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Of Two Minds: An Anthropologist Looks at American Psychiatry
With sharp and soulful insight, T. M. Luhrmann examines the world of psychiatry, a profession which today is facing some of its greatest challenges from within and without, as it continues to offer hope to many.
At a time when mood-altering drugs have revolutionized the treatment of the mentally ill and HMO’s are forcing caregivers to take the pharmacological route over the talking cure, Luhrmann places us at the heart of the matter and allows us to see exactly what is at stake. Based on extensive interviews with patients and doctors, as well as investigative fieldwork in residence programs, private psychiatric hospitals, and state hospitals, Luhrmann’s groundbreaking book shows us how psychiatrists develop and how the enormous ambiguities in the field affect its practitioners and patients.
At a time when mood-altering drugs have revolutionized the treatment of the mentally ill and HMO’s are forcing caregivers to take the pharmacological route over the talking cure, Luhrmann places us at the heart of the matter and allows us to see exactly what is at stake. Based on extensive interviews with patients and doctors, as well as investigative fieldwork in residence programs, private psychiatric hospitals, and state hospitals, Luhrmann’s groundbreaking book shows us how psychiatrists develop and how the enormous ambiguities in the field affect its practitioners and patients.
352 pages, Paperback
First published April 4, 2000
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About the author
T.M. Luhrmann
12 books102 followersTanya Marie Luhrmann is currently the Watkins University Professor in the Anthropology Department at Stanford University. She has been elected to the American Academy of Arts and Sciences, and has been the recipient of a John Simon Guggenheim Fellowship.
Tanya Marie Luhrmann (born 1959) is an American psychological anthropologist best known for her studies of modern-day witches, charismatic Christians, and psychiatrists. She received her AB summa cum laude in Folklore and Mythology from Harvard-Radcliffe in 1981, working with Stanley Tambiah. She then studied Social Anthropology at Cambridge University, working with Jack Goody and Ernest Gellner. In 1986 she received her PhD for work on modern-day witches in England, later published as Persuasions of the Witch's Craft (1989). In this book, she described the ways in which magic and other esoteric techniques both serve emotional needs and come to seem reasonable through the experience of practice.
Her second research project looked at the situation of contemporary Parsis, a Zoroastrian community in India. The Parsi community enjoyed a privileged position under the British Raj; although by many standards, Parsis have continued to do quite well economically in post-colonial India, they have become politically marginal in comparison to their previous position, and many Parsis speak pessimistically about the future of their community. Luhrmann's book The Good Parsi (1996) explored the contradictions inherent in the social psychology of a post-colonial elite.
Her third book, and the most widely acclaimed, explored the contradictions and tensions between two models of psychiatry, the psychodynamic (psychoanalytic) and the biomedical, through the ethnographic study of the training of American psychiatry residents during the health care transition of the early 1990s. Of Two Minds (2000) received several awards, including the Victor Turner Prize for Ethnographic Writing and the Boyer Prize for Psychological Anthropology (2001).
Her fourth book, When God Talks Back: Understanding the American Evangelical Relationship with God (March 2012), examines the growing movement of evangelical and charismatic Christianity, and specifically how practitioners come to experience God as someone with whom they can communicate on a daily basis through prayer and visualization.
Other projects she is working on include a NIMH-funded study of how life on the streets (chronically or periodically homeless) contributes to the experience and morbidity of schizophrenia.
Tanya Marie Luhrmann (born 1959) is an American psychological anthropologist best known for her studies of modern-day witches, charismatic Christians, and psychiatrists. She received her AB summa cum laude in Folklore and Mythology from Harvard-Radcliffe in 1981, working with Stanley Tambiah. She then studied Social Anthropology at Cambridge University, working with Jack Goody and Ernest Gellner. In 1986 she received her PhD for work on modern-day witches in England, later published as Persuasions of the Witch's Craft (1989). In this book, she described the ways in which magic and other esoteric techniques both serve emotional needs and come to seem reasonable through the experience of practice.
