Of Two Minds: The Growing Disorder in
By T.M. Luhrmann
Alfred A. Knopf, 323 pages
When Andrew Goldstein pushed Kendra Webdale in front of a
New York subway train in January 1999, he brutally and
pointlessly ended the life of a 32-year-old stranger. He
also demonstrated, in the most horrific terms, the
burgeoning crisis in American psychiatry. A schizophrenic
with a history of dangerous impulses, Goldstein frightened
even himself, and he had pleaded with state psychiatric
centers to provide him with the treatment he needed to help
him stay on his medication and out of trouble. But over and
over again, he was turned away by hospitals that could not
justify the expense of inpatient and outpatient services for
a man whose illness was supposedly controllable with drugs
alone. It was Webdale who finally paid.
T.M. Luhrmann's impressive "Of Two Minds" is far more than a
simple indictment of the negligent way we have come to treat
acute mental illness in this nation, but that's one of the
more urgent notes it sounds. An anthropologist who set out
in 1989 to write an ethnographic account of the way
psychiatrists acquire the basic skills of their profession
and come to regard their work and their patients, Luhrmann
happened to pick a time when the field was undergoing deep
and disturbing changes.
In the early 1980s, doctors who espoused what Luhrmann calls
a "biomedical" approach to treating mental illness,
regarding madness as an organic disease best controlled
with drugs, supplanted those who hewed to the
"psychodynamic" model rooted in the "talk therapy" that
Sigmund Freud pioneered. The biomedical model also
appealed to managed health care companies, Luhrmann writes,
because "psychopharmacological approaches seemed cheaper and
more like the rest of medicine."
For anyone at all interested in how shrinks are made, the
first half of Luhrmann's book is a fascinating account. A
former medical student, she embarked on four years of fieldwork that
included "more than sixteen months of full-time,
intensive immersion" -- that is, for more than a year she
lived as a psychiatric resident, attending classes, working
at a hospital, even seeing patients and undergoing therapy
herself with a training psychiatrist.
It's always a bit unsettling to be reminded how medical
residents are "taught" their jobs -- a mother-bird strategy
in which fledgling doctors are shoved out of the nest on the
theory that the best way to learn to fly is to just do it.
And Luhrmann's detailed, nuanced descriptions of the way
teams of doctors work together as groups ("Shame is a common
teaching tool in medical education") remind you how
valuable anthropology can be in the rich, specific knowledge
it contributes to the culture.
In the second half, though, when Luhrmann tackles the split
between biomedical and psychodynamic psychiatry, she kicks
"Of Two Minds" into an even higher gear. The conflict
between the two approaches is a debate between "two
profoundly different notions of what it is to be a person,"
she explains, and it takes up "some of our oldest
philosophical dilemmas." Luhrmann can move from the politics
of backbiting gossip among psychiatric nurses (it's usually
worse in the less hierarchical psychodynamically minded
hospitals) to an explication of the disagreement between
David Hume and Immanuel Kant over the roots of moral judgment without ever
being less than impeccably lucid and fair-minded -- which
only makes the breakdown she chronicles that much scarier.
"You have the opportunity of seeing our profession in the
beauty of its great sunset," a psychiatrist tells Luhrmann,
who witnesses the virtual dismantling of the inpatient
psychiatric unit at an urban hospital. "This is chaos and
confusion," the unit director announces as the staffing and
budget cuts take effect. "In these circumstances, we will
kill someone!" Luhrmann presents conclusive evidence
that a combination of psychopharmacology and psychotherapy
is often the only truly effective way to treat acute mental
illnesses -- a conclusion that even the biomedical
psychiatrists she talks to agree with -- yet managed-care
budget cutters prefer to deem drugs a cure-all.
But above and beyond these practical concerns, Luhrmann
insists, the simple "disease" model of mental illness
diminishes all of us. The ideals of psychodynamic psychiatry
are based on the belief that "the mastery of bad
circumstances is inherent to what a person is ... the sense
of a person is of someone who has overcome suffering in a
particular way and forged a specific path through life." We
live in a society obsessed with blame, and the disease model
offers an attractive out once the finger-pointing begins.
But we retire the notion of responsibility at our peril. By
treating severe mental illness as a permanent misfortune
that eclipses a person's self but isn't part of that self,
the biomedical model threatens an individual's humanity.
It's a subtle, abstract argument that Luhrmann renders, in
heroically plain language. It's also one we can't afford to