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Summary: An Intellectual's Journey Through the Field of Psychiatry
Review: What do anthropologists do these days as the number of unstudied tribes in the wild has dwindled to something like zero? They practice urban anthropology as they study various "cultures" within the larger society. Here ethnographer, T. M. Luhrmann of the University of California, San Diego, takes a long look at the psychiatric profession and finds it split into two mind sets as it tumbles toward disorder. On the left side we have the traditionalists who believe in the efficacy of psychodynamic psychotherapy (mainly Freudian psychoanalysis), and on the right, "psychiatric science," the biomedical approach, characterized by the use of various psychopharmacological agents such as Prozac, lithium, clozapine, etc. This bicameralization of psychiatry, Luhrmann argues, is in part the direct result of the rise of the managed care industry which is threatening to put psychodynamic psychotherapy (the "talk" cure) out of business because the insurance companies increasingly won't pay for lengthy psychoanalysis. She sees the "psychopharm" cure, even though it is of limited effectiveness (with unknown long-term side effects) as taking over. Thus we have the "disorder" in psychiatry. Her conclusion is that psychotherapy and psychopharmacology together are the most effective method of treating mental illness.In the course of her work, Luhrmann visited various mental health facilities where she observed their practices while she interviewed the doctors, the nurses, the staff and the patients. She constructed composites of some of the personalities, gave them fictitious names, and quoted them. Her style is lucid, and balanced almost to a fault. For example, on page 269 where she is discussing patient advocacy groups, she refers to a magazine called Dendron which seeks alternatives to what it calls "forced psychiatric drugging." In the next paragraph she presents the alternative point of view of The National Alliance for the Mentally Ill which believes that "mental illness is not the result of poor socialization and inadequate parenting but rather a medical condition in need of medical attention." On page 278 she writes, "...in the years of psychoanalytic dominance, the vulgarized psychoanalytic model was used to humiliate and insult the parents whose children suffered." On page 286 she counters, "The real dilemma...faced by our society...is whether we will allow the seductions of the vulgarized biomedical model to overcome our own responsible commitment to a complex view of human life." Thus one can see that Luhrmann has become of two minds herself! She is not, however, an entirely an unbiased observer. As she points out in the Introduction, she got the idea for this study because she joined "an anthropology department known for its long tradition of psychological anthropology," a discipline that "grew out a tradition of using psychoanalytic ideas to make sense of cultural practices." (The Freudian paradigm making sense of New Guinea tribesmen? I think I'll just pass on THAT.) Luhrmann's father is a psychiatrist, and although she maintains that her background "was more cognitive" her experience in writing this book included attending lectures designed to teach "a clinical perspective on Freud and psychoanalysis" (p. 3). Consequently it is understandable that she supports the Freudian psychoanalytical approach. Even so, Luhrmann does not shy away from quoting authorities to the effect that psychoanalytic theory is without a firm scientific basis. However I don't think she goes far enough. What really needs to be said is that the old Freudian psychoanalytic model in which the patient is psychoanalyzed for several years is no longer tenable. It's not just that the insurance companies won't pay for it. There have been many studies from Eysenck in 1952 to the present demonstrating the dubious effectiveness of psychotherapy, particularly in treating the heavyweights like schizophrenia and psychosis. Luhrmann cites studies both for and against this conclusion. She recalls the old "mantra" (p. 208) that "both psychotherapy and psychopharmacology have the same crude success rate: a third of the time they work well; a third of the time, they have some impact; a third of the time they don't work at all." She also makes the point that no one form of psychotherapy is superior to another, that it is the caring and the time spent with the therapist that helps, not the mode of therapy. This last point is really the crux of the matter. Luhrmann writes on page 202: "If the moral authority of the scientist derives from the knowledge he acquires, the moral authority of the analyst derives from the love he gives." On page 201 she quotes Elvin Semrad: "The most important thing, the thing that makes the difference, the thing that we as psychiatrists are dealing in, is love and humanity." It is NOT the Freudian mumble-jumble that helps patients (to the extent that they are helped), but it is the loving concern and care of the therapist. If this is so, it raises the question, why do therapists need to go to medical school, need to study the now largely discredited Freudian mythology, need to spend years in psychoanalysis to be no more effective than a counselor from the local church? The answer is they don't. And this is part of the reason for the split and the crisis in psychiatry. What needs to be gotten rid of, and I don't think Luhrmann really sees this, is the Freudian baggage. Psychodynamic psychiatry really needs a framework and model more nearly consistent with the advances in knowledge about human beings that have occurred since the days of Freud. Those old ideas of "penis envy" and Oedipus complex, etc., as significant factors in mental illness must be scrapped. The revelations and the paradigms from cognitive psychology and evolutionary psychology need to replace the Freudian construct.
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