Of Two Minds
(Vintage)Dr. Luhrmann is an anthropologist and she uses her background in Of Two Minds to examine the history of American psychiatry, it's purpose and practice up to the coming of managed care --- and to look at the profound changes that have come about due to the economics of health care and the influence of the insurers.
To prepare, she read the clinical journals. She went to the annual meetings. She worked at a variety of in-patient and out-patient clinics --- both as an observer and as a volunteer. She followed medical students around when they are in training to become psychiatrists. She was with them on the wards, in the clinics, in their classes, in their staff meetings, in their group therapy sessions, and --- as far as possible --- in their private practice. She seems to have read everything she can get her hands on --- most rewardingly on Freud and American psychoanalytic theory and practice: her chapter on the American Psychoanalytic Society is a gem.
It's hard to summarize a book as rich as this one. We are staggered not only by the amount of research that went into this volume, but the way that she organized her material --- and, most of all --- the grace of her writing. It is rare that one stumbles across a study of the field that is hard to put down. She describes the many faces of psychotherapy as it developed in America --- not only Freudian psychoanalysis, but the off-shoots (behaviorism, Jungian theory, brief therapy, family therapy, et. al.)
She suggests that the most effective training is that which emphasizes the love that a therapist must have for his patient. She is specific: it is "not possessive love, not sexual love --- but agape," the love of brotherhood that came out of Christianity.
She studies the dyads: how can a therapist love a patient and yet not get enmeshed in the patient's problems to such a degree that he may lose balance --- and the ability to support? How can we compare the use of talk therapy (which has never, in controlled studies, proven to be effective) with the startling power of the newer drugs? How can help for those in mental pain be treated honestly and well, while the insurance companies are demanding cold efficiency which has the effect of putting an end to the many uses of instinct, experimentation, and balance that made psychotherapy such a vital force of change for so many of us?
Most of all, Lurhmann is wonderfully gifted with words:
When psychosis is not brutally awful, it is funny, and sometimes looking for the humor in it makes it more possible to handle the pain of seeing a human being lose his mind. One of the patients on the unit decided that another patient was trying to poison him and gave up eating. The patient he chose as the villain was so depressed that the staff had been worrying about how to get him out of bed, let alone do anything that required so much energy as diabolical crime . . . In practice, the joke could run the other way as well. There was the narcissistic patient who spoke grandly about his personal friendship with the director of the hospital and other important people. His resident was touched by what he took to be the needy loneliness of the old man and mentioned it to the director at a social function. "Sam's here?" the director said. "Why didn't anyone tell me? I must go see him. He's been an important friend to the university."
Her insights are breathtaking. Interns learn early on to see patients as the enemy: they can keep one up all night, and if you blow it, they can sue you (and possibly win). She sees psychoanalysis as "amoral:"
Analysts do tend . . . to listen in order to understand, not to judge. They want to know why someone committed adultery and lied about it more than they want to condemn the action. They are interested in intentions, both conscious and unconscious, and in how these intentions lead to action. They see, as one senior analyst put it, action as in service to the self, and what fascinates them is not what people do, but why --- what self those actions serve.
Luhrmann is not swept up in adoration of any one school. She quotes with glee one doctor who said that going to the American Psychoanalytic Association meetings "was like watching dinosaurs deliberate over their own extinction." She is fascinated with what psychiatrists learn and how they learn it. She says that when they observe the patients in a waiting room at a university hospital, its not unlike the rest of us walking across the field with a birdwatcher: you and I might notice the flowers and trees; they will see twenty different species, in flight and in hiding.
She's interested in how doctors employ words: for instance, the word "use." A psychiatrist will say, "With an older patient I'll use half or a third what I'd use with an adult." Or, "I use trazodone at lower levels during the day if the patient is still anxious and depressed." It's a contrary art. If a patient says, repeatedly, "I am not sick," this becomes a symptom. Most of all, she makes us feel how very different psychiatrists are than the rest of us, especially with their incessant talk about feelings:
They are, with respect to private matters, the singularly most talkative people I have ever met. They talk about private matters to the point that they may feel abused . . . To be open is to be competitive, because it is to assert psychodynamic competence as if to say, "I know myself, while you fear yourself, you refuse to acknowledge your weakness."
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As I said earlier, she writes like a dream. For instance, note here her use not only of imagery ("flashlight in a candle factory"), but the use of a quasi-legal term ("jurisdiction"), a religious one ("theology"), and one from the world of economics ("competitors").
Freud's theories were like a flashlight in a candle factory. He offered models of the mind, elaborate theories, specific explanations (for psychosis, hysteria, even jokes), and a specific technique. The competitors had an optimistic theology and some homespun remedies. Freud's ideas decisively won for the psychiatrists the battle for jurisdiction over ordinary human unhappiness. That victory considerably broadened the patient pool for psychiatrists.
And then there is the dilemma that psychoanalysis represented fifty years ago,
The assumption seemed to be that if a psychiatrist could be everywhere, he would be able to solve all social ills. This was not the psychoanalysis of devastated Europe but a bright, shiny intellectual appliance, an automated floor buffer for messy psyches.
An automated floor buffer! Then this quick study of the paradox of psychological "resistance," what it meant to the early Freudians:
All patients were understood to be crippled by emotional conflict, which made them desperately unhappy. Yet the patients themselves were thought to provide the greatest impediment to the resolution of that conflict. This was their "resistance:" a refusal to see the conflict for what it was, a psychically manufactured distortion of their real experience. The recognition that each of us builds the cage of our own imprisonment and then howls against the injustice of our confinement is brilliant and deep. But it can also be used to argue that the analyst is always right. The failure of therapy could always be attributed to the patient.
She refers to this, rightly, as "arrogance," for it is
the implicit assumption that accepting an analyst's authority was the route to cure, could also have the effect of focusing attention on the interpretation of an illness rather than on the illness itself.
I can't think of any issue I have run across in my rather haphazard psychotherapeutic studies that Luhrmann doesn't touch on. She lists the big three of what she refers to as "strange miseries:" depression, manic depression (or bipolar disorder), and schizophrenia. She spends a great deal of time on DSM III --- the Diagnostic and Statistical Manual of Mental Disorders --- how it came about, how it is used by the insurance companies to define mental problems and define quick solutions.
She shares some delicious insights into the training methods of American medical schools, and on internship and residency. She speaks movingly of how therapists, to be effective, must love. She recites from her own experiences on the wards of the frustrations of dealing with "borderlines" ("These are patients who have usually been badly abused and oversexualized, and they are often seductive, charming, and thoroughly absorbing.")
And she speaks, with true and heartfelt regret, of the dismantling, through HMOs, of much that is good and successful in the old-line hospitals and clinics --- ones that utilized "talk" therapy to help those immersed in emotional grief. The reason: the bottom line, and psychopharmacology --- which "fits more easily into these time-limited constraints than psychotherapy does."