Before I start, let me just give a little bit of background information about the book, Of Two Minds. The book was written by T. M. Luhrman, and at the time when the book was published in 2001, she was a professor in the Committee on Social Thought at the University of Chicago. She may or may not still be at the University of Chicago now. Let me make it clear too that Luhrman is an anthropologist by education, not a psychiatrist, and never enrolled in medical school. In addition to having a background in anthropology, she chooses to concentrate on American psychological anthropology, with a specific interest in the field of psychology. Luhrman did go through training in psychoanalysis, which is based on Freudian theory. The technique of psychoanalysis itself can still be found in the U.S., but it has received less attention and interest as time progresses. The basic theory behind psychoanalysis, however, is still taught in psychology programs and used by many psychologists, but mostly as a way to conceptualize a case, not necessarily as a technique to be used in therapy session.
Other than growing with a father who was a psychiatrist, Luhrman had no other direct exposure to psychiatry. She didn’t enroll in a medical school for this ethnographic study that produced Of Two Minds, but she did atttend several lectures with other medical students as part of her preparation for this project. She also did a round in several hospitals, following medical students and psychiatrists during rounds and being part of the psychiatric team in those hospitals. Of Two Minds is the result of her in-field project working as a medical student conducting rounds in psychiatric units. Not only that Luhrman reported what she saw in her book, but she also included other pertinent information, such as the history of psychology and psychiatry in the U.S. The book is a result of massive amount of work in the field and of research. I recommend the book to be part of reading requirements in all psychology programs. It’s a collection of real-world situations, and what could be more important than this kind of book for green and naive graduate students like myself. Some of those psychology textbooks are so boring, heavy and ’empty’ that they might be best used as paperweight.
Similar to my previous book review on Faces in the Revolution (see previous blog), the following writing was written when I took the same class in the the summer 2008. Enjoy the reading.
I must say that Of Two Minds has definitely been a pleasure to read. Based on what I have seen so far while working at a psychiatric hospital, Luhrman’s research, insights and interpretation are candid, no-nonsense, and perhaps even very direct when revealing the world of psychiatric treatment in the U.S. She tells her findings as how she saw things happened in hospitals or during medical lectures. The use fo ethnographic method gave her the opportunity to be in the middle of psychiatric work, which consequently provided her with the ability to see things based on two perspectives, as an outsider and an insider. She even includes her own reflections regarding her feelings and the mistakes she made.
In Of Two Minds, Luhrman concentrates on two main responsibilities of psychiatrists, psychopharmacology and psychotherapy (mostly in the form of psychoanalysis). There are other things that I am sure psychiatrists have done, such as administrative work and policy work, but she chooses to concentrate on these two main aspects because these are what psychiatrists learn in medical school. She explains taht psychopharmacology derives from the biomedical model that believes in the disease model. Psychotherapy, on the other hand, believes in the illness model or the interpretation of the patient when trying ot make meaning of the problem. Many psychiatrists no longer do psychotherapy and stay with prescribing psychotropic medications only, especially psychiatrist who work in the hospital setting. The biomedical/disease model relies on strict rules and guidelines when investigating a problem, which is done by focusing on symptoms and using those symptoms to finally reach a conclusion (diagnosis). For every problem (symptom), there needs to be a conclusion (diagnosis) in order for a treatment (most likely in the form of medication) to be done. The illness model, on the other hand, believes in how patients understand and explain their pain and suffering, both physical and psychological.
What I like about Luhrman’s writing is how she fairly presents the pros and cons for each model. Although it may look as if her standpoint is against biomedical model, she doesn’t argue for eliminating the model. Instead, she points out that there is an organic characteristic to some mental illnesses. Psychiatric help, however, should not stop at the biological step. In her own words, she describes it perfectly: “…to say that mental illness is nothing but disease, is like saying that an opera is nothing but musical notes” (p. 68). Therefore, in addition to the biological factor, the patient’s illness cannot and should not be taken apart from the sociocultural context where he or she lives. Unfortunately, many psychiatrists have reduced the problem of their patients into a diagnosis of some kind of biological disease.
I like the comparison Luhrman makes between a surgeon’s cutting open a patient’s body and a symbolic action of a psychiatrist writing a prescription as if it is the psychiatrist’s way of surgically open a patient’s body. Both actions have a similarity in that they convey a sense of power. Psychopharmacology and its action of prescribing medications gives a clear, fast and sometimes visible result in reducing symptoms; in which case, these are all actions that may provide an immediate sense of accomplishment to the psychiatrist. Psychotherapeutic approaches to mental illness, on the other hand, may take a longer time and harder work to reduce symptoms. Worse, in some cases, due to complicate circumstances, many symptoms fail to reduce, if not increase. Again, in Luhrman’s own words, “…it is easier to be a competent pharmacologist than it is to be a competent psychotherapist” (p. 81).
I have seen almost everything that she mentions in her book about psychiatric work in inpatient hospitals. The power that psychiatrists have in inpatient hospitals is unbelievably high, even compared to the other medical personnel. Nothing can be done in many units without the order and signature of psychiatrist in charge. For example, patients cannot have a patio pass without a written order from their psychiatrist, or have their own shoes while in the unit without the approval of their psychiatrist, due to safety concerns. Psychological testing cannot be done without a referral from the psychiatrist.
When one reads the history of psychiatry in the U.S., psychiatrists have gained this tremendous amount of power from continuing to believe in the use of biomedical model. If the psychiatric profession suddenly disregards biomedical model, it is questionable whether they will be able to maintain the same amount of power. This is the struggle that the profession of psychologist is going through right now, the struggle to find their own voice and recognition in the field of mental health. Psychologists in most states cannot prescribe psychotropic medications, and therefore, tend to have less freedom to do their work more effectively, which further challenge their opportunity for collaboration with other healthcare professionals in the arena.
The struggle to gain more power, recognition and freedom to make decision has, to a certain degree, influenced the decision for many psychologists to lobby for prescription privilege, which would allow them to prescribe psychotropic medications. This effort is currently happening in Illinois and in some other states. The proponent of prescription privilege argues taht with the ability to prescribe, comes the ability to discontinue medications as well. This argument sounds very appealing at this point due to the problem of an increasing number of overly-medicated population in the U.S., particularly with the young children and youth age group.
My concern with prescription privilege for psychologists is taht I can’t help to wonder whether the profession of psychology will eventually end up where psychiatry is now. In other words, if given the privilege to prescribe medications, will psychologists eventually fall in the trap of enjoying psychopharmacology more than psychotherapy? Based on Luhrman’s book, it is easier to reduce illness into disease and prescribe a quick solution. One source of pressure to come up with a quick solution is the patients themselves. They want a quick answer to their problem. Medication ca provide a quick satisfaction for both the patient and the doctor. Therefore, I can see the temptation for psychologists to take this route in the future. The temptation will make some psychologists to focus more on symptoms in order to arrive to a diagnosis and less on other psychological, social, structural and cultural contexts that define the patient and the illness.
A proponent of prescription privilege also argue that training for prescription privilege for psychologists will be presented as a matter of choice to psychologists, not a must. It means that the profession of psychologist will then have two groups based on the privilege to prescribe. However, given time and pressure from outside forces (i.e., health insurance, patients’ expectations), psychologists may eventually give in to the pressure. This will bring more problems in the future (for one, liability insurance will increase) and then what will happen to psychotherapy?