Her second research project looked at the situation of contemporary Parsis, a Zoroastrian community in India. The Parsi community enjoyed a privileged position under the British Raj; although by many standards, Parsis have continued to do quite well economically in post-colonial India, they have become politically marginal in comparison to their previous position, and many Parsis speak pessimistically about the future of their community. Luhrmann's book The Good Parsi (1996) explored the contradictions inherent in the social psychology of a post-colonial elite.
Her third book, and the most widely acclaimed, explored the contradictions and tensions between two models of psychiatry, the psychodynamic (psychoanalytic) and the biomedical, through the ethnographic study of the training of American psychiatry residents during the health care transition of the early 1990s. Of Two Minds (2000) received several awards, including the Victor Turner Prize for Ethnographic Writing and the Boyer Prize for Psychological Anthropology (2001).
Her fourth book, When God Talks Back: Understanding the American Evangelical Relationship with God (March 2012), examines the growing movement of evangelical and charismatic Christianity, and specifically how practitioners come to experience God as someone with whom they can communicate on a daily basis through prayer and visualization.
Other projects she is working on include a NIMH-funded study of how life on the streets (chronically or periodically homeless) contributes to the experience and morbidity of schizophrenia.
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Displaying 1 - 30 of 37 reviews
December 30, 2007
Luhrmann's ethnography of the psychiatry profession is an engaging and a bit disturbing analysis of how mental illness is conceptualized and treated in the American health care system. Luhrmann's work is accessible to anthro and non-anthro folks alike.
November 27, 2011
I read this book some years ago for a college course, and while informative, I felt it was almost more of a journalist's expose than the culmination of study for an anthropologist's essay. That's not to say it should be dry and disseminating; rather, it had the feel of pushing some hidden agenda than summing up what she had learned in her years of study (namely that 'crazy' people really are 'crazy' and much disdain for anti-psychotic medication versus talk therapy).
May 2, 2020
This book draws on more than five years of ethnographic and participatory research on a psychiatric profession divided against itself and overloaded with patients who are often deranged and sometimes violent. So why is it so dull? Partly because it’s too long and insufficiently synthetic. Also because it deals with a conflict - - psychodynamic versus psychopharmacological psychiatry - - that has been won by the latter since the author finished her main fieldwork (1994) and the book was first published (2000). On the other hand, the description of the sociological and scientific processes behind this transformation is one of the most interesting (although not most original) aspects.
The author vividly describes how Freudian theories and explanations ‘won for psychiatrists the battle for jurisdiction over human unhappiness’, defeating ‘neurologists, social workers, clergymen, advocates of “positive thinking”’ who could only offer ‘optimistic theology and some homespun remedies’. But, by the 1970s, this school could not compete with the scientific apparatus of psychopharmacological psychiatry.
However, the author goes too far when she says that, in the USA, psychiatric research was poorly funded “precisely because there was no way of distinguishing mental health from mental illness”. In fact, for example, the Hamilton Rating Scale for Depression was published in 1960 and has been used in research since then. Here the author ignores other factors (which she does recognise elsewhere in the book) such as the economic incentive to turn round patients quicker by prescriptions than by therapy (even though for many conditions the latter is at least as effective in the long term). Since this section is specifically about government-funded research the author might also have mentioned Loren Mosher, who was forced out of his post as head of the National Institute of Mental Health’s Center for Studies of Schizophrenia because he would not abandon his studies of community-based care.
Another idea that the author expresses vividly is that “psychiatric knowledge seeps into popular culture like the dye from a red shirt in hot water” (what Ian Hacking calls “looping effects”). In other words, people make sense of their feelings in terms of the psychiatric concepts currently available, not only the other way round. This can extend to drug effectiveness. ‘“You want to use a medication,” a psychiatrist once observed to me, “in the first few years, when it still works.”’ Although this may seem ridiculous, it is plausible, e.g. based on patient expectations (e.g. “nocebo” effects). For example, when writing this review, a study was published titled “The trend of increasing placebo response and decreasing treatment effect in schizophrenia trials continues: an update from the US Food and Drug Administration.”
