Of Two Minds
The Growing Disorder in American Psychiatry
by T. M. Lubrmann
Knopf, 352 pp., $ 26.95
The condition of psychiatry today can be compared to that of Russia after the fall of communism. Like Russia after Marxism, psychiatry after Freudianism has lost its once dominant doctrine. Like that vast nation attempting to operate under a rudimentary capitalism, psychiatry now labors under the sway of a classificatory system, The Diagnostic and Statistic Manual of Mental Disorders (DSM-IV), so crude as to foster inept educational programs and clumsy clinical practices. Just as Russia searches for a structure to replace communism, so psychiatry, with Freudianism in ruins, struggles to find a coherent concept of the mental disorders and the best way to treat them.
Surveying this confusing scene, the anthropologist T. M. Luhrmann has produced Of Two Minds: The Growing Disorder in American Psychiatry, a bleak assessment of contemporary psychiatric education. Casting her eye on the "enculturation" of young psychiatrists into their profession, she argues that the recent discoveries in biomedicine, which the public may think are great advances, have in fact plucked the "soul" from psychiatry, leaving it a cold business that dispenses magical pills rather than addressing patients in all their tragic particularity.
Much of Luhrmann's criticism is dead-on target, and it is useful to have it said in this public way. Unfortunately, she concludes that the answer is a return to Freudian psychoanalysis. It is as though, after visiting Russia, an anthropologist decided the country had made an enormous mistake in abandoning Marxism. Luhrmann misleads for two reasons: She slights the history of psychiatry, aspects of which explain both its problems and its promise; and, more important, she neglects fundamental issues of method, particularly those of assessing, differentiating, and understanding patients, from which therapeutics emerge. Thus, Luhrmann fails to see that the present, with all its shortcomings, is actually auspicious, a stage in the development of psychiatry where, even amid the rubble, it is possible to discern the foundations of progress.
I began my own career in psychiatry in the 1950s, in the middle of what historian Edward Shorter called "the hiatus," the generation-long period, roughly from 1935 to 1975, when Freudianism was the unchallenged doctrine of American psychiatry. During the hiatus, psychiatry ceased to grow as a science-based, evidence-driven discipline.
As medical students, my classmates and I were taught that psychoanalysis had revealed that mental disorders differed only in degree rather than in kind. Mental disorders were invariably the consequences of mishandled early-life conflicts of a sexual nature -- universal experiences varying in severity. We were taught that particular symptoms identified the character of those conflicts; no other evidence was needed because the "symptoms tell the tale." Compulsiveness and perfectionism denoted over-forceful toilet training in infancy, anxiety was the product of the childhood discovery of anatomical differences between boys and girls, and paranoid suspicions gave evidence of repressed homosexual conflict.
We were also taught that these early conflicts and pathogenic events were masked by repression but alive in the "dynamic" unconscious, shaping our mental life. Because sexual conflicts in infancy were universal, no real distinction existed between us students and the patients. We were taught that if our society altered its methods of child rearing and attitudes toward sex, mental disorder would diminish and all would be well. A brave new world seemed to be dawning.
At the same time, we students noted that the psychiatric wards differed radically from other medical wards, like neurology, cardiology, and surgery. The most obvious difference was that on the psychiatric wards not only the patients but most of the staff were in therapy. Again, this practice was prompted by the theory that psychiatrists and patients differed only in degree of disorder. Young psychiatrists were told to think of themselves as "little messes" caring for "bigger messes." Their supervisors encouraged this idea.
With most doctors, nurses, social workers, and even office personnel in therapy, the libidinal mini-dramas of everyone's encounters with his or her therapist became a topic of gossip within psychiatric centers. Certain psychoanalysts (particularly those who claimed close descent from Freud and retained the accents of old Vienna) dominated these centers and frequently used the political power that came from knowing many secrets to advance their favorites and banish their foes.
The psychiatrists-in-training, preoccupied by their own therapy, gravitated toward the patients who were most like themselves, withdrawing attention from the seriously mentally ill (patients with schizophrenia and manic-depression). Young and articulate patients, often female and worried over romantic adversities, were sought out, especially if they (or their parents) were wealthy enough to support the standard psychoanalytic treatment, a years-long course of fifty-minute therapy sessions as frequent as five times a week. A corrupting self-absorption pervaded psychiatric departments.
The seriously mentally ill -- the counterparts of the seriously physically ill, who were the mainstays of training programs in the other medical specialties -- were considered "too regressed" for educational purposes, too damaged by experience in their childhood to be promptly helped by psychotherapy. They were transferred to the state hospitals, though authorities in the universities promised that their time for treatment would come after the less-seriously disturbed had resolved their troubles. It never did.
