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==== {{anchor|ACCLAIMFORTMLUHRMANNSOFT}} ACCLAIM FOR T. M. LUHRMANN’SOF TWO MINDS ====

===== “Of Two Minds needs to be read by every psychiatrist, and every psychiatric resident, and by psychologists, social workers, nurses, and laypeople who possess an interest in psychiatry, because it is the single best account of what is happening to psychiatry. Beautifully written.… A triumph!” =====

<div style="text-align:right;">—Arthur Kleinman, M.D., Professor of Anthropology and Psychiatry,Harvard University</div>

===== “An important book, shedding light on the world of psychotherapy as only a caring outsider would do.” =====

<div style="text-align:right;">—Harold Kushner, author of''When Bad Things Happen to Good People''</div>

===== “Written with verve, Of Two Minds is a tour de force of careful, empathetic scholarship that deserves the widest of audiences.” =====

<div style="text-align:right;">—''Austin American-Statesman''</div>

===== “A spirited, clear-eyed visit to the land of American psychiatry, where the insurance industry drones and the drug-cowboys of psychopharmacology are taking over. This terrific book urges us to preserve what truly heals: a shared journey of mutual, compassionate connection.” =====

<div style="text-align:right;">—Samuel Shem, M.D., Ph.D., psychiatrist at Harvard Medical School,and author of ''The House of God'' and ''Mount Misery''</div>

===== “One of the most important studies of society and mental health over the past three decades, Of Two Minds is destined to become a classic. It is must reading for everyone concerned with the study and treatment of personal distress.” =====

<div style="text-align:right;">—Bertram J. Cohler, William Rainey Harper Professorof Social Sciences, University of Chicago</div>

===== “Scrupulously fair … Of Two Minds is the best book on mental illness and its treatment that I have read since The Powers of Psychiatry by Jonas Robitscher.… Issues of morality and responsibility—on the part of psychiatrists, of society and of the mentally ill themselves—permeate her discussion.” =====

===== “Riveting.… Readers will turn the last page of this book feeling that they have been given a rich, generous, behind-the-scenes look at a profession that is intrinsically fascinating and that may affect them at some crucial point in their own lives.” =====

<div style="text-align:right;">—''The Women’s Review of Books''</div>

<div style="text-align:center;">''Persuasions of the Witch’s Craft''</div>

<div style="text-align:center;">''The Good Parsi''</div>

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==== {{anchor|FIRSTVINTAGEBOOKSEDITIONAUG}} {{anchor|TopofLuhr9780307791900epubc1}} [Copyright] ====

<div style="text-align:center;">FIRST VINTAGE BOOKS EDITION, AUGUST 2001</div>

<div style="text-align:center;">''Copyright © 2000 by T. M. Luhrmann''</div>

<div style="text-align:center;">All rights reserved under International and Pan-American Copyright Conventions. Published in the United States by Vintage Books, a division of Random House, Inc., New York, and simultaneously in Canada by Random House of Canada Limited, Toronto. Originally published in hardcover in the United States by Alfred A. Knopf, a division of Random House, Inc., New York, in 2000.</div>

<div style="text-align:center;">Vintage and colophon are registered trademarks of Random House, Inc.</div>

<div style="text-align:center;">The Library of Congress has cataloged the Knopf edition as follows:Luhrmann, T. M. (Tanya M.), [date]Of two minds : the growing disorder in American psychiatry / T. M. Luhrmann.p. cm.eISBN: 978-0-307-79190-0Psychiatry—Study and teaching. 2. Psychiatry. I. Title.RC336.L78 2000616.89’0071’173—dc2199-40732</div>

<div style="text-align:center;">''Author photograph by Elena Siebert''</div>

<div style="text-align:center;">[http://www.vintagebooks.com www.vintagebooks.com]</div>

<div style="text-align:center;">v3.1</div>

<div style="text-align:center;">{{anchor|Formyfather}} {{anchor|TopofLuhr9780307791900epubd}} ''For my father''</div>

I would like to thank my wife, Sally.… Along those lines—Thanks respectively to Wyeth/Ayerst Laboratories and Stuart Pharmaceuticals for further expanding that narrow channel of joy by manufacturing Effexor and Elavil; drugs so good they feel illegal.

<div style="text-align:right;">—Thom Jones, ''Cold Snap''</div>

Trying to understand experiences that are at once personal and cultural calls for a kind of passionate detachment that is, I think, almost impossible to sustain alone. Susan Robertson, my psychotherapist, has been a constant source of emotional support and thoughtful analysis.

