Tanya Luhrman, Of Two Minds

Tanya Luhrmann is my favorite anthropologist (not that I've got many anthropologists). Her writing is like a good novel: it puts me in people's shoes that I'd never imagined before. This book of hers is about psychiatric training and practice, focusing on the split between "talk" and "pill". It is both a rich description (based on years of interviewing and immersion) and a polemic. Luhrmann believes that the displacement of therapy by pharmaceuticals -- in reaction to the delusory arrogance psychoanalysis had twenty years ago, and under the pressure of managed care -- is bad for the profession and bad for the patient, and that it risks losing beyond recall an entire way of thinking.

A few bits: How it is that politically liberal graduates who go into Lawrence Livermore Labs evolve into ardent weapons scientists. What it is like to be in a psychiatric residency program, where "If you do not talk about your feelings and their sources in one-on-one social interaction, you are substandard." How the process of becoming a psychiatrist -- the unlearning of social interaction instincts -- changes the way you relate to people. The different ways that traning in talk therapy and in drug therapy cause students to think about patients and their own interaction with patients: narratives versus classification. John Hood, a high-functioning schizophrenic who sits on the California Mental Health Planning Council, and his explanation of why he can't consider schizophrenia a disease, why he has to own it as part of himself.

Part of why I read books like this is that I feel I tend too often to assume that people are basically like me; it's easier to use myself as a model than to realize how alien someone else is. I was thinking about this off and on as I read, so it was amusing to run across this quote:

The more psychodynamic psychiatrists tended to assume that other people thought that psychiatric patients were strange and different. They were likely to tell me to tell people how similar we all were. [...] "This taught me," the psychodynamic director said, "that psychiatric illness is merely a powerful magnification of the emotional current in all of our lives."

By contrast, on this biomedical unit the staff were more likely to assume that other people thought the patients are like all of us and that the problem was that the public did not properly understand how different they were, that they were far more sick than most people imagined, and that this sickness was a terrible, terrible accident in their lives. [...] "No one conceives of the severity. You ought to write about that."

Peter Kramer, Listening to Prozac

I read Listening to Prozac with the impression that it would be a pill-over-talk counterpolemic to Of Two Minds. It isn't at all; the author comments that "To my mind, psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety [...] the belief -- espoused not infrequently by health-care cost-cutters in the `managed care' industry -- that medication can obviate psychotherapy conceals, I believe, a cynical willingness to let people suffer." He talks about how drugs interact with therapy. In one patient, experiencing the drug effect, even temporarily, gave a glimpse of a different way of living. In another, the drug-given ability to bear troubling emotions deepened the affective quality of memory, as talk therapy may hope to. The author usually prescribes drugs only after therapy; a suicidal patient who was given an immediate prescription said that his mood improved, but he felt phony and could not accept his medicated personality as himself.

The book is not really about Prozac as a treatment for depression, but Prozac as a modifier of personality (he is talking about a minority of responders to the drug): how this changes the way we think about personality, and about mental health and illness. He suggests, for example, that some people have an unusual sensitivity to negative social cues, to rejection and loss, which may be culturally shaped into a histrionic, emotionally needy personality, or into a closed-off one. An SSRI's effect may be to decrease the sensitivity. Some people experience less pleasure than others, or have a weaker drive to seek pleasure, which could lead to passivity or to a sense of emptiness in life. Some people have a greater avoidance of risk; some have subclinical obsessional tendencies. At least in some people, SSRIs can alter all of these traits, which can alter personality in turn. The author is not much interested in whether any of these traits are inborn or acquired, but he does believe that they can persist through all kinds of circumstances (including psychotherapy). His focus on personality change goes as far as "The evolutionary model [...] holds that in a given society an `antidepressant' is any chemical that leads to a rewarded personality -- different cultures may have different antidepressants," though I don't think he would insist on this point.

As I have been doing in these book writeups because I am lazy, let me drop a few thought-provocative quotes on you:

If someone develops a pill that makes people less gullible, we will see gullibility as a biological predisposition -- shake our heads sadly behind the backs of parents of gullible children, express annoyance at gullible adults who fail to seek treatment, and wonder in a different way about ourselves if now and then in our social dealings we find ourselves taken in.


More recent observations by Suomi suggest that nervous, shy infants foster-reared by unusually nurturant mothers grow up precocious and socially adept. In particular, when subjected to social stress these monkeys tend to recruit others to help -- and this trait enhances their social status in the troop. [...] Perhaps social facilitation is the healthy version of reactivity [...]


It is my observation that patients who say they have not grown since early childhood, and who in fact appear immature or socially stunted, often do quite well when properly medicated -- and without the need for any social-skills training. Having observed people in the school or workplace, and watched television shows and read books that model social behavior, and dreamed of social competency, seems to be enough for them. Once they are less inhibited, they interact with surprising success. The limiting factor in their past failures was social anxiety or a missetting of the sensor for social distance, and not any failure to have matured.

the verdict on celery root

Eh, tastes like celery. (Background on my character: I don't particularly care for celery.) The experimental sauce was kind of interesting, with macadamia nut butter and lemon juice and too much sugar and water.