Despite offering interesting insights, Luhrmann presented a potentially biased portrait of the psychiatric world which this review will unpack. Is there hope for psychiatry in the future? Or will it continue to follow trends into irrelevancy?
Luhrmann critically disseminates Western psychiatry in her astute book ‘Of Two Minds’ (2001), which perniciously challenges the validity, reliability and perhaps even relevancy of the profession. Luhrmann explored tensions between the psychodynamic and biomedical approach during a significant period of change in psychiatry due to the influence of managed care. Her ethnographic accounts investigated these models and how they pertained to wider epistemological critiques, the therapeutic relationship, and the inner world of American psychiatric culture from the experiences of medical students to the seasoned psychiatrist. She powerfully illustrated the array of emotions, insecurities, uncertainties and frustrations personnel faced due to academic and institutional politics and hierarchy, as well as highlighting psychiatry's issues in evolving. Luhrmann’s chapters cover vast areas, from exploring the contentious relationship between doctors and patients, to the problems of each psychiatric approach.
‘Of Two Minds’ presented intriguing arguments across morality, autonomy, and personal responsibility by guiding the reader on a tour through psychiatry’s history and delving into the changes and conflicts that lifted psychopharmacology into becoming “the great, silent dominatrix of contemporary psychiatry” over talk-therapy due to powerful influences of ideology, socio-economic forces, Western cultural dependencies on ‘quick, cheap fixes’ and pressures from managed care; capturing the chaotic societal and medical upheaval of the time. Despite offering interesting insights into the factors that influenced this change, Luhrmann presented a potentially biased portrait of the psychiatric world which this review will unpack.
Modern psychiatry began when madness was reconceptualised during the 18th Century as a disease rather than due to witchcraft or possession (Fabrega, 1991; Spanos & Gottlieb, 1979). The biological model consequently grew in favour as it provided psychiatry with identifications of disease categories, diagnoses, and specialised therapies directed at particular diseases. Freud et al. presented competing ideas which addressed patient’s problems of character, personality, and adaption to life-stressors, which were conceptualised and treated psychoanalytically rather than attributed to moral weaknesses or the result of the inevitability of the human condition (e.g. Lazarus & Folkman, 1984). These theories and concepts were initially linked to medicine and psychiatry, but are considered less today, and are more theoretical rather than empirical.
There was initial resistance against mental disorders having organic aetiology in loyalty to psychoanalytic principles (Fulford et al., 2013). Psychiatric personnel were divided between two minds (hence Luhrmann’s apt title?) with some lobbying the idea that psychiatric disturbances amassed from issues of personality from a pathological family environment, whilst others supported genetic and brain-chemistry theories. Both positions underpinned psychiatry but involved little cooperation between them. Luhrmann described the two camps as being 'at war' due to their profoundly different methods and philosophies, existing as opposing cultures in the psychiatric world dividing perceptions, thoughts and feelings (p. 8). Students were expected to be adept in both approaches despite the models' antagonistic relationship, which often caused tension and confusion practically, as supervisors pressured students to 'pick a path'. This, plus the influences of managed care, significantly impacted how psychiatric personnel conceptualised and handled the patient, causing doctors to view patients as the ‘enemy’, whilst psychotherapeutic personnel regarded them with what Luhrmann described as ‘love’.
Despite the two approaches battle for superiority, Luhrmann highlighted the biomedical models' effectivity and ethical issues in treating various types and severities of disorders; and psychoanalyses’ appropriateness, timeliness, and cost issues. It is important to note when considering Luhrmann’s arguments, that her analyses were conducted on facilities that were greatly psychoanalytically oriented, which may have restricted her analytic scope. Furthermore, the extent to which themes reflected her subject were at times limited, as her descriptions appeared more generic than reflective of psychiatry itself. Luhrmann also missed expanding on substantive scientific and economic questions that preoccupied psychiatry at the time, which had potential to influence the future of the profession in regards to effectivity and cost.
Despite Luhrmann’s criticisms of psychiatric approaches, she maintained that managed care was the real issue in the industry. She expressed that patients were worse off without psychoanalysis and yet without medication, readmission rates and costs were much higher. Managed care in America did have many issues in regards to the devolvement of the therapeutic relationship and quality of patient care, as staff were pressured to limit hospital stays and reduced psychodynamic treatments in favour of quicker and easier pharmaceutical solutions. Staff were laid-off whilst workloads soared, which consequently meant that patients were often prematurely discharged whilst still posing a threat to themselves or others. The reality of these dire straits in psychiatry during this period justified Luhrmann’s impassioned plea for society to make better moral choices when caring for the mentally ill. Considering this, it is understandable why Luhrmann concluded that a combination approach of medication and talk therapy was needed - not just to satisfy moral standards, recovery rates and costs, but also so the profession itself could evolve and thrive. Twenty years on since the publication of Luhrmann's analysis, has it?