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<div style="color:#0000ff;"><u>''Cover''</u></div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epuba1|Other Books by This Author]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubt|Title Page]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc1|Copyright]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubd|Dedication]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epube|Epigraph]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epuba2|Author’s Note]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubi|Introduction]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc2|CHAPTER ONE:]]$$$@@@[[#TopofLuhr9780307791900epubc2| What’s Wrong with the Patient?]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc3|CHAPTER TWO:]]$$$@@@[[#TopofLuhr9780307791900epubc3| The Arrow of Harm]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc4|CHAPTER THREE:]]$$$@@@[[#TopofLuhr9780307791900epubc4| The Culture and Its Contradictions]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc5|CHAPTER FOUR:]]$$$@@@[[#TopofLuhr9780307791900epubc5| The Psychiatric Scientist and the Psychoanalyst]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc6|CHAPTER FIVE:]]$$$@@@[[#TopofLuhr9780307791900epubc6| Where the Split Came From]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc7|CHAPTER SIX:]]$$$@@@[[#TopofLuhr9780307791900epubc7| The Crisis of Managed Care]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubc8|CHAPTER SEVEN:]]$$$@@@[[#TopofLuhr9780307791900epubc8| Madness and Moral Responsibility]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epubb1|Bibliography]]$$$</div>

<div style="color:#0000ff;">@@@[[#TopofLuhr9780307791900epuba3|Acknowledgments]]$$$</div>

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This ethnographic material has been taken from hundreds of hours of tape recording, note taking, and more casual conversation. In the interest of anonymity, the names of people interviewed have been changed (except for some whose work, by its visible nature, removes their anonymity). In the interests of coherence, some quotations have been edited for flow, although content has been preserved. And in the interests of both narration and anonymity, some individuals, while loosely based on real people, are intended to be composite figures, and some quotations by other people have been attributed to them. The story of “Gertrude,” for example, is a composite of events in the lives of three different women. All the events, it should be said, happened in the manner described, and all the details and quotations are accurate within the limits of anthropological note taking, although identifying details have been omitted or changed. Some quotations are based on taped conversations. Others are based on field notes taken after the encounter and often recorded in the third person.

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In the autumn of 1989, I arrived as a new assistant professor in an anthropology department known for its long tradition of psychological anthropology. I was already an experienced ethnographer, with a book on modern witchcraft behind me and another on Zoroastrianism under way. But I was a relative newcomer to psychological anthropology, at least in its American form (I had done my training in England), and my colleagues suggested that it might be helpful for me to attend the lectures to the new psychiatrists in training.

American psychological anthropology grew out of a tradition of using psychoanalytic ideas to make sense of cultural practices. (My background was more cognitive.) Margaret Mead was one of its founding mothers. She used a loosely Freudian understanding of childhood experience in different societies to explain their adult behavior. So for years, graduate students in my department had been sent to learn a clinical perspective on Freud and psychoanalysis from the lectures given to young psychiatrists. As it happened, they had long been complaining that the lectures had nothing to do with anthropology, but I didn’t know that at the time. I just showed up, with a mixture of excitement and trepidation, in a year when no graduate students came along.

I told myself that the lectures would not be entirely unfamiliar territory: my father is a psychiatrist, and I myself had seriously considered becoming one, settling on anthropology because I saw myself more as a writer of books than as a healer of patients. As one of my colleagues points out, this makes me a “halfie” anthropologist, someone who grew up half in the world she writes about professionally, like an anthropologist with an Egyptian father who goes off to live with the Bedouin. There are a number of halfie anthropologists these days. Being one gives you a little edge, because you grew up speaking the language of the world you later describe.

So when I began to go to the Thursday-morning classes for the new psychiatrists in training, I was not thinking of writing an ethnography. I wanted to learn about psychosis and depression, how psychoanalysis works, and whether the psychiatric illnesses I saw in San Diego would look the same in Tibet and Borneo, places where virtually no one had heard of Freud. For six months I went to two classes every Thursday morning, fascinated by this complicated, contradictory, confusing world. Then one of the young psychiatrists turned around one morning and asked, “Why don’t you write about us? Isn’t that what anthropologists do?”

He was, of course, right. (He was also somewhat alarmed that I took him seriously.) I had found the process of psychiatric training—at least, what I could see of it then—disturbing and perplexing but also deeply intriguing. I knew I was beginning to see people in a different way, to search for the marks of darker moods in the way they held themselves and glanced and gestured. In part that was because I was literally beginning to see different people. In the everyday world, you don’t see the patients who end up in psychiatric inpatient units, or at least you don’t see them sick. The odds are that in a lecture hall of a hundred students, several have something seriously amiss psychiatrically, but I rarely saw it; nonpsychiatrists rarely do. When people were a little too impulsive, a little too sad, a little too thin, it was easy to read them as having a bad week. They were still normal, still like “us.” (There was, of course, the student who took exception to Émile Durkheim and on the morning of the final exam presented me with the charred remains of ''The Elementary Forms of the Religious Life''. She was unusual.)