Overall, though, the 300 small-print pages have too few interesting passages to be worthwhile.
The author vividly describes how Freudian theories and explanations ‘won for psychiatrists the battle for jurisdiction over human unhappiness’, defeating ‘neurologists, social workers, clergymen, advocates of “positive thinking”’ who could only offer ‘optimistic theology and some homespun remedies’. But, by the 1970s, this school could not compete with the scientific apparatus of psychopharmacological psychiatry.
However, the author goes too far when she says that, in the USA, psychiatric research was poorly funded “precisely because there was no way of distinguishing mental health from mental illness”. In fact, for example, the Hamilton Rating Scale for Depression was published in 1960 and has been used in research since then. Here the author ignores other factors (which she does recognise elsewhere in the book) such as the economic incentive to turn round patients quicker by prescriptions than by therapy (even though for many conditions the latter is at least as effective in the long term). Since this section is specifically about government-funded research the author might also have mentioned Loren Mosher, who was forced out of his post as head of the National Institute of Mental Health’s Center for Studies of Schizophrenia because he would not abandon his studies of community-based care.
Another idea that the author expresses vividly is that “psychiatric knowledge seeps into popular culture like the dye from a red shirt in hot water” (what Ian Hacking calls “looping effects”). In other words, people make sense of their feelings in terms of the psychiatric concepts currently available, not only the other way round. This can extend to drug effectiveness. ‘“You want to use a medication,” a psychiatrist once observed to me, “in the first few years, when it still works.”’ Although this may seem ridiculous, it is plausible, e.g. based on patient expectations (e.g. “nocebo” effects). For example, when writing this review, a study was published titled “The trend of increasing placebo response and decreasing treatment effect in schizophrenia trials continues: an update from the US Food and Drug Administration.”
Overall, though, the 300 small-print pages have too few interesting passages to be worthwhile.
March 15, 2009
the parts about how psychiatrists learn to manage patients may be instructive, but the part about how they learn psychoanalysis -- no way. there *might* be training psychiatrists who routinely learn psychoanalysis and undergo analysis themselves, but you have to physically take me to see them for me to believe it.
June 13, 2021
This is a book that really makes you think a lot. I highly recommend this to anyone who is entering the mental health field. It basically explains in great detail the history behind two approaches to looking at psychiatric conditions within the field of psychiatry and beyond. Those two approaches are the biomedical model and the psychodynamic model. What this book eloquently lays out is how your approach matters not only to how we treat these conditions but also how we view people who are diagnosed with psychiatric conditions and how they think of themselves. I feel that psychiatry is a field that should always hold a critical eye on itself based on its history and the vulnerability of the patient population. I feel like this book does that in a way that feels absolutely authentic and I hope to carry its wisdom with me in the future.
Favorite quote: "But the real story of 20th century psychiatry is how complex mental illness is, how difficult it is to treat, and how, in the face of this complexity, people cling to coherent explanations like poor swimmers to a raft."
Favorite quote: "But the real story of 20th century psychiatry is how complex mental illness is, how difficult it is to treat, and how, in the face of this complexity, people cling to coherent explanations like poor swimmers to a raft."
Want to read
October 29, 2022Rachel Aviv recommendation on Ezra Klein
August 16, 2019
An anthropologist studies the tribe
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 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.
--Dennis Littrell, author of “The World Is Not as We Think It Is”
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 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.
--Dennis Littrell, author of “The World Is Not as We Think It Is”
May 21, 2013
Having read Luhrmann's anthropological study of prayer, When God Talks Back, I couldn't wait to pick up this anthropologist's eye view of psychiatry. I could've gotten the same thing reading a good, long magazine article on the subject. I'm not sure anymore what the difference is between anthropology and journalism, maybe there was no difference, anyway.
