OF TWO MINDS: The Growing Disorder in American Psychiatry

In Structural Anthropology (1963), Claude Levi-Strauss retells the story, collected by Franz Boas, of the sorcerer Quesalid, a Kwakiutl Indian of Vancouver, Canada. Quesalid is a skeptic who studies with shamans in order to expose their tricks. Their darkest secret involves a tuft of down which the shaman hides in his cheek and, at the crucial moment, spits out, covered with blood—false evidence of illness sucked from an afflicted body. But Quesalid finds himself trapped: As an apprentice shaman, he cures patients with such success that he cannot cast off his calling. His attitude changes. He comes to value conscientiousness and forget his initial doubts. The signs of the true shaman, he declares, are that "he does not allow those who are made well to pay him" and that he never laughs.

Each year, I assign this passage to beginning psychiatry trainees. It speaks not only to their cynicism, but to their growing sense of competence as they enter a fellowship whose methods are vulnerable to attack and yet demonstrably effective.

Of Two Minds examines how psychiatric residents become acculturated in this fellowship. Luhrmann, an anthropology professor at the University of California, San Diego, calls her method ethnography, but she writes like a journalist who has dived into psychiatric training. The result is a reasoned and reasonable report on the current state of psychiatry and its struggle with Cartesian dualism—mind and brain.

Luhrmann shares the viewpoint of her subjects: Mental illness exists, and it responds to both medication and the talking cure. Despite their contradictions, she finds, these two methods can be combined to good effect. She recognizes and appreciates wisdom and experience in senior clinicians. To her, psychiatry is a vital and fascinating field—"unquenchably compelling because it forever changes the way you understand human experience"—unjustly inhibited by excessive managed care. The book’s provocative subtitle notwithstanding, she mostly admires what she sees in American psychiatry.

Luhrmann is a good storyteller, convincing in her accounts of professors, students, and patients. She ignores, however, a substantial literature on the training of physicians. We never learn how becoming a psychiatrist here and now contrasts with entry into other professional cultures, or with entry into psychiatry in other countries or (except in passing) other eras.

But she gets the portrait right; at least I see the profession as she does: honorable, demanding, flawed in the manner of all human enterprises. And at a time when the profession is under siege, accuracy is virtue enough.

—Peter D. Kramer