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Of Two Minds: The Growing Disorder in American Psychiatry

by T.M. Luhrmann

Alfred Knopf, 2000. 338 pages. Hardcover: $26.95
Review by Harriet Baldwin, David Seaman, and William Zaccagnino, NAMI Literature Committee

T.M. Luhrmann is an anthropologist at the University of California, San Diego. She studied the medical education of psychiatrists during several years of fieldwork, observation, reading, and interviewing residents and practicing specialists at a number of hospitals and outpatient psychiatric units.

Of Two Minds is scholarly, thoroughly researched, anecdotal and analytical, well organized, interesting, and often eloquent. Luhrmann's anthropologist perspective provides new and important insights as she travels the familiar terrain of diagnosis and treatment. She notes a striking conflict within the practice of psychiatry, which is the "growing disorder" to which her subtitle refers.

Luhrmann studied the two current branches in psychiatry and psychiatric training, the biomedical model and the psychodynamic model. She believes the split occurred in the late 1970s and early 1980s. (See her excellent chapter, "Where the Split Came From.") The rise of managed health care in the 1990s began pushing talk therapy out of the picture and replacing it with a growing number of increasingly successful medications. After all, prescribing medications is easier and faster and cheaper than talk therapy. This shift, Luhrmann maintains, comes at considerable cost to consumers and their families.

Many psychiatrists use both medication and forms of talk therapy. The latter is practiced widely by clinical psychologists, social workers, and counselors. Luhrmann calls the combination "two-tone therapy." But her book raises serious and worrisome questions about the separateness of the two approaches and the different methods of training, with little crossover, and the philosophical and ideological dispute that underlies the separateness. She is emphatic that "for most psychiatric problems, a combination of psychopharmacology and psychotherapy provides the most effective treatment." Neither talk therapy nor medication alone is the answer for most ill persons, and reduced services under managed care are threatening access to both.

Luhrmann's final chapter addresses society's moral responsibility for providing suitable care for people with mental illnesses. NAMI members and friends should heed this advice. A long road stretches ahead as we work to further understand the complexity of these serious illnesses, but Of Two Minds is good map of today's landscape