She contrasts the two minds of psychology, the biological medical model, with the Freudian. Doesn't she know that Freudianism died many years ago? Wouldn't narrative therapy, or client centered therapy, or any one of the many family approaches be a more worthy opponent to the medical model?
She gets a lot of things right: the arrogance and the opacity of the Freudians, as well as the arrogance and reductionism of the medics. Let's face it, psychiatrist is just, well, arrogant. Anyone who is not intimately knowledgeable about psychiatry needs to know that. Anyone, like me, that is, needs to never forget it.
She contrasts the two minds of psychology, the biological medical model, with the Freudian. Doesn't she know that Freudianism died many years ago? Wouldn't narrative therapy, or client centered therapy, or any one of the many family approaches be a more worthy opponent to the medical model?
She gets a lot of things right: the arrogance and the opacity of the Freudians, as well as the arrogance and reductionism of the medics. Let's face it, psychiatrist is just, well, arrogant. Anyone who is not intimately knowledgeable about psychiatry needs to know that. Anyone, like me, that is, needs to never forget it.
September 15, 2007
I found this a very interesting read and agree with most of Ms Luhrmann's analysis on psychiatry today. For an "outsider" (she's an anthropologist by training I believe so not in the mental health field per se), I think she did a great job of recognizing and articulating the problems faced by psychiatry. Though I do think that at times she gets a bit too pessimistic and fails to give adequate recognition to certain contexts/settings in which psychiatry has overcome some of the challenges she outlines in her book.
May 25, 2019
A fascinating if sometimes meandering text on the current American psychiatric landscape. As a current psych resident I found her insights about psychiatric training to be spot on, and I really respect the amount of on-the-ground research Luhrmann did for this book. The latter half of the text was a little slow and repetitive, but overall I still found it to be a v. worthwhile read that I would recommend to other clinicians.
December 4, 2007
One of my first exposures to medical anthropology, gets into detail about psychiatry residency training as well as the historical context to the anti-psychiatry movement.
June 12, 2022
10 stars, if possible, y'all. I am nearly dumbstruck with the care that was taken in writing this book. First off, I love the idea an anthropologist spending 10 years on and off doing fieldwork studying a remote tribe within our midst—psychiatrists. It is written for a lay person to understand (and puts its more anthropological theoretical talking points in the footnotes).
Second, if you read through the footnotes, it is clear that Luhrmann has digested a LOT of literature on the subject (including other anthropologist's books on, say, the medical school experience! I was not aware that this was a genre!) and has spent a lot of time trying to deeply understand the people as well as the material that she's learning. Luhrmann goes through psychiatry residency classes, rotations at various clinics, and so much more—noting the different ways in which different kinds of psychiatrists treat their patients (and colleagues).
I had originally picked up this book at the recommendation of a good friend who seemed skeptical of the Freudian project, and assuming that this book might have been where she had gotten that sense from, decided that this would be a good book to read in case I was in a bubble.
I was thus surprised to find an extremely even handed consideration of psychodynamic technique (though she definitely does not look away from abuses either—naming everything she sees), and was even more surprised to find out that when she saw where psychiatry was going (towards the path of excising psychodynamic expertise in psychiatry in favor of a more biomedical model of mental illness), she dedicated her conclusion to explaining how she thought it was a moral mistake to lose the psychodynamic part of the training.
Now, this book was published in 2000, and a lot has changed since then, but it was really amazing to be able to get a glimpse into what psychiatry looked like in the 90s (and before, through interviews), from an outside (and inside) observer.
As an added bonus, it made me at once, both appreciate doctors for the amount of grueling training they are required to go through AND also see how the way in which the way that educational system is set up might mess with your ability to relate to people in a certain way (and thus, gave me both compassion and understanding about the uncomfortable conversations with doctors I've had in the past).
Again, I was really impressed with the depth at which Luhrmann talks about the various different stances you might take as a psychiatrist—the cultural implications of those stances on the relationship to the patients and your other colleagues, and the ways in which it might help the work, or hurt it. She also isn't afraid to face the vast oceans of grey space that exist in mental illness, and grapple with questions that we could be asking, but don't.