Nevertheless, despite raising interesting points, Luhrmann arguably presented a rather dull conclusion and has not convincingly demonstrated that a combination approach is theoretically superior than either one, as her focus was primarily on the impact of managed care. Furthermore, at times Luhrmann’s arguments translated in a very sympathetic tone towards the trials and tribulations of various individuals and the “woes” of the industry. This invites the reader to wonder whether Luhrmann strayed from maintaining critical anthropological objectivity and instead may have “gone native” by becoming far too emotionally invested in the lives of those she studied, potentially biasing her arguments towards negatively tarring the industry as a whole. The overall tone of the book seems to want to discourage students from entering psychiatry all together in a seeming attempt to dismantle the vocation as a whole but offers limited useful or constructive solutions. How effective have critical works such as Luhrmann's been in this regard, considering the gradual but obvious decline and change of psychiatry two decades later?
Luhrmann had also demonstrated some inconsistencies in her writing. For example, in Chapter 2 'Arrow of Harm', Luhrmann stated that “when young psychiatrists learn to diagnose and prescribe, they learn that a patient can hurt a doctor” (p. 101), whilst later she says that “doctors can hurt patients” (p. 102). These points appear contradictory and similar issues are reflected throughout other areas too, highlighting fundamental issues in Luhrmann's ability to pitch reliable arguments to the reader, as well as revealing her difficulty in maintaining her role as an anthropologist, rather than posing as an expert on psychiatric matters. She earlier in the book, labelled herself as a ‘halfie’ due to her experiences in both anthropology and psychotherapy. Her father was a psychotherapist and she apparently treated 8 patients with psychoanalysis and received this treatment herself for over 3 years, which may explain why at times her writing appears misleading and poorly anthropologically written - again causing the reader to wonder whether she had “gone native” during her time studying psychiatric culture. Luhrmann explained how being a ‘halfie’ gave her an edge as she “grew up speaking the language of the world” she then described in ‘of two minds’ (p. 3). This had the potential to be interesting and useful, however, she did not deeply explore what affects her ‘halfie’ status afforded her during her ethnographic work, or its limitations, such as potentially biasing her interpretations.
Furthermore, Luhrmann missed discussing psychiatry’s absence in examining the social world regarding potential reasons for people's mental disorders. There was significant emphasis on nature and nurture debates in Luhrmann’s book (e.g. genetics and brain anatomy vs childhood trauma), but there were little-to-none notable analyses of how socio-economic factors, stigma, or discrimination effects may have impacted individuals mental health. Moreover, Luhrmann notably ignores other psychological approaches that were also taught during the time of her writing, such as cognitive and behavioural therapies. Luhrmann would have benefitted from more deeply exploring wider areas of discussion. For instance, Luhrmann's assertions about the dual perspectives in psychiatry stop short after she links it to the 17th Century mind-body dualism. She could have expanded on this by referencing ‘The Perspectives of Psychiatry’ (McHugh & Slavney, 1983) for example, which examines the conceptual foundations of psychiatry, arguing that the war between the approaches resulted from a failure to appreciate that psychiatric thought derives from two modes of reasoning (analysis of form and analysis of function) which can be usefully appreciated within their limits. The first mode looks for laws and mechanisms that provide causal links between various forms that may be correlated with one another, whilst the second concerns the analysis of function (e.g. humans seeking to discover meaning and purpose of various psychological phenomena). McHugh & Slavney (1983) said that these "perspectives of psychiatry" supersedes the biomedical-psychodynamic or brain-mind dichotomy – topics that underpin Luhrmann’s decipher of the conceptual approaches. Both modes can be observed in the psychoanalytic perspective, suggesting greater complexities than Luhrmann gives credit.
Overall, Luhrmann presents an impressive analysis of the broad field of psychiatry and provides the reader with a unique report, however, limited in its anthropological and conceptual reach. Nevertheless, it is arguably difficult for any scholar at that time to have produced a complete deduction of the state and future of psychiatry during the rapidly changing climate of care and politics. Therefore Luhrmann's interpretations do have considerable value, but her insights should not be taken for granted.
It’s intriguing to reflect on the content and meaning of Luhrmann’s work now in 2021, inviting me to wonder what her book would look like if written today. Psychiatry has changed, evolved, and de-evolved in considerable ways, as the face and function of psychology in therapeutic regards has shifted greatly, along with our socio-cultural values and perspectives. Is there hope for psychiatry in the future? Or will it continue to follow trends into irrelevancy, especially as movements further towards psychologists being given prescription rights in the future?
What do you think?