Scientific research was neglected. Why do research when we already knew, on the basis of Freud's writings, just what constituted the causes of mental problems? Research -- if you can dignify such work by that term -- took the form of composing ingenious metaphors linking conjectured sexual conflicts to the symptoms seen in patients.
The classic Freudian example proposed that paranoid delusions -- especially the persecutory, jealous, or amorous ones -- were all distorted expressions of homosexual conflict derived from "arrests" in childhood sexual development. Thus a man's latent, unconscious, and unacceptable idea "I love him," once transformed by unconscious mechanisms, manifested itself as one of three delusional beliefs: the persecutory ("He hates me"), the jealous ("My wife loves him"), or the amorous ("Another woman loves me").
By the 1950s, leading American psychoanalysts were competing to see who could derive the flashiest connections from superficial resemblances between mental symptoms and events in patients' lives. The interpretation of genital symbols became a way of finding sexual meaning in mental disorders. None of this could be called research, and none of it advanced the care and treatment of patients or the elucidation of mental illnesses.
A telling and ultimately fatal flaw within the psychoanalytic movement was its fissiparous character -- present almost from the start, when Adler and Jung split from Freud to produce their own schools of thought. In America, the Freudian school was initially successful in dominating the strategically crucial centers of the university clinics and teaching hospitals in the East and the salons of Los Angeles and Hollywood in the West (where Freudian ideas influenced the motion picture industry).
Dissension between orthodox and reform sects of American Freudianism soon erupted, as subgroups of psychoanalysts hived off into separate psychoanalytic training institutes in every large city, with much ill will and repudiation all round. Each center devolved its own organization, initiation rights, rules of membership, and official doctrine about the "keys to meaning." Each presented itself as providing a different kind of analyst -- and postulants faced the problem of choosing among them. This fractionalizing demonstrated the cultic character of psychoanalysis; it was more Greco-Roman than modern, in its call for commitments to different conceptions of reality rather than to the single medico-scientific method guided by observation, reason, and experiment.
This sectarianism not only added heat to psychoanalytic convictions, but made criticism of Freudian ideas more difficult. Psychoanalytic propositions became moving targets, and challenges from psychiatrists outside the establishment were evaded or rejected as ignorant of the present state of the art.
I can testify to the frustration felt by those questioning psychoanalytic concepts such as repression, the dynamic unconscious, dream interpretation, and the rest of it. We were dismissed as being either in bad faith ("Freud bashing") or simple-minded and insensitive, given the "advancing" character of theory and the subtle, "concerned" thought of psychoanalysts. I learned firsthand the validity of philosopher Ernest Gellner's comment about psychoanalysis: "Evasion is not brought in to save the theory: It is the theory."
During the 1960s, events conspired to bring the dominance of psychoanalysis in America to an end. The most dramatic of these was deinstitutionalization of the seriously mentally ill. This radical venture rested on two related justifications. The chief one came from the discovery (mostly by chance) in the 1950s and 1960s of medicines that acted against the symptoms of schizophrenia and manic-depression, relieving the hallucinations and delusions that had kept patients sequestered in mental hospitals. It was only logical that the mentally ill -- who, remember, in theory were just like the rest of us only more seriously disturbed -- shouldn't be locked up in distant hospitals if medications could make them less threatening and dangerous. They deserved what the less-ill had long been allowed: freedom to look after themselves, while receiving psychotherapy in centers for ambulatory patients.
Vast deinstitutionalization of the mentally ill was launched in the late 1960s. Patients who had lived for years in outlying, dilapidated state psychiatric hospitals were released to urban and academic psychiatric centers for treatment. The psychiatrists there, previously honored for their therapeutic skills, found that they could not manage these new arrivals. They did not understand the medications that had been used in the state hospitals, and the Freudian-based psychotherapies, so time-consuming, were ineffective. The patients spilled out into the city streets, and the deficiencies of psychiatric know-how became obvious to anyone with open eyes.
The psychopharmacological advances on which these hospital discharges depended also made it possible to differentiate patients. How could anyone claim that mental illness is all one, a la Freudianism, when only patients with manic excitement responded to lithium salts? And if anti-depressant and anti-schizophrenic medications worked only for certain patients, then one must conclude that the patients differed in their brains. As distinctions like these became critical for treatment, psychiatrists began to look back to the decades around the turn of the century when the distinctions between conditions such as manic-depression and schizophrenia had first been identified.
Psychiatry began to stumble toward the path of empirical science that general medicine had followed since the mid-nineteenth century. Progress began to appear, especially in the diagnosis and treatment of the seriously ill. Psychotherapy itself came under study, and several investigative psychiatrists began to challenge the claim that cure came from treating the Freudian "pathogenic" events of childhood -- the Oedipal complex, castration anxiety, penis envy, and the like.
