patient care in general but particularly on psychotherapy.

Why is psychotherapy so necessary a component of a rounded effort to relieve human mental suffering? Dr. Luhrmann deals with this issue in many ways, but I think it could be made clearer. It is because, although medication can often deal more effectively with the symptoms of mental illness, drugs lack the power to cope with the human suffering in relationships and feelings that impair the functioning of people who seek psychiatric help, whether they are seeking help for schizophrenia or a bad marriage. The medical model cannot fully penetrate the elusive warrens of the human condition, nor can it offer a soma to narcotize all misery, as in Aldous Huxley's Brave New World.

Dr. Luhrmann's portrayal of "the growing disorder in American psychiatry" is gloomy, even alarming. How accurate is it? One can suspect that her attraction to dynamic psychotherapy, as exemplified in her admiring description of the Norton Inn, a psychoanalytic hospital, has eroded her objectivity. Although not a panacea, biological psychiatry can be more exciting and helpful than comes through in this book. I think back in my own career to how eagerly I would have welcomed lithium in the late 1950s when I was attempting to treat a florid manic-depressive with analytic psychotherapy.

Although there are data supporting the claim that a combined approach is preferable for serious mental illness, the psychotherapeutic side of this equation is not filled exclusively by dynamic Freud-based therapy. Although she mentions other forms of psychotherapy, Dr. Luhrmann gives them short shrift, and even seems to include, in treating schizophrenia, psychosocial measures, which are not really psychotherapy.

It should be noted, finally, that some of the coarsening of the fabric of the therapeutic encounter in psychiatry that she deplores may be a consequence of psychiatry's descent from a profession into a business—which, sadly, is occurring in medicine generally. However, even if there may be elements of exaggeration in her dark portrayal, Dr. Luhrmann has presented psychiatrists with a well-documented and thoughtful account of a real threat to the health of the profession. Her book should be read.