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At a time when mood-altering drugs like Prozac have revolutionized the treatment of the mentally ill and HMOs are forcing caregivers to take the cheaper and quicker pharmacological route, the psychiatric profession, says UC San Diego anthropologist Tanya Luhrmann, may be as tormented as the patient it seeks to treat.

"Psychopharmacology," says Luhrmann, "is the great, silent dominatrix of contemporary psychiatry. It is what psychiatrists do that other mental health therapists cannot do, and more and more psychiatrists spend more of their time prescribing medication. More money is spent on developing psychopharmacogical drugs than in any other area of psychiatry. Psychiatric medications, however, treat symptoms, not illnesses. They treat people’s brains, not their minds."

Luhrmann spent more than 4 years shadowing new residents and psychiatrists as they made their rounds at mental hospitals, private clinics, and hospitals at teaching universities, resulting in the newly published book "Of Two Minds: The Growing Disorder in American Psychiatry," (Alfred A. Knopf). As a psychological anthropologist, Luhrmann set out to discover and explain how psychiatrists are trained, how they develop their particular way of seeing and listening to their patients, what makes a psychiatrist successful, and how the enormous ambiguities in the field today affect its practitioners and its patients.

She concludes that the two primary approaches to mental illness, psychotherapy and psychopharmacology, are taught so differently that they become almost different cultures.

"Young therapists are supposed to learn to become equally good at both talk therapy and drug therapy." explains Luhrmann. "The American Psychiatric Association thinks that this integration is what training programs in psychiatry teach. Psychiatrists are supposed to understand these approaches as different tools in a common toolbox, yet they are taught as different tools, based on different models, and used for different purposes. Some psychiatrists do integrate them to some extent. But those who do have to integrate two approaches that are different from the outset, that carry with them different models of the person, different models of the cause of illness, and different expectations of the way a person might change over time."

Despite the different interpretations as to the causes of mental illness, Luhrmann found that most psychiatrists agree that the best treatment often involves both psychopharmacology and psychotherapy. But, a combination of socio-economic forces and ideology is driving psychotherapy out of psychiatry. This, she argues, is a terrible mistake.

"If psychotherapy is axed from psychiatry by the bottom-line focus of managed care companies, psychiatrists will be taught to see, think, and respond only as the biomedical task would teach them. That would be a terrible mistake. It would be bad for psychiatrists, and it would be bad for society. Biomedicine, for all its benefits, encourages a way of thinking about mental illness that can strip humanity from its sufferers. Above all, it would be bad for patients, who will be treated less well and less effectively if treated from a purely biomedical perspective."

According to Luhrmann, these two approaches now exist in an uneasy alliance with each other. They are a kind of contradiction to each other because their models of how suffering works are so opposed. Young psychiatrists are socialized into this contradiction, she says, so that they learn to believe and to say that these different models should be integrated in the practice of psychiatry. As an anthropologist, she was interested not in answering the question of which approach was more correct but in understanding how the approaches worked as "culture" for the psychiatrists and thus for their patients.

In her book, Luhrmann traces the roots of these two approaches – the psychodynamic and the biomedical – to the more fundamental Western division between mind and body that our society still endorses. We still think of the body, she says, as something unintentional, something given, something for which the individual is not responsible. To underscore this fact, she points to our obsession with metabolic set points, inborn temperaments, learning disabilities, and the genetic roots of attention deficit disorders.

"Biology is the great moral loophole of our age," said Luhrmann. "If something is in the body, an individual cannot be blamed; the body is always morally innocent. If something is in the mind, however, it can be controlled and mastered, and a person who fails to do so is morally at fault. A moral vision that treats the body as choiceless and non-responsible and the mind as choice-making and responsible has significant consequences for a view of mental illness precariously perched between the two."

During her years of fieldwork, including more than 16 months of full-time, intensive immersion, where she hung out with residents, sat in on clinical interviews, and attended hundreds of lectures, as well as major psychiatric conferences, she never ceased to be amazed by the sharply different cultures displayed by the two psychiatric camps.

"At the lectures, some mornings, men (almost always men) would come in wearing white medical coats. They would talk about neurotransmitters and catecholamines and draw diagrams of biochemical interactions on the board," Luhrmann recalled. "Other mornings, they would arrive in tweed jackets wearing spectacles. They would sit, hands folded, and talk with us about loss, mourning, and the nadir point in psychotherapy. They spoke as if life happened inside the mind. One time, there was someone who drew graphs that explained when schizophrenics were born -- he thought the Christmas drinking season might be partly to blame -- and someone else who practiced therapy but didn’t believe in the unconscious."

At these morning lectures, Luhrmann heard discourses on alcohol, combat, sexual abuse, sleep disorders, epilepsy, and the whole range of psychopharmacological treatments. But behind all this – the biochemical diagrams and the whole range of psychotherapeutic transference – she says, lay at least two profoundly different notions of what it is to be a person: to feel, to choose, to do good, to have meaning.

"Those different models have different moral implications for the way that we conceive of emotional suffering and the way we understand our responsibility towards those who suffer," said Luhrmann. "Ultimately, these moral implications are as important as the pragmatic benefits of particular treatments. The biomedical model has helped to reduce the loathsome stigma associated with mental illness. But the vulgarized medical model – the view that these illnesses have no more meaning than a winter cold, that medication is all we need to treat them and that the medication always works – invites us to see as less than human those who struggle with mental illness at its worst."