Of Two Minds

Managed care is drastically shortening the time in which the mentally ill can afford to be hospitalized, and making it harder for most people to afford outpatient psychotherapy. Drugs are cheaper and faster. But do they solve the underlying problems in people's lives, or merely mask symptoms? The growing distance between those who believe in medication and those who put their primary faith in therapy is one of the burning issues Tanya Luhrmann explores in this excellent work.

On the question of whether or not mental illness is biological, she writes, "A recent survey on world mental health observed that in all different age, gender, and cultural categories everywhere, the most important risk factor for mental health is social disruption . . . Poverty, war, and dislocation are bad for people-an obvious point, but important if you are tempted to think of psychiatric illness as purely hereditary." Although she considers many different points of view on the question, here is one of her own conclusions: "I believe both the biomedical and psychodynamic approaches to psychiatric illness to be substantially correct and equally effective, although not always for the same person." Not everyone agrees with her, of course.

Of the current trend in psychiatry she says, "Psychiatric science is now configured, at least for many of the more senior scientists, as a rejection of the psychodynamic approach to mental illness. This rebellious aspect of psychiatric science might well vanish in two decades. But now it is very real." The author is an anthropologist who decided to study the training of American psychiatrists, and the result is a dense but not difficult book. Her research is very thorough: over the course of more than four years, she immersed herself in psychiatry classes and hospital rounds; she shadowed young doctors and interviewed numerous patients. She observed those in psychotherapy and those on medication. Luhrmann reports on the courseload, the workload, the strengths, weaknesses, fears, and successes of the psychiatrists-in-training. What are they trying to do? Are they making a difference? Truly helping patients? Is their training adequate to equip them for the real-life situations they encounter? Are they too constrained by the limits of health insurance to offer proper care? Too quick to offer drugs when human interaction is called for? Or too hung up on Freudian theories to recognize when a problem is simply chemical? The human stories here are well-written, moving, and insightful, and the conclusions are well-documented and clearly explained.

Among other topics, Luhrmann looks at some of the causes of depression, a very important question in this modern "Prozac Nation" in which it sometimes seems that everyone is taking drugs for something. If we're all depressed, then what's normal? Here's one of her answers to that: "Depression, and mood disorders in general, may be more common in the twentieth century than every before, because in no other time of human history have so many people been so isolated." "More people," she says, "live alone in America than ever before-a quarter of all Americans, compared to less than 10 percent in 1940 and probably almost none in our ancestral past. . . From a human evolutionary perspective, this is bizarre." Anyone with a serious interest in mental health can find much that is useful, elucidating, and even intriguing here.

© 2001 Heather C. Liston