anthropological look at psychiatry: questioning a system

I am reading a book called Of Two Minds: An Anthropologist Looks at American Psychiatry by T.M. Luhrmann. While a bit on the academic side for “pleasure” reading, it is a fascinating look at the culture and process of how psychiatrists begin to think like psychiatrists. It was published in 2000, and many things have changed in the field of psychiatry in the past fifteen years, but many arguments that Luhrmann makes are, I believe, still very valuable today.

This illuminating quote is a bit long and jargon-y, but bear with me, there’s some good stuff in here. Luhrmann writes, “If a very new resident is asked whether a patient meets DSM [The Diagnostic and Statistical Manual of Mental Disorders] criteria for, say, schizophrenia or paranoia, that resident will pick up DSM and read the criteria for each. She may find that the patient meets some for both and the difference between the two categories is not that straightforward, at least in this case. If you ask that same resident about such a patient one year later, when she has developed prototypes for the illnesses, she will probably not reach for the diagnostic handbook, and she will probably not feel that the difference between the categories is inherently uncertain. She is more likely to believe that there are clear differences between illness categories and more likely to pick up data in a case presentation that correspond to the prototype and ignore information that does not. As this happens, it becomes difficult for the psychiatrist to remember that initial skepticism about the diagnostic criteria. A patient’s illness seems less like a sorting problem–is it like this or like that?–and more like an identification task. Diagnoses begin to feel like real, distinct objects in the body” (Luhrmann 42).

In terms of documenting how psychiatrists begin to think, this is a bit frightening, no? Human beings become more likely to be defined by their diagnosis as a psychiatrist gains more training. Of course, at the same time, the psychiatrist is gaining more experience, and therefore their instinctual diagnoses might be more likely to be on target. Still, given the amount of mis-diagnosing that occurs, and that a diagnosis often leads to a medication prescription, this is a bit scary.

Then there is the topic of stigma, and how those of us who struggle with mental health issues begin to internalize the diagnose(s) we are given. In my case, I am fairly certain my diagnosis is correct. However, has it impacted the way I see myself, and the way I think about how others see me? Absolutely.

I don’t feel I know nearly enough about the inner workings of psychiatry or psychiatric training to make broad generalizations about the quote above (I haven’t finished the book, and even if I had, woe to the person who reads one book on a subject and thinks themself an expert.) However, being on the other side (i.e., being a patient and not a clinician) it feels very personal to read one account of how the minds of those judging my own mind get changed early and throughout their training. The quote mentions the likelihood, over time, to notice more and more what fits with the gut diagnosis, and ignore what doesn’t. We all do this throughout our days, in some form or another, in terms of “selectively seeing” and “selectively noticing.” There is simply too much for us to see and notice to be able to take it all in with equal amounts of attention. However, human beings are complex, and it concerns me that with more training a diagnosis procedure would become less–not more–complex.

I am aware that many psychiatrists have helped many people, including me, and that there is a great deal of good that is done in the field. However, recent experiences have led me to question the system and process itself, and whenever there is an eagerness to question a system, I think we ought to start exploring.

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