Luhrmann never (as far I I noticed) falls into the trap of saying things need to be either one thing or the other, but takes as her task understanding each perspective with nuance, and describing clearly what she sees in each.
I can also sense that Luhrmann, while also having an extremely strong academic and analytic core, also has a writer's heart, with passages like this:
I want to spend more time with this book during my break, but here are my dense but initial reactions thus far. I'm totally a Luhrmann fan and am looking forward to reading her latest book on people's experiences of God.
Second, if you read through the footnotes, it is clear that Luhrmann has digested a LOT of literature on the subject (including other anthropologist's books on, say, the medical school experience! I was not aware that this was a genre!) and has spent a lot of time trying to deeply understand the people as well as the material that she's learning. Luhrmann goes through psychiatry residency classes, rotations at various clinics, and so much more—noting the different ways in which different kinds of psychiatrists treat their patients (and colleagues).
I had originally picked up this book at the recommendation of a good friend who seemed skeptical of the Freudian project, and assuming that this book might have been where she had gotten that sense from, decided that this would be a good book to read in case I was in a bubble.
I was thus surprised to find an extremely even handed consideration of psychodynamic technique (though she definitely does not look away from abuses either—naming everything she sees), and was even more surprised to find out that when she saw where psychiatry was going (towards the path of excising psychodynamic expertise in psychiatry in favor of a more biomedical model of mental illness), she dedicated her conclusion to explaining how she thought it was a moral mistake to lose the psychodynamic part of the training.
Now, this book was published in 2000, and a lot has changed since then, but it was really amazing to be able to get a glimpse into what psychiatry looked like in the 90s (and before, through interviews), from an outside (and inside) observer.
As an added bonus, it made me at once, both appreciate doctors for the amount of grueling training they are required to go through AND also see how the way in which the way that educational system is set up might mess with your ability to relate to people in a certain way (and thus, gave me both compassion and understanding about the uncomfortable conversations with doctors I've had in the past).
Again, I was really impressed with the depth at which Luhrmann talks about the various different stances you might take as a psychiatrist—the cultural implications of those stances on the relationship to the patients and your other colleagues, and the ways in which it might help the work, or hurt it. She also isn't afraid to face the vast oceans of grey space that exist in mental illness, and grapple with questions that we could be asking, but don't.
Luhrmann never (as far I I noticed) falls into the trap of saying things need to be either one thing or the other, but takes as her task understanding each perspective with nuance, and describing clearly what she sees in each.
"Psychiatry is inevitably entangled with our deepest moral concerns: what makes a person human, what it means to suffer, what it means to be a good and caring person. By the word "moral" here I do not mean a code of right behavior so much as our instinctive sense of what it is to be responsible, when to assign blame, and how we come to see our ambitions as fundamentally right and good. The biomedical and psychodynamic approaches nurture two very different moral instincts by shaping differently the fundamental catagories that are the tools of the way we reason about our responsibilities in caring for those in pain: who is a person (not an obvious question), what constitutes that person's pain, who are we to intervene, what intervention is good. These two approaches teach their practitioners to look at people differently. They have different contradictions, different bottom lines. Both have their strengths and weaknesses. Each changes the way doctors perceive patients, the way society perceives patients, and the way patients perceive themselves. " (23)
I can also sense that Luhrmann, while also having an extremely strong academic and analytic core, also has a writer's heart, with passages like this:
“Today we use the word “tragedy” in a more pedestrian sense, to refer to personal circumstances over which we genuinely have no control: an aircraft exploding in mid-flight, a flood wiping out a summer’s crops, a senseless, arbitrary murder. I say pedestrian, but life is really made up of small circumstances that hem us in so tightly we can scarcely move. To understand that these circumstances are more important than the choice we make within them is to see a very different staging of human experience. That difference is the major tension in the way psychiatrists are taught to look at the world.”
