Young doctors studying to be psychiatrists must often choose between two
seemingly contradictory points of view.
By STEPHEN S. HALL
 
OF TWO MINDS
The Growing Disorder in American Psychiatry.
By T. M. Luhrmann.
337 pp. New York:
Alfred A. Knopf. $26.95.

There is a popular aphorism among research scientists to the effect that if,
in the course of performing an experiment, you pose the question in the wrong
way, you are doomed to arrive at the wrong answer. That bit of scientific
folklore occurred to me repeatedly as I made my way through ''Of Two Minds:
The Growing Disorder in American Psychiatry,'' T. M. Luhrmann's fascinating
anthropological study of the way young doctors learn to be psychiatrists.
What becomes clear, as one reads deeper into her book, is that we are in the
midst of an enormous social and medical experiment about the way we deal with
mental illness in this country. Not only have we posed the question
incorrectly, according to Luhrmann, but we are doomed to reach a tragically
wrong, and profoundly immoral, answer by doing so.

The question that lies at the heart of ''Of Two Minds'' is one that, in
simplified form, has riven psychiatry for at least 20 years. Are mental
illnesses like schizophrenia, depression and personality disorders a matter
of biological dysfunction and thus best treated pharmacologically, or are
they the product of psychosocial factors -- family dynamics, early childhood
experiences, the whole closet of Freudian baggage -- and thus best treated by
psychotherapy? What makes the question flawed, of course, is the way it is
posed, as an either-or proposition. Luhrmann's book bears witness --
unwittingly at first, then with increasingly cleareyed intellectual analysis
-- to the fact that a third party, namely managed care, has seized upon that
flawed question and answered it ''irrevocably'' in favor of biological
psychiatry, with ramifications that will very likely be felt in this country
for decades to come.

Aspiring psychiatrists straddle two seemingly contradictory worlds: the hard,
quantitative world of medical science and the more ambiguous, intuitional
world of human interaction. Trained as doctors, they attend four years of
medical school and serve internships for a year in settings that resemble
''E.R.,'' not Freud's study in Vienna. Then they typically spend at least
three years as residents specializing in psychiatric medicine, treating both
the severely ill (in the hospital setting) and the less incapacitated (in
outpatient clinics). It is during the formative years of residency that the
two rival models of psychiatric medicine compete for the hearts and minds of
tomorrow's practitioners, and it is the voices of this population -- earnest,
confused, overwhelmed and more and more cynical -- that fill ''Of Two
Minds.'' As Luhrmann writes, young psychiatrists are in principle supposed to
learn to be equally good at talk therapy and drug therapy, equally conversant
in the theories underlining psychotherapy and biomedical psychiatry. But in
practice, the two approaches are often seen as antagonistic. ''By the end of
your second year,'' a resident says, ''you have to decide which camp you're
in.''

In the course of nearly a decade of research, Luhrmann, a professor of
anthropology at the University of California, San Diego, inhabited the
various nests of these psychiatric fledglings. Her shrewd, witty observations
ring true: when she innocently begins inquiring about a claim she's heard
that residents at a university in Kentucky diagnose mental disorders in 30
seconds, administrators at the hospital she's visiting hasten to assure her
that diagnoses are based on a thorough and painstaking patient interview,
while the residents on the front lines respond by wondering what takes their
colleagues in Kentucky so long.

By good fortune, Luhrmann happened to choose a particularly pivotal moment in
the history of psychiatry. Most readers will be familiar with the tectonic
ideological stresses that have caused such visible upheaval in the field
today: the repudiation of many Freudian tenets, the rise and undeniable
success of new medications to treat the most intractable forms of mental
illness and the more impersonal, hurried approach that often comes with the
dispensing of drugs. But these ideological differences reverberate day by day
for trainees. ''Working with these different models,'' Luhrmann writes,
''changes the way the staff joke, the way doctors relate to nurses and even
the sense of the unit's ultimate goal. Ultimately, these differences help to
produce different moral sensibilities about mental illness.''

Part of this dynamic, of course, involves psychoanalysis' fall from grace.
Almost willfully nonquantitative, as Luhrmann notes, the field never bothered
to prove its worth with outcome studies, never conceded that talk therapy
might be wholly ineffective against the most severe disease and never owned
up to the scandal of implicating family dynamics in models of illness that
now seem firmly rooted in brain dysfunction. The handwriting on the wall, in
terms of the beginning of the end of psychoanalysis' golden age, coincided
with the handwriting on the prescription pad. In 1954, Smith Kline & French
began to market the antipsychotic drug Thorazine as a treatment for severe
illnesses, and as neuroscience became increasingly sophisticated and
increasingly molecular in the decades that followed, ''illness'' as the term
of choice for mental disorder subtly gave way to ''disease.'' In one
fascinating aside, Luhrmann reports that psychiatrists who trained during the
1960's began to distrust the psychoanalytic model in part because of their
own use of recreational drugs like LSD. ''If a drug can do this to my sense
of reality, what am I doing taking all this psychoanalytic stuff at face
value?'' one psychiatrist recalls thinking.

Luhrmann is not the first observer to lament the loss of the psychodynamic
component in the treatment of psychiatric disorders. The power of her book,
however, derives from the intuition that initially brought her to the
project: by focusing on trainees, she positions herself to understand sooner
than the rest of us that the brief, swift and brutal impact of managed care
is destined to diminish the practice of psychiatric medicine for years to
come. ''Patients are less well off without psychotherapy,'' she writes near
the end of her book. ''They do less well, are readmitted more quickly,
diagnosed more inaccurately and medicated more randomly.'' She approvingly
quotes one senior psychiatrist as saying, ''You cannot adhere to untruths
without being immoral in some way.''

Many readers may find Luhrmann's sympathetic discussion of psychotherapy a
little too forgiving. I found it refreshing. All the same, I would have liked
a less understated treatment of the enormous excitement about contemporary
neuroscience, and perhaps more than a nod in the direction of some of
psychotherapy's successes, like cognitive behavioral therapy.

There are two casualties of psychiatry's split personality. The first, and
most obvious, is the patient. Toward the end of her fieldwork, Luhrmann
revisits a hospital where she spent considerable time in 1992; she describes
the experience as ''a little like coming back to a tree-lined London
neighborhood after the blitz.'' A third of the staff had been fired;
gardeners and cooks had been dismissed; salaries were about to be slashed;
and many senior psychiatrists had left, in sorrow and disgust. ''I left
myself,'' one psychiatrist said, ''when a patient came onto my unit and tried
to hang herself twice by the end of the first day, and then Utilization
Review [a hospital office that negotiates with the insurer] said she'd only
been authorized for a two-day admission and would have to be discharged. I
kept thinking about what the jury would say if she killed herself and I was
the one held liable.'' The reader comes away with the overwhelming sense that
an institutional, economic and almost philosophical form of medical
malpractice has been unleashed upon psychiatric medicine, and it has
condemned -- in the name of controlling costs -- thousands of patients to
permanent illness.

The other casualty is less obvious. One can foresee, in the not-too-distant
future, what might be called a grand unification theory of psychiatry, a
convergence of the psychosocial and the molecular, of talk therapy and drug
therapy, where the psychological residue of hectoring mothers and absent
fathers might plausibly find microscopic correlation in the residue of
proteins in synapses, and where the psychoneurological patterns associated
with those residues might plausibly be rearranged not only by drugs but by
conversation. It is the demoralizing implication of ''Of Two Minds'' that we
now might never have a chance of reaching that future at all.
 
 
 

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Stephen S. Hall is the author, most recently, of ''A Commotion in the Blood:
Life, Death and the Immune System.''