In these psychiatry classes, I saw a man brought in for treatment because he had been found in his kitchen, holding his wife’s bloody heart in his hands, a carving knife beside him on the floor. I remember a woman, a graduate student in comparative literature at one of the best schools in the country, with long, golden ''Baywatch'' hair. But she hunched over with her hair across her face and her misery was so palpable that my throat choked up as if I would cry. I remember a man so anxious that I wanted to jump from my chair and run, but the room was full of watching students and the man’s eyes scanned us forward and back. Nobody dared to move. I began to be afraid of the highway, because two patients said they had thought of committing suicide by shutting their eyes at seventy miles per hour. A little later I met an undergraduate who was sophisticated, chic, articulate, slender—when I had been an undergraduate, I had yearned to be someone like that, an Audrey Hepburn from Central Park West—and she was checking into the hospital because she was anorexic and her mother was divorcing her father and sending her money from Europe but not answering the phone.

Psychiatry is unquenchably compelling because it forever changes the way you understand human experience. It lets you into the back bedroom of conventional behavior, so that you glimpse behind the polite interfaces of everyday life the true weirdness of human feeling. It shows you despair harsher than you had imagined and exhilarating, terrifying ecstasy and strange irrationality. Most of us are charitable interpreters of other people’s behavior, to use the philosopher Donald Davidson’s phrase. We assume that other people are just like us—normal—until it becomes apparent that they are not. Psychiatry forces upon you, more abruptly and with an in-your-face confrontation, the lessons anthropology is meant to teach: that the landscape of human thought and feeling is more gaunt and jagged but also more breathtaking than most of us, Horatio-like, have dreamed of in our little local worlds. I thought that if I could describe the way I was learning to see, which is the way psychiatrists are taught how to see, I would be doing what every anthropologist is supposed to do, but by traveling into the familiar, not away to the exotic.

But psychiatrists do not see in one single manner. The Thursday-morning lectures were remarkably diverse. Some mornings, men would come in wearing white medical coats. They would talk about neurotransmitters and catecholamines and draw diagrams of biochemical interactions on the board. They spoke a language I hadn’t heard since high school science. Other mornings, men (almost always men) 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. There was someone who drew graphs that explained when schizophrenics were born (he thought the Christmas drinking season might be partly to blame), someone else who practiced therapy but didn’t believe in the unconscious, and yet another who carefully wrote Erik Erikson’s life stages on the board and then never discussed them. I heard lectures on alcohol, combat, sexual abuse, sleep disorders, epilepsy, and the whole range of psychopharmacological treatments. Behind all this, behind the advice, the biochemical diagrams, and the commentary about psychotherapeutic transference, 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. No one mentioned those deep issues explicitly. They talked about what you should do with a particular patient. But surrounding the practice issues around, say, a late-night suicidal phone call were some of our oldest philosophical dilemmas.

Why do we suffer? In the dramas of classical antiquity, we watch great individuals suffer, and we feel pity and terror for them because in the inexorable doom of the unfolding story, we see that they are caught up in circumstances they have not chosen but in which they have made choices that will destroy them. Antigone does not choose the conflict between blood rights and state rights: her greatness is that she sees but does not flinch from the moral need to bury her brother, despite her king’s command that she must not. Being the person she is, she chooses to honor family over king, and so she dies whereas another person might have lived. The flaws in her character are also the unwavering commitments that make her great. Today we use the word “tragedy” in a more pedestrian sense, to refer to personal circumstances over which we genuinely have no control: an aircraft exploding in midflight, a flood wiping out a summer’s crops, a senseless, arbitrary murder. I say pedestrian, but life is really made up of small circumstances that hem us in so tightly that we can scarcely move. To understand that these circumstances are more important than the choices we make within them is to see a very different staging of human experience. That difference is the major tension in the way psychiatrists are taught to look at the world.

Psychiatrists have inherited the Cartesian dualism that is so marked a feature of our spiritual and moral landscape. Sometimes they talk about mental anguish as if it were cardiac disease: you treat it with medication, rest, and advice about the right way to eat and live. A person who has had a heart attack will never be the same—he will be always a person who has been very seriously ill—but he is not his heart attack. His heart attack is in the body, not the mind. When psychiatrists talk in this manner, psychosis and depression become likewise written on the body. This style of speaking has gained preeminence in the last two decades. It is usually called “biomedical” psychiatry, an approach to mental illness that treats it as an illness of the body that is more or less comparable to other physical illnesses. Sometimes, though, psychiatrists talk about distress as something much more complicated, something that involves the kind of person you are: your intentions, your loves and hates, your messy, complicated past. This style is associated with psychoanalysis and psychoanalytic psychotherapy, usually called “psychodynamic,” which dominated psychiatry in the middle decades of this century and which remains the fountainhead of all psychotherapies. From this vantage point, mental illness is in your mind and in your emotional reactions to other people. It is your “you.”

