IN a penetrating ethnographic study of American psychiatry, Tanya Luhrmann (2000) comes to a troubling diagnosis. At the end of the century, psychiatric practice, theory, and training are riven by a deep divide between two ways of understanding mental disorder. These orientations–the biomedical and the psychodynamic–have lived in uneasy coexistence for several decades, struggling to dictate the terms in which mental disorder is classified, formulated, and treated. Now, Luhrmann argues, the struggle is coming to an end, not in a grand and hopeful synthesis or a comfortable pluralism, but in the overwhelming victory of the biomedical orientation.
Some of the forces that have led to this state of affairs are economic and institutional. The advent of effective pharmacological therapies :for many disorders has enabled less time-intensive treatment, and made psychotherapies seem wastefully time-consuming. Changes in reimbursement practices and continued public funding shortages have led to increasingly short inpatient stays in which psychotherapy can barely be begun. Diagnostic systems have become increasingly medicalized. Research funding has poured into biochemical, neurophysiological, and pharmacological research. Academic psychiatrists have striven to raise the status of their specialty by moving it toward a more orthodox medical ethos. Nonmedical specialties have competed with psychiatry in the ecology of mental health care delivery, forcing a division of labor in which psychiatrists concentrate on somatic rather than talk therapies.
In addition to these concrete determinants of American psychiatry’s current state, however, there is an important ideological conflict. Biomedical and psychodynamic orientations to psychiatry differ fundamentally in their understandings of the nature of mental disorder, personhood, and the moral dimension of treatment, and Luhrmann devotes considerable space to the articulation of these diverging understandings. The biomedical model, she argues, apprehends mental disorder as something separate from the patient’s individuality and life history, the product of a "broken brain" or "twisted molecule," so that treatment targets a malfunction of the body, an "it" rather than a person. "The explanatory foundation of mental illness … lies beyond personhood, in biological microstructures that escape uniqueness" (p. 181). For all the problems of psychodynamic understanding and practice, the psychotherapeutic sensibility has a vital but increasingly neglected contribution to make to psychiatry. "Patients are less well off without therapy," Luhrmann contends. "They do less well, are readmitted more quickly, diagnosed more inaccurately, and medicated more randomly" (p. 262). Psychiatry is facing a very real loss, she argues, and is in danger of becoming increasingly mindless. Importantly, these changes are not confined to the clinic, the research lab, and the medical academy, but radiate out into the wider world, as biological psychiatry supplies new understandings of mental disorder, self, and suffering to be taken up by the lay public.
In this essay, I would like to explore some of the cognitive dimensions of the ideological struggle that Luhrmann dissects so keenly. What kind of thinking is involved, I ask, when people think about mental disorder in biomedical terms, and what implications does this kind of thinking have for how we understand and respond to the disordered?
The Disease Model of Mental Disorder
The ideological divide in psychiatry that Luhrmann analyzes is fundamentally about the nature of mental disorder. The ascendant biomedical approach presents disorders in a particular way, governed by a set of more or less tacit assumptions, which differ from the basic assumptions of the psychodynamic approach and have distinct implications for treatment. The biomedical understanding of disorder has often been dubbed the "medical" or "disease" model, which has frequently been the target of critical analyses by nonpsychiatrists. The pitch of these analyses has often been shrill and denunciatory. However, it is possible to distill the basic tenets of the disease model as it is more or less consensually understood by the combatants (e.g., Guze, 1992; Kiesler, 1999; McHugh and Slavney, 1998; Reznek, 1991; Tyrer and Steinberg, 1998; Valenstein, 1998) without taking sides. These abstract features will be the focus of my discussion.
The disease model, I would argue, makes the following four claims about mental disorder. First, it maintains that the causes of mental disorders are to be found in disturbances or abnormalities of biological structures, functions, or processes. These aberrations underlie and give rise to characteristic patterns of symptoms and signs; they are, therefore, to be identified by neuroscience and targeted by somatic treatments. Second, for each disorder there is a specific etiology, a single common abnormality that determines the nature or form of the disorder. Third, disorders are discrete categories such that affected individuals differ qualitatively from the unaffected. Disorders correspond to real, categorically distinct entities, rather than simply being pragmatically useful ways of sorting people into groups with similar features, and the taxonomy of disorders is therefore a crucial task for psychiatry. Diagnosis is equally crucial, a matter of identifying the kind that the individual exemplifies, involving an inference from observed clinical features back to an underlying type. Considering the individual primarily as an instance of a kind is vital because each kind is a potent source of inductive inferences about cause, pathological mechanism, clinical expression and course, and response to treatment. Fourth and finally, the disease model implies that mental disorders are not deeply culture- or time-bound, what Reznek (1991) terms the "universality thesis." Historical and cross-cultural variations are generally minor and incidental, because the expressions of mental disorders are primarily outgrowths of biological processes and "the social and psychological dimensions of sickness are seen as epiphenomenal" (Kleinman, 1988, p. 143).