Book Review

Of Two Minds: The growing disorder in American psychiatry

N Engl J Med 2000; 343:1579November 23, 2000

Article

Of Two Minds: The growing disorder in American psychiatry
By T.M. Luhrmann. 337 pp. New York, Alfred A. Knopf, 2000. $26.95. ISBN: 0-679-42191-2

Modern psychiatry began in the 18th century, with the reconceptualization of madness as a disease and not the result of witchcraft or demonic possession. This new idea led to dramatic successes, such as the delineation of syphilitic infection as a cause of general paresis, and more is expected in the near future as we unravel the genetics and neurobiology of schizophrenia and bipolar disease. It also led to the growing use of a medical model in psychiatric practice, with disease categories, diagnoses, and disease-specific therapies. A second, and in many respects competing, idea formulates problems of character, personality, and adaptation to the stresses of life as understandable and treatable psychological patterns rather than moral weaknesses or the inevitability of the human condition. This view was tied to medicine and psychiatry by Sigmund Freud and his psychoanalytic followers.

These two views existed side by side for many years, but despite their basic differences, they caused little conflict in psychiatry, because overlap between them was minimal. The disease model predominated in the treatment of patients with major psychoses in mental hospitals. The psychoanalytic model influenced outpatient “talking” therapy. This dichotomy continues in many parts of the world today. However, after World War II, things changed in the United States. Psychoanalytic models of intervention seemed to be effective in treating the acute stress and post-traumatic syndromes of the battlefield, and Army doctors returned home eager to replace the custodial care of persons who were severely mentally ill with new treatments based on scientific theories of the causes of mental illness. In addition, intriguing psychoanalytic theories relevant to general medicine (psychosomatic theories) began to develop. Psychoanalysts led in the medicalization of psychiatry and, at least in the United States, came to dominate academic psychiatry. At the same time, hospital psychiatrists who followed the medical model struggled to develop scientific, biomedical treatments, but shock therapies received poor press, and lobotomies turned out to be disastrous.

By the 1960s, the scene changed again. Psychodynamic treatments, which had seemed promising for acute reactions to stress in patients without previous psychopathology, failed in hospitalized patients with chronic disorders. Psychosomatic theories enriched the understanding of patients' experience of illness but were less helpful in explaining the causes of or suggesting treatments for disease. Furthermore, pharmacologic treatments proved highly popular and fairly effective, at first with seriously ill inpatients and then with outpatients. Meprobamate (Miltown), diazepam (Valium), and fluoxetine (Prozac) became part of popular culture, and the biomedical and psychoanalytic paradigms began to compete in the community as well as in clinical and academic arenas.

At this point in the story, in 1989, Tanya M. Luhrmann, an anthropologist, began her participant-observer studies of American psychiatry and the socialization of psychiatrists. She visited psychiatry residency programs, shared in the experiences of trainees, befriended trainees and faculty members, and reflected on her own experiences. The result is a compelling and often moving account of how this world looks to psychoanalytically and humanistically inclined young residents in psychiatry. It is the product of excellent journalism and captures and conveys their experience. However, it leaves a good deal out.

The institutions Luhrmann studied are distinguished, but they are more psychoanalytically oriented than most of the profession. Luhrmann ignores the history of psychiatry and the extent to which the themes she describes reflect professions and professional socialization in general rather than psychiatry in particular. The book closes with a discussion of “madness and moral philosophy,” but the substantive scientific and economic questions that preoccupy the profession and that will determine its future — what works for whom, and at what cost — are not explored. The reader might be surprised to learn that psychiatry is far closer to neurology than it is to moral philosophy. Luhrmann states as a fact (without reference) that “the available evidence we have suggests that for most patients and for most disorders, psychopharmacology and psychotherapy work best in combination.” However, there is no such evidence. Certainly, many patients do well with this combination, but for even more, particularly those with major psychoses, it has been difficult to demonstrate that psychotherapy offers more than sensitive, humane concern.

Luhrmann returned to the field a few years after her first visit and discovered that the struggle between psychoanalysis and psychopharmacology had been superseded by the war against managed care. She had observed the inequities and inefficiencies that paved the way for changes in the health care system, but they had failed to claim her interest. The result is a powerful but highly selective portrait. Early in the book she describes herself as having the advantages and the biases of a “halfie” anthropologist (her father is a psychiatrist and she herself had considered becoming one), “like an anthropologist with an Egyptian father who goes off to live with the Bedouin.” Later she tells us that during the study, she herself treated eight patients with psychoanalytic psychotherapy (more than the average resident) and was herself receiving “twice-a-week psychotherapy with a senior psychoanalyst for more than three years.” She may have become a one-and-a-halfie.

Professions evolve, and professional education always involves tension between the past that is revered by many of the senior faculty members and the future that is espoused by some of the younger faculty. The neurobiologic revolution and managed care provide the rhetoric for the “new” psychiatry, whereas psychoanalysis has become the symbol of the past. Luhrmann captures the experience of traditional students encountering this conflict as they enter the field. We must still await the anthropologic, sociological, and historical analyses that will help us understand where we are and how we got here and that will help us plan how to proceed.

Robert Michels, M.D.
Cornell University, New York, NY 10021

Citing Articles (1)

Citing Articles

1. 1

   (2001) Of Two Minds. New England Journal of Medicine 344:12, 937-938
   Full Text