Of course, this is a false dichotomy, as most psychiatrists would agree. But it is the way that psychiatrists are taught. It seemed clear to me that there were, broadly speaking, two main areas of skill that psychiatrists in training are expected to acquire: on the one hand, diagnosis and psychopharmacology, which are usually the dominant focus of inpatient psychiatry, and, on the other, psychodynamic psychotherapy, which tends to be taught as an outpatient specialization distinct from the skills of hospital psychiatry. The psychiatrists and the staff I spent time with spoke comfortably about the differences between psychotherapy and biomedical psychiatry. They argued about psychiatry in ways that took the dichotomy for granted. Their training schedule (at least two lectures a week, usually one on psychopharmacology and diagnosis, another on psychotherapy) clearly indicated that their seniors thought that those were the two major and different areas of skill. They learned two different ways to identify, understand, and respond to mental anguish. Young psychiatrists are supposed to learn to be equally good at both talk therapy and drug therapy, psychotherapy and biomedical psychiatry, and 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 causation, and different expectations of how a person might change over time.

The actual practice of psychiatry is, of course, greatly complex. Psychoanalysts, although they dominated psychiatry for many years, never had an exclusive hold on psychotherapy inside or outside the psychiatric profession: milieu therapy, group therapy, cognitive behavioral therapy, interpersonal therapies—talk therapies are as various as the country is wide. Nor are biomedical psychiatrists a single kind of doctor. Different psychopharmacologists have very different styles, and the gap between a clinician’s view of an illness and the view of a laboratory-based psychiatric scientist can be a ravine. There are psychiatric specialties in community psychiatry, geriatric psychiatry, cultural psychiatry, the psychiatry of substance abuse, and many others that are not primarily oriented toward psychotherapy but certainly could not be classified as “biological.” Nevertheless, the psychiatry of the last half century has been formed around the psychoanalytic rise to power and the new psychiatric science, followed by the health care revolution, which has brought psychoanalytic dominance to its knees.

These two approaches now exist in 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, so that they learn to believe and to say that these different models should be integrated in the practice of psychiatry. But no one really knows where truth lies, although periodically brilliant new syntheses are published in the leading journals. As an anthropologist, I 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. I wanted to know the way these different approaches changed the way the psychiatrist perceived, felt, thought, the way he became excited and challenged, the way he became bored. After all, these two approaches, the psychodynamic and the biomedical, have their roots in the more fundamental Western division between mind and body that our society, for all its sophisticated caveats, still endorses. We still think of the body as something unintentional, something given, something for which any individual is not responsible. That is why we are so interested in metabolic set points, inborn temperaments, learning disabilities, and the genetic roots of attention deficit disorder. 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. If someone is fat because he gives in to craving, we can laugh at him, we think; certainly for years, during the height of the fat-conscious decades, those who were fat were perceived by many, not least themselves, as morally weak. But if someone is fat because his metabolism is unalterably askew, we must admire his courage. If a child gets poor grades because of a learning disability, she should not be punished for not studying but should be given special help, the way we help those with other special physical needs. If I am lazy because I was born that way, I don’t need to be guilty and embarrassed by the slope of my career. Biology is the great moral loophole of our age. This is not to say that I think this to be entirely inappropriate. As a good American, I believe that it is wrong to hold people responsible for something they cannot control. Nevertheless, a moral vision that treats the body as choiceless and nonresponsible and the mind as choice-making and responsible has significant consequences for a view of mental illness precariously perched between the two.

Understanding the way a set of ideas and practices can change a person is what anthropologists are trained to do, and as an anthropologist, I was better positioned to observe these changes than a member of the tribe. I went through much of the formal learning process. But I didn’t need to commit myself professionally as a member of the field. My professional job was to watch myself learning, to watch others learning, to sketch out a kind of anatomy of the way learning took place, and to understand what was learned that was not necessarily intentionally taught. My job was to understand how a nonpsychiatrist (an ex–medical student) can enter the culture of psychiatry and become a fluent speaker of the local tongue. This informal learning is manifestly not the kind of thing that people talk about in interviews, because it happens so accidentally and changes you so incrementally that people often do not even notice that they have become profoundly different. Like the rest of medicine, psychiatry is a craft. It involves a kind of hands-on knowledge that is as much doing as knowing, something that invokes the philosopher’s distinction between “knowing that” and “knowing how” (this is also known as declarative and procedural knowledge). A young psychiatrist—skilled, competent, articulate—learns to ''do'' psychiatry, not so much to describe what she does. She learns her psychiatry the way a young violinist learns to play the violin: to listen for the notes of a scale, to hear pitch and know when a string is in tune, to feel pride in the calluses that develop on the tips of the fingering hand, to know how to hold a bow by the feel of its weight. For someone who is good at her task, those ways of perceiving settle in so deeply that they become the way the person moves, hears, and observes when at that task. To understand what psychoanalysts and psychopharmacologists see, you must follow what young psychiatrists are taught and how they learn it. You must understand what they begin to do naturally as they carry out their tasks. You must understand how they come to think, how they feel, to what they aspire, and from what they flinch. You must understand how they handle their own anxiety about being any good at their profession. You cannot understand this just by asking people about it, any more than you can learn to canoe in an armchair with a reading lamp.