I want to spend more time with this book during my break, but here are my dense but initial reactions thus far. I'm totally a Luhrmann fan and am looking forward to reading her latest book on people's experiences of God.
Read
March 14, 2022My review from 2005: The author is an anthropologist, and the book examines the culture pf psychiatry, focusing on the differences and coexistence of the two schools of thought, psychodynamic and biochemical. The author joined the culture, taking classes, observing, and participating with psychiatric residents in training programs in several different psychiatric units, and even did some therapy as a volunteer.
The book is amazing - I can't praise it highly enough. I learned a lot about the psychiatric culture and its problems and trends. Psychotherapy has made way for the new biomedical approach that uses drugs as the primary treatment, with much more reliable and measurable results. Freudian theory and many later theories rightly are seen as outdated and quirky, often not necessarily in agreement with reality. Yet talk therapy has been shown to be effective, and it's well documented that the best treatment incorporates both approaches. Unfortunately, pressure from the insurance companies is making it so that talk therapy is much less available, at least in psychiatric settings.
In with all this, there's enough clinical detail to get a good idea of the range of mental illnesses, and enough empathy that the reader gets some understanding of the patients as well as the practitioners.
The book has a wealth of details, stories, and interpretation, all of which I found fascinating and illuminating. The author's writing style is clear and compelling, and the book is well organized. The observations cohere into a broad picture of the culture and to very supportable conclusions and even value judgments.
The book is amazing - I can't praise it highly enough. I learned a lot about the psychiatric culture and its problems and trends. Psychotherapy has made way for the new biomedical approach that uses drugs as the primary treatment, with much more reliable and measurable results. Freudian theory and many later theories rightly are seen as outdated and quirky, often not necessarily in agreement with reality. Yet talk therapy has been shown to be effective, and it's well documented that the best treatment incorporates both approaches. Unfortunately, pressure from the insurance companies is making it so that talk therapy is much less available, at least in psychiatric settings.
In with all this, there's enough clinical detail to get a good idea of the range of mental illnesses, and enough empathy that the reader gets some understanding of the patients as well as the practitioners.
The book has a wealth of details, stories, and interpretation, all of which I found fascinating and illuminating. The author's writing style is clear and compelling, and the book is well organized. The observations cohere into a broad picture of the culture and to very supportable conclusions and even value judgments.
April 10, 2019
I picked up this book at the recommendation of my qualitative research methods professor who is a medical anthropologist by training. All I can say is, "THANK YOU, PROFESSOR" for introducing me a book that had captivated me from cover to cover. Luhrmann's language is beautiful and I never got bored of reading her writing.
Never in a million years did I think that I would read an anthropological account about the development of American psychiatry over the years, from the early days of Freudian psychoanalysis to the more modern biomedical approach to mental illnesses. I found the comparisons so carefully constructed that Luhrmann had essentially given equal coverage on both sides of psychiatry.
My favorite part is when Luhrmann was interviewing psychiatrists, most of whom were trained as psychoanalysts, about the damaging effects of managed care when it first rolled out--unstable patients are now released within a week of admissions, a time that is not nearly long enough for a patient to recover fully. Patients are then discharged half-treated and will more often come back again worse off than before. This whole section was truly poignant and it shed light on what managed care had done to the healthcare system. Luhrmann did point out that managed care did save a LOT of psychiatric hospitals from bankruptcy, so that was a good thing.
Anyways, I highlighted so many beautiful sentences that I believe are public on my profile. Check them out and I highly recommend this book to anyone who's remotely interested in the field of psychiatry.
Never in a million years did I think that I would read an anthropological account about the development of American psychiatry over the years, from the early days of Freudian psychoanalysis to the more modern biomedical approach to mental illnesses. I found the comparisons so carefully constructed that Luhrmann had essentially given equal coverage on both sides of psychiatry.
