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Book Forum: History: Changes and Challenges   |    
Of Two Minds: The Growing Disorder in American Psychiatry
Am J Psychiatry 2001;158:983-985. doi:10.1176/appi.ajp.158.6.983
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New York, N.Y.

By T.M. Luhrmann. New York, Alfred A. Knopf, 2000, 328 pp., $26.95.

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This is a book about the theory and practice of psychiatry in the United States, as conveyed to those in psychiatric residency training. It is written by an anthropologist, Tanya Luhrmann, who studied psychiatric residents and their teachers over many years, as one might study a strange tribe with established customs that is undergoing challenge and change. Luhrmann used methods of close observation and even participation for her project. Although I question some of the author’s conclusions, I strongly recommend reading Of Two Minds. The book provides both pleasure, as it reveals the intriguing strangeness of aspects of our profession that we take for granted, and intellectual challenge, as it conceptualizes the moral and philosophical implications of the currently competing models of illness and treatment.

Luhrmann, the daughter of a psychiatrist, is a professor of anthropology at the University of Chicago. She did more than 4 years of field work for this book, including 16 months full-time in a variety of clinical settings, much of it with psychiatric residents as they went about their rounds, conferences, and lectures. She also conducted extensive interviews of these residents and their teachers and provided intensive psychotherapy to patients herself. She was supervised by a psychoanalyst for this treatment and was in her own intensive analytic psychotherapy for "more than three years."

Her observations and descriptions of everyday aspects of academic psychiatry provide some of the best reading—not because they describe something unfamiliar to those of us in the mental health field but because they demonstrate how interesting, perhaps even strange, the familiar can be. Luhrmann’s observations of different psychiatric cultures, as revealed in professional meetings, are among these:

When he [a psychoanalyst] speaks, his listeners draw conclusions not only about whether he is smart or stupid but about whether they would send a patient to him for analysis. This fact about psychoanalysis not unnaturally shapes the way analysts present their public papers.

The main gathering of the American Psychoanalytic Association occurs in New York the week before Christmas.…It is always held at the Waldorf-Astoria, a hotel, like the profession itself, that is elegant and nostalgic for its past.…The men wear professional jackets, sometimes a little scruffy. The women wear soft, textured knee-length suits in muted colors.…Their clothes are intended to display their graciousness and their carefully calibrated tolerance for the unconventional. "Anthropologists," a psychoanalyst said to me with some disapproval, "can be flamboyant. Psychoanalysts are not allowed to be flamboyant." (p. 183)

For the most part, however, Luhrmann describes, and analyzes, two competing models of illness and treatment in psychiatry—the biomedical and the psychodynamic. She claims neutrality in the dispute, stating that she believes both approaches are "substantially correct and equally effective although not always for the same person." She also believes evidence suggests that "for most patients and for most disorders psychopharmacology and psychotherapy work best in combination." Historically, she sees the competition as having arrived at détente, a "two tone psychiatry" in the 1980s, but then managed care weighed in and was the deciding factor in turning psychodynamic psychotherapy into a "ghost." However, Luhrmann also sees the biomedical and psychodynamic approaches as almost incompatible, at least to the psychiatric residents being asked to learn them, because of very basic differences when they are seen as "ideals."

These two ideals embody different moral sensibilities, different fundamental commitments, different bottom lines. In some ways the differences are subtle; in others they are sharp and striking. The differences become part of the way the young psychiatrist imagines himself with patients, the way he comes to empathize with patients, and, ultimately, the way he comes to regard his patients as moral beings. (p. 158)

The description of these ideals is the strength of this book. To illustrate, the two models see "What’s Wrong With the Patient" (chapter 1) very differently—one as symptoms and illness, the other as "emotion-motivation-behavior bundles." Thus, "In the process each approach constructs a different person out of one unhappy patient." In chapter 4, "The Psychiatric Scientist and the Psychoanalyst" there is a depiction of teacher archetypes—the "fearless investigator of truth" versus the "wise wizard of insight." However, it is impossible to convey here her nuanced descriptions of these differences as actually experienced by residents in their clinical practice and in their efforts to develop their own theoretical concepts.

If there is a weakness in Luhrmann’s support for this argument, it is that the real extent of the incompatibility of these "two minds" is not presented systematically. Although the differences are emphasized and illustrated—e.g., through a description of an extremely atypical inpatient facility that uses an exclusively psychoanalytic psychotherapeutic approach—the theoretical and practical limits to combining these approaches are not explored sufficiently. Also, facilities or faculties that attempt to combine the treatments are not described with the same anthropological thoroughness. I believe that such efforts at integration do currently exist at the practical, theoretical, and educational levels, including at my own institution.

In addition, I question Luhrmann’s analysis of the one difference between the biomedical and psychodynamic that she most emphasizes. This is their differential regard for patients as "moral beings." The importance of this issue seems to come more from herself than the psychiatrists she studied, although she also finds it strongly voiced in patients. Her argument is that psychodynamic psychotherapy holds patients responsible for their actions, whereas the biomedical view, which regards psychiatric disorders as illnesses and patients as victims, does not.

Biology is the great moral loophole of our age.…A moral vision that treats the body as choiceless and nonresponsible and the mind as choice-making and responsible has significant consequences for a view of mental illness precariously perched between the two. (p. 8)

Does the psychodynamic approach indeed see the mind as "choice-making and responsible?" In her view, yes. "The irony is that while Freud perhaps saw himself as demonstrating that human nature was shackled by its own design, his legacy has been to create a moral expectation of human agency and self-determination that we do ill to jettison." It would be very possible to argue the opposite, that the psychoanalytic point of view is quite deterministic with "choice" only a metaphor for immutable unconscious motivation.

Why is the issue of agency and self-determination of such concern? As a nonpsychiatrist, Luhrmann is as much focused on the society at large as on the realm of psychiatric disorders. She sees a danger of this biological "moral loophole" being expanded: "Psychiatric knowledge seeps into popular culture like the dye from a red shirt in hot water." Also, she has embraced the position of patient (consumer) groups that resent the view that their actions stem from illness rather than from "themselves." In her final chapter, "Madness and Moral Responsibility," Luhrmann states that the different psychiatric approaches to agency have "profound consequences for the way we feel compassion for the person we need to help." The empathy stemming from the biomedical model is "simple empathy," whereas the psychodynamic model, by assuming intentionality in illness, leads to "complex empathy," "empathizing with the patient’s self-destructiveness as well as with his despair." The psychiatrist’s choice between these two views of patients is for Luhrmann a moral decision in itself. At the very end of her book this is stated in stark terms: a choice between understanding patients "only as the detritus of a broken brain" or as "engaged in the struggle to be decent, responsible people." If we choose the former, "the loss of our souls is a high price to pay." In other words, the biologically minded psychiatrist falls into this great moral loophole, even when treating patients humanely, if he or she "constructs" the patient as an incapacitated victim of illness.

It has been said that adopting the medical model risks a mindless psychiatry. Luhrmann warns that it might make our field, through the attitude of our trainees, soulless as well. This book itself, however, has a lot of heart. Reading it will make you smile, laugh, frown, and think.




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