Book Review : Psychiatry divided

Of two minds: the growing disorder in American psychiatry T.M. Luhrmann Alfred A. Knopf, New York; 2000 337 pp. $39.95 (cloth) ISBN 0-679-42191-2 Having spent 30 years of my life as a psychiatrist, I find it interesting to see my profession as others do. Tanya Luhrmann, a psychological anthropologist at the University of California, is well suited to the task of holding the mirror up to psychiatry. In preparing Of Two Minds: the Growing Disorder in American Psychiatry, she spent several years researching the training of psychiatrists in the United States. She studied various residency training programs and teaching hospitals, interviewing psychiatrists, psychiatric residents, hospital administrators and other mental health staff at both inpatient and outpatient facilities. She attended lectures for psychiatry residents and was present for all of the usual activities in the training program, including admission work-ups, case conferences, community meetings, group therapy sessions and supervision interviews. She was even given the opportunity, with supervision by a senior psychiatrist, to admit and treat patients. To immerse herself in the total experience of psychiatric training, she went twice a week for three years to a psychiatrist for psychodynamic psychotherapy. “I did this,” she writes, “following the advice that to understand therapy, one must do therapy and be in therapy.” The initial premise of Luhrmann's research was that some feature in the experience of residency would orient the resident toward either biomedical or psychodynamic psychiatry. However, during the course of her research her focus changed, partly as a result of the shift in the American health care system toward “managed care.” Reading her book was like having my life reviewed before my eyes. Although I took my psychiatry training in Canada and New Zealand, Luhrmann's account of the American training experience was very familiar; I have faced many of the trials and issues she describes. Much of the book focuses on psychoanalytic versus biologic approaches toward mental illness and its treatment. The author provides a thorough and readable history of psychiatry, including the changes that occurred with the development in the 1950s of pharmaceuticals to treat depression, anxiety and psychosis. She describes how the theories of Freud and other analysts ruled psychiatric treatment and training until the 1970s. There was great resistance to the idea that mental illness arose from an organic disorder of the brain and should be treated medically. For a while it seemed that there were two camps. One interpreted all psychiatric disturbance as the result of a clash between the patient's personality and a pathological environment (especially in the family). This could be treated by providing years of psychoanalysis in a safe, nurturing setting. The second camp considered that mental illness was caused by genetic and unknown external factors leading to altered brain chemistry, which could be treated by altering the balance of certain neurotransmitters. Initially, there was little cooperation between the two camps. In the psychiatric training programs that Luhrmann studied, residents were exposed to both concepts and were often expected to integrate the two, while their mentors wanted them to choose one path or the other. She describes the completely different atmospheres on wards where the patients were treated in accordance with one approach or the other. This confused not only the psychiatrists in training, but also the patients in their care. In the psychoanalytic model, patients were considered responsible for their actions and treatment. In the biologic model, patients were the victims of their illness, and medication was the primary route to recovery. Moreover, if a patient responded to psychiatric medication, it seemed to follow that the illness had an organic cause. Some of Luhrmann's conclusions mirror my own experience and probably that of most psychiatrists in North America. She presents evidence that, for some mental illnesses, pharmacotherapy is the most effective approach, while for others a psychodynamic approach is more appropriate. “Psychodynamic” and “psychoanalytic” approaches are not the same, although both are based on common principles; Luhrmann does not seem to advocate the latter, as it is expensive, time-consuming and of questionable efficacy. She concludes that combining pharmacotherapy with psychodynamic treatment is the most effective. For example, patients with schizophrenia or bipolar disorder benefit from but are not cured by medication. They still benefit from counselling in managing their lives with mental illness. Other interventions such as education about medication and supportive living and working arrangements can greatly improve quality of life. At the end of the book Luhrmann discusses the truly frightening crisis of managed care. In the US the economics of medical insurance has compromised patient care, especially for those with mental illness. An insistence on shorter hospital stays has essentially eliminated psychodynamic approaches in favour of pharmaceutical “stabilization.” Institutions have been forced to cope by reducing staff (especially costly psychiatrists), increasing the workload of those who remain, and increasing admissions while decreasing length of stay. Patients are often discharged before they are considered to present no risk to themselves or others. Thus, Luhrmann is compelled to conclude with a chapter on “madness and moral responsibility,” in which she makes an impassioned plea for society to make moral choices rather than economic ones in caring for the mentally ill. I recommend this book to anyone interested in the treatment of mental illness, especially psychiatric residents and their mentors. It is easy to read, and the issues addressed are vitally important to all of us.

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