Dr. Jerome Frank at Johns Hopkins, a pioneer in psychotherapy research, investigated hundreds of patients and concluded that healing depended upon general rather than specific factors: the patient's receiving an acceptable and persuasive explanation for his distress from a therapist who could evoke some emotional arousal during the treatment and who carried some culturally licensed authority as a healer. These characteristics were common to many psychotherapies, not restricted to psychoanalytic ones.
More important, Frank proved that patients in psychotherapy did not resemble one another in the cause of their distress. No common theme of childhood sexual conflict or developmental arrest, no particular psychic complex, characterized them. Rather, these patients were alike in their symptoms and in the habitual ways they approached difficulties: They were all "demoralized," overmastered by some problem usually related to their present life. Frank noted that successful symptom-relieving psychotherapy worked by providing patients with ways to achieve mastery of their situations; it did not depend primarily on insight into early life conflicts. He demonstrated these facts about psychotherapy with standard scientific methods, among them placebo controls, comparative outcome studies, and numerate evidence.
Jerome Frank's work was an enormous challenge to both the theories and the practices of psychoanalysis. In the 1970s, Dr. Aaron T. Beck of the University of Pennsylvania furthered this advance in psychiatry by developing and teaching an effective psychotherapy that attempted to correct the self-defeating attitudes and assumptions that provoke demoralization. Calling his program "Cognitive Behavioral Therapy," he demonstrated in therapeutic trials that patients so treated recovered more frequently from depression and anxiety than did patients treated less systematically. Evidence-based psychotherapy at last became a reality.
Like Frank, Beck showed that no single attitude and no common early childhood trauma afflicted his patients. They all needed and responded to a treatment that uncovered how they were demoralized by their habitual attitudes and presumptions. These could be directly challenged and rescripted as the patient came to see the role they played in his distress and as the psychotherapist proposed and reinforced more constructive ways of thinking and responding to the circumstances life had set before the patient. Since Beck's work, other therapists have demonstrated ways of encouraging patients to recognize how their attitudes and assumptions are self-defeating and can be changed.
The preeminence of Freudian psychoanalysis was essentially over by the end of the 1970s. Freudianism did not end with a bang, as did Marxism. It just petered out, as fewer and fewer of the best students came to believe that they should devote time to it -- though a nostalgia for psychoanalysis persists in some circles to this day.
T. M. Luhrmann's Of Two Minds turns out to be just such a nostalgic glance back. Begun as an empirical work, it is the product of her four-year study of American psychiatric education. Luhrmann -- a professor at the University of California-San Diego and author of previous works on ritual magic and colonial society -- visited a number of centers where psychiatrists are trained. She observed the care being delivered by resident psychiatrists and the teaching methods employed to guide them. She put in long hours talking with teachers, residents, medical students, and patients.
In many of the centers she visited, Luhrmann found confusion and misdirection. Sometimes she found students deeply distressed over conflicts among their teachers and over the restrictions placed on services by insurers. She reveals how, in some training centers, the teaching of thoughtless diagnostic formulas and reflexive prescriptions for medication is dehumanizing the contacts between patients and psychiatrists. Depression? Bring out the Prozac. Attention Deficit Disorder? Toss down the Ritalin. The very advances in biomedicine that have immensely facilitated the treatment of mental illness have damaged the psychiatric profession. Young psychiatrists lack both the time and interest to bring their patients "the commitment we feel toward full-fledged human beings."
But a problem arises. Early in her book, Luhrmann notes that, in preparation for her immersion in the field of psychiatry, she herself entered into psychoanalytic psychotherapy. She did so because psychoanalysts told her that, if she were a patient with them, her understanding of the educational and treatment services she would be witnessing would be deepened. Unfortunately, her own psychoanalysis has left her a partisan, a captive of one of the vested interests whose influence on the course and content of psychiatric education she intended to study.
Because of this bias, Luhrmann found only in the outpatient services, where psychotherapy is dispensed, what she deemed a proper concern for individual patients. The title of her book, Of Two Minds, is intended to emphasize that students of psychiatry feel themselves citizens of two worlds: one of brain material and medications, the other of human feeling and the "soul-craft" of dynamic psychotherapy; one of white-coated scientists who expound on brain systems and medications and treat patients like objects, the other of thoughtful, tweed-coated psychotherapists explaining the tortured lives of people who, but for the grace of God, are you and I. Ominously weighing in on the side of the white coats are the administrators of managed care, who, Luhrmann says, see the soul-craft of psychotherapy as unnecessary.
