© 2002 The Royal College of Psychiatrists
Book reviews |
Of Two Minds: The Growing Disorder in American Psychiatry
Queen Margaret Hospital, Whitefield Road, Dunfermline KY12 0SU, UK
EDITED BY SIDNEY CROWN and ALAN LEE
By T. M. Luhrmann. London: Picador. 2001. 337 pp. £20.00 (hb). ISBN 0 330 48535 0
This book suggests a diagnosis for the ailing condition of American
psychiatry. In the early part of the 20th century, the author argues,
psychoanalysis ruled the psychiatric world, but its reign was challenged by
the rise of the neurosciences. There ensued a bitter conflict, in which the
opposing camps eventually settled into what an American clinician has called a
‘happy pluralism’. However, with the recent emergence of
‘managed care’, insurance companies have been able to dictate the
nature of the treatment given to patients. They have favoured pharmacology
over psychotherapy, because it seems cheaper and more like the rest of
medicine. As a result, the psycho-dynamic approach is being excluded and may
become extinct. These trends have serious implications. Trainee psychiatrists
no longer possess the skills to communicate with patients. Those with mental
illnesses feel that they are not being understood, and the imperatives of
managed care mean that patients are being discharged from hospital long before
they have recovered. Clinicians are being forced to confront the moral dilemma
of whether to prescribe treatment they consider inappropriate. Finally, the
adoption by the general public of a vulgarised neurobiological model of mind
has led to a simplistic view of humanity which ignores meaning and
complexity.
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T. M. Luhrmann is an anthropologist and, in reaching her diagnosis, she has spent several years observing and inter-viewing psychiatrists in a variety of clinical settings. She has paid particular attention to psychiatrists in training, and records their attempts to master the often confusing and contradictory nature of clinical practice. We learn that trainees who take their work too seriously are considered a liability and that young clinicians read little in the way of psychiatric theory. We also learn that research is seen as superior to mere clinical work and that psychotherapy is considered an unsuitable job for a man.
Luhrmann views with alarm the disappearance of the art of listening, and repeatedly advocates the nostrum that it takes both pills and talk to make a patient better. Like many millennial commentators, she calls for a reconciliation between the opposing forces of neuroscience and psychotherapy — between what Eisenberg (2000) has called ‘mindless’ and ‘brainless’ psychiatry. There have, of course, been other perspectives on contemporary American psychiatry. A bleak account is provided by Samuel Shem's (1999) satirical novel, Mount Misery, which trainees in Luhrmann's book recommend as a true picture of their experience. A more upbeat assessment is given by Nancy Andreasen (2001) in a recent editorial, although she too worries that the ability to talk to the patient is diminishing as the emphasis on symptom checklists increases.
Rather curiously, given that the writer is not a psychiatrist, the book lacks critical distance and frequently takes psychiatry at its own estimation. Perhaps this is to be expected, because the author is not only the daughter of a psychiatrist but has also been in therapy. A much more searching anthropological account of psychiatry is to be found in Barrett's (1996) The Psychiatric Team, in which he questions the ‘taken-for-granted’ assumptions of clinicians. Luhrmann is hindered by a verbose and repetitive prose style, and readers who do not share her enthusiasm for Freud or Christianity may have reservations about her conclusions. Despite this, and despite its concentration on the American experience, many of the concerns of the book are of fundamental importance to British psychiatry. It is, therefore, well worth reading.
REFERENCES
- Andreasen, N. C. (2001) Diversity in
psychiatry: or, why did we become psychiatrists? American Journal
of Psychiatry, 158,
673-675.
[Free Full Text] - Barrett, R. J. (1996) The Psychiatric Team and the Social Definition of Schizophrenia. Cambridge: Cambridge University Press.
- Eisenberg, L. (2000) Is psychiatry more mindful
or brainier than it was a decade ago? British Journal of
Psychiatry, 176,
1-5.
[Free Full Text] - Shem, S. (1999) Mount Misery. London: Black Swan.
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