My favorite part is when Luhrmann was interviewing psychiatrists, most of whom were trained as psychoanalysts, about the damaging effects of managed care when it first rolled out--unstable patients are now released within a week of admissions, a time that is not nearly long enough for a patient to recover fully. Patients are then discharged half-treated and will more often come back again worse off than before. This whole section was truly poignant and it shed light on what managed care had done to the healthcare system. Luhrmann did point out that managed care did save a LOT of psychiatric hospitals from bankruptcy, so that was a good thing.
Anyways, I highlighted so many beautiful sentences that I believe are public on my profile. Check them out and I highly recommend this book to anyone who's remotely interested in the field of psychiatry.
August 27, 2017
For the psychiatric interns you want to learn what they will go trough or have been trough. For the psychiatrist to remember how was their internship.
Besides this enactment of the internship upon the intern, tells a interesting story about changes in handling psychiatric disorders - not only different medical/psychological models but also the interference of politics and insurance companies.
Everyone that wants to learn how organizational changes aren't indifferent in the medical handling patients, should read this.
Besides this enactment of the internship upon the intern, tells a interesting story about changes in handling psychiatric disorders - not only different medical/psychological models but also the interference of politics and insurance companies.
Everyone that wants to learn how organizational changes aren't indifferent in the medical handling patients, should read this.
April 3, 2020
10/10
February 14, 2025
Really interesting viewpoints and comparisons of the American psychiatric field. The text is dense and the words are small so it's a bit of a trek to get through, but ultimately, it was illuminating.
December 15, 2009
As an Anthropology major who has read plenty of works dealing with abstract concepts, I would have to say that "Of Two Minds" is probably one of the most accessible ethnographies that I have read. Tanya Luhrmann's writing is very clear and her arguments are sophisticated yet easy to understand. If you aren't a psychiatrist (or a psychiatrist-in-training), you will probably be fascinated, unsettled and maybe even slightly repulsed by the culture of psychiatry that Luhrmann describes through her top-notch participant observation and interviews. Although her work focuses on the training of young psychiatrists, it's easy to see how the process by which they are socialized into the culture of psychiatry could affect their future practice.
"Of Two Minds" is light on the theory, the conclusions (especially those regarding managed care) that she draws from her solid ethnographic research are informative, and I daresay relevant to the current health care debate.
Read this book if you want to learn more about the field of psychiatry or if you simply want to read an exemplary ethnography.
"Of Two Minds" is light on the theory, the conclusions (especially those regarding managed care) that she draws from her solid ethnographic research are informative, and I daresay relevant to the current health care debate.
Read this book if you want to learn more about the field of psychiatry or if you simply want to read an exemplary ethnography.
Read
June 30, 2012Fabulous; anyone interested in psychiatry should read this insightful, interesting, and well-written analysis of psychiatrists themselves and the way they interact with patients. Luhrmann--who recently published a fabulous ethnography of evangelical Christians (When God Talks Back: Understanding the American Evangelical Relationship with God)--is even-handed, reserving outright judgment of the field while showing great respect and deference for the people who practice it. She is also very fair to the issue of mental illness itself, dispelling romantic notions of the "mad" (à la Foucault The Birth of the Clinic: An Archaeology of Medical Perception and Camus
) and legitimizing the field of psychiatry without looking at it through an unrealistically rosy lens.
) and legitimizing the field of psychiatry without looking at it through an unrealistically rosy lens. 
June 21, 2014
I'm sorry to miss the book club discussion on this because I'd be curious to hear what other people thought. I found the discussion on the economies of mental health care more interesting than the philosophies of the different branches, so I'm glad I stuck it out through the end of the book. There really does need to be a change in how Americans deal with long-term chronic conditions (hospitalizations are getting shorter, but alternative care situations are not covered, etc.), and mental health is one of those fields where it's almost all chronic conditions. It's one thing to be cured from a one-time infection, it's quite another thing to be on medication for the rest of your life. I also found it interesting that there is not good data on the long-term effects of psychiatric medications. At least for my life time, there has pretty much always been Prozac, Ritalin, etc., so I hadn't really considered that those drugs have not been around that long. I guess NIMH has their work cut out for them.