Since 1989, I have done more than four years of fieldwork, including more than sixteen months of full-time, intensive immersion. (I should say that I did all the work within the constraints of the willingness of the participants. Patients were always asked if they were comfortable having me sit in on a clinical interview, and if they declined, as they sometimes did, I left; I also left when psychiatrists were not comfortable with my presence.) The work began in a local hospital, where I attended lectures, hung out with residents (residency is the three-year specialty training in psychiatry after medical school and a one-year internship), and participated in medical meetings. I also spent four months at an elite private psychiatric hospital; three months in a community service hospital; and stretches of a week or two each in a psychoanalytic hospital, a scientific research unit, a state hospital, and a nonacademic community hospital’s psychiatric unit. I traveled around the country (to Kansas, Louisiana, New York, Massachusetts, California) speaking with hospital administrators, psychiatry residency program directors, and young psychiatrists. I watched hundreds of lectures to residents through three years of training; I attended well over a hundred rounds or team meetings in which patients are presented and sometimes interviewed with the aim of establishing a diagnosis and treatment plan; I have “shadowed” residents during the day on the inpatient unit and during on-call evenings, and I have spent substantial periods of time on psychodynamic, eclectic, and biological units; I have watched countless admissions interviews; I have interviewed most residents in every class at one program annually for three years and many others elsewhere; I have followed eight individual patients for psychotherapy under the supervision of a senior psychoanalyst, one once a week and three twice a week for more than a year; I was in twice-a-week psychotherapy with a senior psychoanalyst for more than three years; I jointly led a group for indigent patients for a year; I attended fifteen major psychiatric conferences; I had so many meals with psychiatrists that for a time there was a standing joke among my friends that my entire social life was tax-deductible.

Let me say quickly that my role as an anthropologist is compromised (or liberated, depending on your point of view) by the fact that I believe both the biomedical and psychodynamic approaches to psychiatric illness to be substantially correct and equally effective, although not always for the same person. It seems clear to me that people have motivations that are not apparent to them, and that the way they experience the world is profoundly shaped by their personal history, often in ways they do not grasp; it also seems clear that there is something organically wrong with most people who are sick enough that they are admitted, these days, into a psychiatric hospital. I don’t think that either approach mirrors the reality of mental illness, but then I don’t think that any domain of knowledge “mirrors” the world as it is. The real issue for me is how one learns to look at mental illness through different lenses and the consequences of those ways of seeing.

The lenses are terribly important, and understanding how psychiatrists see is also terribly important, because madness is both frighteningly, palpably present, and yet elusive. There are no diagnostic tests in psychiatry (at least, none for genuinely psychiatric disorders: there are some conditions, such as brain tumors, that at first appear to be classic psychiatric disorders but are not). You cannot draw someone’s blood, stick someone into a magnetic resonance imager, or take any medical reading that will tell you definitively whether that person is depressed or not. So it matters a great deal how a psychiatrist is taught to look at mental illness, because the “how” cannot be clearly separated from the “what” of the disease. To understand psychiatric ways of seeing, we have to proceed knowing that what counts as “fact” is a tinted window onto a world you cannot step outside to see.

It used to be fashionable in intellectual circles to say that madness didn’t really exist at all, that it had been created when society’s quest for order defined some people as deviant. This was done with crudeness by the antipsychiatry movement of the 1960s and 1970s and with finesse by Michel Foucault. Foucault did presume that madness had always existed, but he romanticized it in a way that, despite all his insights, did a terrible disservice to its pain. He argued that asylums had emerged in the eighteenth century as embodiments of middle-class morality and were like a kind of “gigantic moral imprisonment”; they dampened the free intensity of madness into “the stifling anguish of responsibility.”@@@[[#1MichelFoucaultMadnessand|1]]$$$ He wrote movingly about the way that after the asylum, the true genius of madness could be seen only in the writings of philosophers and poets. Others made similar arguments out of a naive yearning for a past when those we now call psychotic would have been esteemed as religious experts. (Some of these arguers come to my office wanting to write papers on how today’s schizophrenics would have been yesteryear’s shamans.) George Devereux, a psychiatric anthropologist who was not so much romantic as persuaded that the shamans in the society he worked in were pretty odd, wrote a famous paper arguing that shamanism provided a social role for the mentally ill that our society conspicuously lacked. “Briefly stated, my position is that the shaman is mentally deranged.”@@@[[#2GeorgeDevereuxBasicProble|2]]$$$ He suggested that the difference between the publicly recognized shaman and the “private” psychotic is that the shaman is able to use ritualized conventions in his society to manage his distress. This is a complicated and important issue, because it is clear that the way a culture interprets symptoms may affect an ill person’s prognosis. However, in the 1960s and 1970s, people used popular versions of this notion to suggest that our society was too fearful and uptight to tolerate vivid passions and so condemned these people as sick. Peter Shaffer’s very successful play ''Equus'', for instance, dramatized a young boy whose therapist comes to see the attempt at therapy as the destruction of his passion and a kind of moral hubris. “The Normal is the indispensable, murderous God of Health, and I am his Priest,” the therapist says. “I have talked away terrors and relieved many agonies. But also—beyond question—I have cut from them parts of individuality repugnant to this God.”@@@[[#3PeterShafferEquusandShri|3]]$$$ R. D. Laing argued, with the style of a social prophet, that the schizophrenic was just someone who was too creative, too insightful, too existentially aware for our society. We normals were afraid, he implied, to be so bold.@@@[[#4RDLaingTheDividedSelf|4]]$$$

