Psychiatric caricature and Luhrmann's "Of Two Minds"

Seems appropriate to start with the caveat that this is meant to be a personal exercise, rather than any sort of public presentation - I'm trying to get some ideas straight, and writing online somehow seems less of a confrontation with the abyss than writing in a journal. If you're reading this, be charitable, but know that commentary or discussion about any of it would most certainly help in whatever secret enterprise of mine this feeds.

With the above said, and with two hours left in this, my second day as a temporary receptionist in Toronto, I'll begin with some rambling about psychiatric suspicion and Tanya Luhrmann's fantastic book "Of Two Minds: The Growing Disorder in American Psychiatry" (available here).

The book - a multi-site ethnography drawing on fieldwork in medical schools, psychiatric residency programs, in-patient treatment institutions, and hospitals - deservedly won both the Victor Turner Prize for Ethnographic Writing and the Boyer Prize for Psychological Anthropology. It traces the origins of the gulf between the psychodynamic and the biomedical models of mental suffering and psychiatric treatment, as well as the ascendance of the latter as "managed care" insurance programs came to dominate the funding of mental health interventions (and, as a result, to leverage decreases in time, cost and consistency of care). I won't synopsize further; rather, I'd like to stress the subtlety and respect (albeit critical) with which she treats her subject matter.

Too often, criticism of psychiatry takes a facile view of the discipline, reducing its evolving and often contradictory discourses to a single plane - usually biomedical, often indifferent to the complexities of subjective life, always oriented toward profit. This last is the bursting coffer of individual therapists, psychiatrists as a horde or, through the alchemy of capital, the psycho-pharmaceutical industry. Granted, the links between industry pressure, gift-giving, conference and support-group funding, etc., and mental health professionals all deserve acute scrutiny - but simplifying them into caricatured profiteering by all involved only confuses the picture. If you want to understand anatomy, you don't take a scalpel to a straw man. Similarly, the psychodynamic model is popularly condemned, Freud having been "debunked," as though the merits of its practice (ongoing and intensive analysis of the patient's subjectivity and personal history) are negated by its flawed theory and ontology. But the one needn't be reduced to the other, and in fact medical professionals largely lament the loss of the psychodynamic approach as a complement to their now all-too-brief encounters with patients.

The picture Luhrmann paints is in shades of grey, thankfully. Rather than taking for granted the hostility with which practitioners on either side of the divide refuse one another, she listens to her informants as they criticize the new, rigidly biomedical regime, even if they rake in far more money now per working day than ever before. Profit, while certainly working to sustain a practitioner's subscription to the biomedical model, is a secondary player in the broader field of change. The increasingly foundational role of the Diagnostic and Statistical Manual (DSM-IV-TR, soon to be DSM-V) and its use by insurers to insist on more immediate and "treatable" (i.e. reducing dangerous symptoms within several days of in-patient holding or through out-patient drug treatment) diagnoses has been the real catalyst. When insurers began offering "managed care" insurance, through which patients are able only to receive pre-approved treatments at pre-approved institutions, they became able to use their portfolios of thousands (or more) of potential patients to leverage dramatically decreased costs for treatments, making lengthy psychodynamic interventions not just less profitable by comparison, but entirely unworkable as a treatment option.

The result was, first, a generation of psychiatrists who, despite their zeal for the biomedical model, still maintained the practical worth of a complementary psychodynamic approach; and, in the generation following, a complete lack of substantial training or experience in this latter approach, leaving it neglected and increasingly irrelevant. The ambivalence and sometimes despair of psychiatrists caught in this changing tide - forced to provide desperate patients with less than their conditions require; regretful that they no longer "know" any one of their patients with anything like the intimacy they once saw as foundational to therapy; ethically frustrated by their conflicting responsibilities to help patients and families while also having to insist on a hospital stay even when it may bankrupt them; pleasure at the reduced risk and increased functioning of patients on the right drugs, tinged with the knowledge that they no longer have any role to play in these patients' support networks, and that they'll likely see them return again to the emergency room - this ambivalence punctures any notion of psychiatry as a purely exploitative or corrupt discipline. I believe this is important work.

I'm being interrupted by my overlords - there's a pressing need for me to research brand loyalty programs in the Canadian food products market. My life too is one of conflict and strenuously-negotiated satisfactions. So's everyone's, if you look at them right. There's a lesson for you. Thanks, Ms. Luhrmann!