Luhrmann champions psychoanalytic teaching as fundamental to the training of young psychiatrists. In this, she is simply mistaken. We can no more return to the old orthodoxy than Russia can revive the Soviet Union. Luhrmann fails to appreciate that psychiatry is well free of the dominance of a conjectural theory that cheated many patients out of helpful treatment and caused a great many talented students to waste years of their lives on fruitless study.
It may be that Luhrmann expects some compromise to emerge, in which a portion of the old Freudian creed is reassumed. Reasonable though this sounds, no middle ground is possible. The psychoanalyst and the science-based psychiatrist are not to be thought of as simply having different ways of interpreting an agreed upon set of clinical observations -- interpretations that could be negotiated between them. The hard fact is that the two take opposing positions over what exists -- what counts as real in mental life -- and how one should study it. Repudiation of the other, not conciliation, is the aim of each, as both parties will gladly explain.
I disagree with Luhrmann, too, about the role of managed care. Like many of the psychiatrists she talked with in her travels, she views it as menacing the future of psychiatric practice and education. But managed care, while an annoying burden, is one, I'm afraid, that psychiatrists brought on themselves. Back when psychological treatments ran solely on Freudian concepts, patients were often kept in treatment until their money ran out.
Little or no effort was made to test the efficacy of psychoanalytic programs. For all that the business ethic of managed care now threatens benefits to patients, this threat will subside when outcome studies demonstrate what evidence-based psychiatry can do. Psychiatrists must show how their diagnostic formulations and therapeutic plans lead to recoveries. Only then will they become powerful advocates for their patients and see their opinions taken seriously by health systems.
Where T. M. Luhrmann sees growing disorder in psychiatry, I see growing pains. These will be resolved through study of the methods that psychiatry uses, which Luhrmann neglects. Psychiatrists must learn how to think about different psychiatric patients. They must employ different methods of reasoning for different patients -- methods that, though distinct in their application, are not in conflict.
The German psychiatrist and philosopher Karl Jaspers spoke to the fundamental issue of method with great penetration and lucidity in his magisterial book General Psychopathology, published in 1913. (Although brought out in English by the University of Chicago in 1963, this work has been largely unnoticed in the United States. It was reissued by Johns Hopkins University Press in 1997.) Jaspers laid out the methods that psychiatrists need to employ to evaluate and make sense of the different mental disorders. He provided the rules, standards, and means for making useful, replicable observations of psychiatric patients. He delineated the different mental states and symptoms psychiatrists would find when they studied their patients systematically. And then he described the two distinct methods of reasoning available to psychiatrists to explain their patients' signs and symptoms.
Jaspers noted that psychiatrists, in seeking to explain mental illnesses, drew both from medical science, where the processes of nature that damage health are discerned, and from history, where fateful events and personal choices disrupt mental serenity. Specifically, he taught that some mental disorders derive from brain diseases, whereas others derive from conflict between a person's hopes and what life deals out to him. He defined the strengths and limitations of each of these methods of reasoning: scientific reasoning from empirical evidence, and historical reasoning enriched by empathetic insight. He demonstrated how both are indispensable to the psychiatrist, who must not confuse one with the other.
By distinguishing the explanation offered by science from the compassionate understanding offered by history, Jaspers identified the epistemological and therapeutic divide into which Luhrmann stumbles. Jaspers proposed that psychiatrists receive an education in theory and practice that demonstrates both methods in action -- an education best provided by teachers who apply them in research. He wrote brilliantly about psychotherapy and also anticipated the advances in brain science and pharmacology we are witnessing today.
Jaspers saw not Luhrmann's two minds but a single psychiatry encompassing two explanatory methods. These methods are not difficult for a single mind to grasp, if they are exemplified in teaching and research. They are readily integrated in practice -- both for seriously ill patients who have major brain diseases and for demoralized patients facing conflicts in their personal lives.
But woe, Jaspers said, to those who do not understand the distinctions between these methods of reasoning and try to make one method dominate psychiatry. They will interrupt progress and alienate their students. Jaspers went unheeded in America, even as he warned against the tragically wasteful hiatus produced by Freudian dominance, which has left psychiatry today in its conceptually primitive state.
But I am optimistic. As psychiatry becomes more coherent -- pushed in part by managed care and instructed in part by a reassessment of its methods of thought -- psychiatrists can present themselves to the public just as physicians and surgeons do, and no longer as practitioners of a mystery cult, condescendingly proposing crude, sexualized ideas about human nature. Psychiatrists can then emerge as members of a medical specialty who, like all other doctors, are committed to healing -- rather than indoctrinating -- their patients.
Paul R. McHugh is the Henry Phipps professor of psychiatry and director of the department of psychiatry at Johns Hopkins University School of Medicine, psychiatrist in chief to Johns Hopkins Hospital, and the author, with Phillip Slavney, of The Perspectives of Psychiatry.