More recently, Susanna Kaysen wrote ''Girl, Interrupted'', an account of her psychiatric hospitalization as a teenager. She was admitted when she was an adolescent, when she was angry at her parents. It was 1967, and she wore black and slept around and was deeply unhappy. When she went for a doctor’s appointment, he put her in a taxi and sent her to McLean, a lovely, graceful hospital, where she remained for nearly two years. When the book was published, the reviewers condemned psychiatry for characterizing emotional women as mentally unstable and for treating teenage unhappiness as a scapegoat for a dysfunctional family. “How thin the line is,” Susan Cheever fumed in the ''New York Times Book Review'', “between those society deems mad and those it deems sane.”@@@[[#5SusanCheeverADesignated|5]]$$$ Yet despite Cheever’s understandable indignation, it is clear that something was wrong. Kaysen had tried to kill herself before she was admitted. She was suicidal. She wrote, “I was having a problem with patterns. Oriental rugs, tile floors, printed curtains, things like that. Supermarkets were especially bad, because of the long, hypnotic checkerboard aisles. When I looked at these things, I saw other things within them.… Reality was getting too dense.”@@@[[#6SusannaKaysenGirlInterru|6]]$$$ She describes the experience of what she calls insanity, which she says comes in two forms, a viscosity so sluggish you cannot breathe and a velocity so frenetic you cannot cope.@@@[[#7Ibidp75|7]]$$$

Madness is real, and it is an act of moral cowardice to treat it as a romantic freedom. Most people who end up in a psychiatric hospital are deeply unhappy and seriously disturbed, and many of them lead lives of humiliation and great pain. To try to protect the chronic mentally ill by saying that they are not ill, just different, is a misplaced liberalism of appalling insensitivity to the patients and to the families who struggle so valiantly with the difficulties of their ill family members. Most people who are really schizophrenic are far too ill to serve as religious experts.

Moreover, the fantasy that innocent victims are imprisoned in asylums where they go slowly mad under the weight of the psychiatrist’s expectation and society’s rejection is exactly that, a fantasy. These days, with the pressure of insurance companies eager to deny psychiatric care if at all possible, the only people admitted to psychiatric services are usually so ill that there is no other option. Patients’ rights are in general well protected, although this varies from state to state, and a patient who is able to explain where he lives, perhaps has some money—maybe $20—or at least some place to go, and claims to have no intent to kill himself or anyone else goes free if he wants. Given that one of the common characteristics of psychosis is that the person does not experience himself as ill, people just barely able to function often reject psychiatric help. (“Psychosis” describes an unmistakable distortion of reality, such as believing that the CIA has implanted a microchip radio broadcaster in your mind. It is not a psychiatric disorder per se but a symptom of psychiatric illness, the way a sore throat is a symptom of a cold.) I never saw anyone held against his or her will in a hospital whom I felt was there unjustly. On the contrary, my experience was that people were denied clinical care when they should have been treated. At one point during my study, my liberal friends would lecture me on the evils of psychiatric incarceration while one of my psychiatrist friends was being stalked by a psychotic man refusing psychiatric care.

It is hard to describe, to someone who has never seen it, how terrible and intractable madness often is. Even firsthand narratives do not always help, either because the author (now recovered) seems either too sane to have been ill (as in Kaysen’s case) or because the story seems too storied and bizarre (as in ''I Never Promised You a Rose Garden''). The way we perceive madness does affect the madness experienced, but still there is an obdurate, unignorable presence to these illnesses. Over the years, at least for the last few centuries (some people argue that schizophrenia is a product of the last few centuries@@@[[#8IrvingGottesmanSchizophren|8]]$$$), certain strange miseries have recurred in the history and literature of madness. Psychiatrists have classified them somewhat differently over the past few decades, but the symptoms and their severity have remained consistent. These days, they are classified as depression, manic depression (also known as bipolar disorder), and schizophrenia. Residents call them the “big three” because they dominate inpatient services and psychiatric emergency rooms. They have a kind of irrefutable reality.

