In the 1990s, the anthropologist T.R. Luhrmann did a period of fieldwork among psychiatrists in residency at a hospital, observing young members of that tribe as they acquired its skills and assimilated its mores. The title of her book on this research, Of Two Minds (Knopf, 2000), pointed to a divide within the profession between approaches to mental illness.
One is psychodynamic: It regards symptoms as the most visible dimension of conflicts and tectonic strains deep within the individual personality. The other is biomedical: The psychiatric disorder reflects a problem in the organism, usually at the level of neurochemistry. The distinction points to old philosophical problems. (Are mind and body composed of different substances? What is the relationship between an event within consciousness and something observable happening in the brain?) But for psychiatric practice it amounts to differences in modes of treatment -- between the couch and Prozac, to put it in shorthand.
As Luhrmann’s ethnography showed, it also corresponded to different professional cultures, which were in flux under the double impact of brain research (the elder president Bush had proclaimed the Decade of the Brain on January 1, 1990) and the changing economics of health care. The tools available to biomedical psychiatry had once been very blunt, but the new pharmaceuticals were much more precise. Insurance companies and HMOs were making it harder for patients to get coverage for “talk therapy,” whether Freudian or otherwise. The psychodynamic approach had once enjoyed higher prestige than the biomedical, but this was no longer true. While new practitioners continued to be exposed to both during their residencies, it was pretty clear which one was riding the crest of prevailing trends.
A decade after Of Two Minds appeared, it remains a vivid study of how people become initiated into a professional culture – selecting, and then being shaped by, their path through one of its sub-sectors. An interesting and sometimes riveting counterpoint to it is Danger to Self: On the Front Line with an ER Psychiatrist by Paul R. Linde, just published by the University of California Press. Linde, a clinical professor of psychiatry at the University of California at San Francisco, also serves as a doctor in the city’s General Hospital.
He belongs to the generational cohort described in Luhrmann’s study. But his first stint in a psychiatric emergency room left him with a sense that the vital distinction was not between biomedical and psychodynamic approaches. Instead, it was the distinction between the more buttoned-up, careerist wing of the profession and what his emergency-room colleagues sometimes call “meatball psychiatry.” (The phrase suggests that they are fans of M*A*S*H and identify with the surgeons.)
“I wasn’t obsessive enough to be a psychoanalyst or a researcher,” Linde writes. “I was a little too glib, a little too forthright, and far too much of a nonconformist, rebellious toward authority figures, to submit to the prevailing doctrines of either of American psychiatry’s dominant paradigms: one rapidly rising, the biomedical explosion; the other gradually declining, Freudian psychoanalysis.... The work [in a psychiatric ER] appeals to folks whose temperaments combine an odd mixture of low-grade attention deficit disorder with a high tolerance, but a distinct need, for maximal stimulation.”
It also requires a degree of egalitarianism: “In the psychiatric emergency setting, nurses and doctors work very closely, side by side, with each other.... While it is the physician who has the final say and ultimate responsibility from a practical and medico-legal perspective, it is a foolish emergency psychiatrist who does not collaborate with his or her knowledgeable and experienced psychiatric nurse colleagues in making clinical decisions.”
Linde’s book is a series of essays -- some of them case studies, and some reflections on his continuing education in the structural problems in the world outside the ER that leave wreckage at his door.
Psychiatric dehospitalization is sometimes portrayed as the result of efforts to draw an emancipatory lesson from Foucault’s Madness and Civilization. But the shutting down of six state hospitals during Ronald Reagan’s administration as governor of California might have had more to do with it. “Not only did psychiatrists begin seeing more patients out in the community,” he writes, “but they were also seeing sicker and sicker patients, many of whom just a few years earlier would have been taken care of in state hospitals. It’s not too big a stretch to posit that the explosion of hardcore drug abuse and infectious disease transmission of the 1980s and after was at least partially due to this dehospitalization.”
This had the effect of imposing new responsibilities on the psychiatric ER staff -- duties that were “more and more consistent with police powers than with medical ones.” Obliged to assess the patient’s likelihood to pose “a danger to self or others," Linde says his colleagues are held to “the crystal ball standard." At the same time, there are limits to how much care they can dispense when the law allows them only 72 hours of observation. Medications are now available to treat severe psychiatric problems such as chronic schizophrenia. But they do little sustained good while the revolving door keeps spinning.
“The practice of emergency and acute care psychiatry,” writes Linde, “is more highly influenced today by health-care policy makers, insurance and pharmaceutical companies, regulators, activists, and lawyers than it is by those who actually provide the care.... It’s become convenient for cynical advocates of ‘no new taxes,’ and for politicians and government bean-counters, to ally themselves with impassioned advocates of individual freedom who champion a person’s right to refuse treatment rather than a person’s right to [get] treatment.”
The texture of Danger to Self is more memoiristic than the passages I have quoted may suggest. The author is frustrated with a system that so often puts him in the untenable position of trying to help people while feeling helpless himself.
But most of the essays are stories of trying to do so anyway -- using whatever he can draw from the available stock of drugs while also practicing the mode of active listening taught by the psychodynamic tradition. All the while, he has the complicated and ultimately thankless task of evaluating the patient’s potential for suicidal or homicidal violence.
That, in turn, poses the danger of turning the whole thing into an exercise in voyeurism for the reader -- a danger that, in my opinion at least, Linde avoids. In the final pages, he quotes from the autobiography of William Carlos Williams, where the poet and small-town doctor reflects on his work:
“I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness which was affecting them, it was as though I was awakening from a sleep. For the moment I myself did not exist, nothing of myself affected me.”
Can someone manufacture a pill that will produce this mental state? I doubt there is much profit in it, so probably not. For now, we have this book -- a study in empathy charged up with adrenaline, and functioning against very long odds.