April 13, 2012
This is a fascinating study on how psychiatric treatment divided between the therapeutic and bio-chemical models upon the discovery of anti-psychotic medicine and the rise of managed care organizations. At the heart of this book is the question of person-hood. Is the mind the essence of a person, and therefore the foundation of medical ethics or, is the mind what the brain does and something to be treated with medicine? There are deep consequences in terms of personal responsibility, and the definition of "human being", when one considers the debate about the source of mental illness. Is psychiatric pain a disease of the brain, and therefore a bio-medical concern where the person suffering is a passive medical respondent, or is it a consequence of social circumstance and something that demands an integration of trauma driven by individual empowerment. The debate continues and new discoveries in brain science and mind-body realities seem to be deepening it.
September 8, 2009
i had mixed feelings overall. she makes some really good points about the split between biomedical psychiatry and psychoanalysis, but although it was published in 2000 a lot of her work was in the 90s and is now outdated... there are also sections that basically explain how to become a psychiatrist, which obviously was a little boring for me.
on the other hand, her prose is just excellent -- she has a surefooted clarity that makes one feel that things one inherently knows are more firmly true now that they are phrased so well. and there are glimmers of brilliant commentary about what its like to train and work in psych -- in the end it was really worth the 45 pages of boring to hit the ingenious moments of resonance. i definitely want to read her other work that is NOT about my work :)
on the other hand, her prose is just excellent -- she has a surefooted clarity that makes one feel that things one inherently knows are more firmly true now that they are phrased so well. and there are glimmers of brilliant commentary about what its like to train and work in psych -- in the end it was really worth the 45 pages of boring to hit the ingenious moments of resonance. i definitely want to read her other work that is NOT about my work :)
August 12, 2022
"Managed care is a moral crisis for doctors, particularly for psychiatrists whose primary identity is psychotherapeutic. The despair of psychiatrists who see the medical world changing around them comes from a sense of moral violation, from the horror that they cannot care for people in the way that good doctors do, that they have been forced to break trust with their patients, that they can no longer respond empathetically. They feel like bad people. The feel that they have been trained to understand a grotesque misery, yet all they are allowed to do is hand out a biomedical lollipop to its prisoners and then turn their backs. They feel as if they have been eating lunch on a park bench while the man across from them died, and they watched and did nothing."
November 4, 2011
For those interested in psychiatry or mental health, and certainly for future practitioners, this is a book worth reading. It's useful for those who have wondered where mental illnesses come from. One of the reasons this might puzzle you is that psychiatry has two very distinct answers: the brain and the mind. Unfortunately, the moral of this story seems to be that the insurance industry (less on big pharma) has hijacked the way psychiatrists practice, essentially forcing the psychotherapy/mind-origin contingent out of business. This development, according to Luhrmann and many empirical studies, is bad news for patients.
December 17, 2012
I almost put this book down after the first 20 pages because I didn't think I was likely to get much out of it, but I'm glad I stuck with it. It is true that much of the information is old, given that the research Luhrmann wrote on was conducted at least 15 years ago. However the book provides a valuable perspective on the history of the field and a offers a useful account of how the flaws of the past have paved the way for the current dilemmas and weaknesses of psychiatric care and mental health care in general.
July 28, 2010
Interesting look at how psychiatrists are trained, with emphasis placed on the "divide" between psychopharmacological and psychoanalytical approaches to treatment, as well as the role of managed care.
November 4, 2013
A remarkably fine ordering of the period of my training as a psychiatrist and e subsequent years. Even handed tracing of the miserable state of psychiatric practice in the USA today. Since being published in 2000 things have gotten only worse and more so as described. Terrific book.
August 7, 2016
Skimmed the end, some very interesting parts, but also some very repetitive themes. Can't imagine this would be terribly interesting to people outside of the mental health world, or maybe even just psychiatrists
January 18, 2011
Dense at times but overall a fascinating topic to read about
April 10, 2009
read for Psych Anthro at UCB
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