William Styron was able to capture some of the gravitas of major depression in ''Darkness Visible'' by recounting, in blunt detail, the forced steps taken by his mind as the depression came upon him like a darkness with talons:

===== I was on Martha’s Vineyard, where I’ve spent a good part of each year since the 1960s, during that exceptionally beautiful summer. But I had begun to respond indifferently to the island’s pleasures. I felt a kind of numbness, an enervation, but more particularly an odd fragility.… [T]he overall effect was immensely disturbing, augmenting the anxiety that was by now never quite absent from my waking hours.… [Then] it was October, and one of the unforgettable features of this stage of my disorder was the way in which my old farmhouse, my beloved home for thirty years, took on for me at that point when my spirits regularly sank to their nadir an almost palpable quality of ominousness.… One bright day on a walk through the woods with my dog I heard a flock of Canada geese honking high above the trees ablaze with foliage; ordinarily a sight and sound that would have exhilarated me, the flight of birds caused me to stop, riveted with fear, and I stood stranded there, helpless, shivering, aware for the first time that I had been stricken by no mere pangs of withdrawal but by a serious illness whose name and actuality I was able finally to acknowledge.… [F]ood … was utterly without savor … my few hours of sleep were usually terminated at three or four in the morning.… Death … was now a daily presence, blowing over me in cold gusts.@@@[[#9WilliamStyronDarknessVisi|9]]$$$ =====

Those who suffer from major depression cannot sleep, do not eat, and are obsessed by the thought of their own death. Their depression feels to them like a physical pain. They cannot concentrate. They cannot function. Many of them cannot leave their beds. One in every six will kill themselves.@@@[[#10HaroldKaplanandBenjaminS|10]]$$$ Styron was lucky, even though he did not respond to medication. He came very close to suicide. He destroyed his personal notebook (emblem of a writer’s self), rewrote his will, plotted his death. (He couldn’t write a suicide note; this Pulitzer Prize—winning author could not find the words.) He felt, he wrote, that he had made an irreversible decision. Then, late at night, brooding, he heard some music that somehow pierced his desolate chill. He roused his wife. She made some phone calls. He soon found himself in the safety of the hospital, protected from the domestic goods that seem harmless to most of us but are deadly invitations to the suicidal: razors, staircases, knives, plastic bags, ropes, vodka, medicine cabinets. Time slowly healed him.

Depression, psychiatrists say, strikes one in five to ten people.@@@[[#11Thelifetimeprevalenceisr|11]]$$$ Schizophrenia strikes one in one hundred. Recent research suggests that there may be more than one disease process involved in schizophrenia (in other words, more than one bodily abnormality), but patients bearing this diagnosis have similar traits. They have seriously abnormal thoughts: that Peter Jennings is speaking specifically to them, that their bodies have died and been replaced by plastic. Psychiatrists call this divorce from reality “psychosis.” In addition, their faces seem curiously flat and blunted, and their lives fall apart. One in ten will commit suicide.@@@[[#12Thisisobviouslyalimited|12]]$$$ Their illness tends to have a chronic, debilitating course, although as many as a third of schizophrenic patients may ultimately recover or at least lead somewhat normal lives.@@@[[#13KaplanandSadockPocketHa|13]]$$$ One of the most famous literary schizophrenics was a real woman known as Sylvia Frumkin whose life was chronicled by Susan Sheehan in ''The New Yorker'' and later in ''Is There No Place on Earth for Me?'' It is a painstaking account of the life of a young, brilliant woman whose illness was basically unaltered by either medication or psychotherapy, who went into and out of psychiatric institutions of varying quality, and whose life was chaotic and painful for herself and her family. This remarkable book opens with this paragraph:

===== Shortly after midnight on Friday, June 16, 1978, Sylvia Frumkin decided to take a bath. Miss Frumkin, a heavy, ungainly young woman who lived in a two-story yellow brick building in Queens Village, New York, walked from her bedroom on the second floor to the bathroom next door and filled the tub with warm water. A few days earlier, she had had her hair cut and shaped in a bowl style, which she found especially becoming, and her spirits were high. She washed her brown hair with shampoo and also with red mouthwash. Some years earlier, she had tinted her hair red and had liked the way it looked. She had given up wearing her hair red only because she had found coloring it every six weeks too much of a bother. She imagined that the red mouthwash would somehow be absorbed into her scalp and make her hair red permanently. Miss Frumkin felt so cheerful about her new haircut that she suddenly thought she was Lori Lemaris, the mermaid whom Clark Kent had met in college and had fallen in love with in the old “Superman” comics. She blew bubbles into the water.@@@[[#14SusanSheehanIsThereNoP|14]]$$$ =====

Sylvia Frumkin was articulate, engaging, and bizarre. When she was tested in grade school, her IQ was 138. She was not well liked then, although her teacher thought her sensitive and eager. Other girls her own age said she was uncouth. Sylvia went to one of New York’s best public high schools, but in tenth grade things began to go wrong. The psychiatrist she saw at that point described her as unattractive, untidy, restless, overtalkative; she switched too readily from tearfulness to giggles; she interpreted people poorly and in odd ways. She was diagnosed as paranoid schizophrenic. Sylvia seemed to do well in therapy and to become more like a normal adolescent: she acquired a best friend, she listened to popular music, she liked the Beatles, she cut her hair and bought attractive clothes. Then she was hit by a car, by a teenager driving alone on a learner’s permit. She briefly lost consciousness and suffered a concussion. Soon she became more anxious than before (she had always been nervous). She would stay up all night; each day she smoked three packs of cigarettes and took three showers. Her casual comments sounded more and more crazy. Her therapist began to give her small doses of Stelazine, an antipsychotic. Two months later, Sylvia became highly agitated and began asking people to adopt her. She was hospitalized for the first time. She insisted, as she drove to the hospital, that Paul McCartney was going to come and take her away to England. From then on she went into and out of psychotic delusions and psychiatric hospitals.

Manic depression, or bipolar disorder, is the third of the trio. It is, like depression but unlike schizophrenia, classified as a “mood” disorder, which means that the most salient problem lies with the patient’s emotional tone, not his or her thought process, although a bipolar patient in the grip of mania can seem crazy in the same way as an acutely psychotic schizophrenic patient. People with manic-depressive disorder experience periods when they are profoundly depressed and other periods when they are manic, a state of erratic, disinhibited euphoria: they don’t sleep, they talk wildly, they are grandiose and sometimes psychotic. Kay Jamison’s memoir of manic-depressive disorder, ''An Unquiet Mind'' (1995), describes her years before she allowed herself to manage the illness with lithium:

===== I was a senior in high school when I had my first attack of manic-depressive illness; once the siege began, I lost my mind rather rapidly. At first everything seemed so easy. I raced about like a crazed weasel, bubbling with plans and enthusiasms, immersed in sports, and staying up all night, night after night, out with friends, reading everything that wasn’t nailed down, filling manuscript books with poems and fragments of plays, and making expansive, completely unrealistic, plans for my future.… Not only did everything make perfect sense, but it all began to fit into a marvelous kind of cosmic relatedness.… I did, finally, slow down. In fact I came to a grinding halt. Unlike the very severe manic episodes that came a few years later and escalated wildly and psychotically out of control, this first sustained wave of mania was like a light, lovely tincture.… Then the bottom began to fall out of my life and mind.… Nothing made sense.… [My mind] was incapable of concentrated thought and turned time and again to the subject of death.@@@[[#15KayRedfieldJamisonAnUnq|15]]$$$ =====

Many people who are manic-depressive, or who experience bouts of depression, function quite well when not ill, but some never manage to live a normal life. Like those who have a “unipolar” depression (they are never manic), one in six will kill themselves. “He reminded me,” Jamison writes of a patient who was not among the lucky ones, “of films I had seen of horses trapped in fires with their eyes wild with fear and their bodies paralyzed in terror.”@@@[[#16JamisonAnUnquietMindp|16]]$$$ Her own life after high school became a riveting story of voyaging between extremes. In her first job, as assistant professor of psychiatry at UCLA, she found herself exuberant and brilliant at a professional party and went higher; she bought a fantastic array of stuff, among it three expensive watches, twelve snakebite kits, and, most horrifying later on, a stuffed, preserved fox; higher still, she wrote a poem, inspired by her spice collection and archived in the refrigerator, entitled “God Is a Herbivore.” Then she crashed, with a bloodred vision of a splattered test tube. Over the years she swung high, then low. She bought a gun, confessed she owned it, gave it away. She fought with lithium and the need to take it, then overdosed on a massive amount of it. She was saved by sheer luck. She wrote of that time, “I can’t calm this murderous cauldron, my grand ideas of an hour ago seem absurd and pathetic, my life is in ruins and—worse still—ruinous.… In the mirror I see a creature I do not know but must live and share my mind with.”@@@[[#17Ibidp114|17]]$$$

These are not romantic illnesses. Nor are they creativity and insight in another form. Every culture recognizes certain people at certain times as mad, and treats them as being different.@@@[[#18ArthurKleinmanRethinking|18]]$$$ (The diagnoses that are generally accepted to be valid worldwide are schizophrenia, manic-depressive disorder, major depression, substance abuse, and certain anxiety disorders, although, as we will see, the local experience of illness may vary widely.) These people do not become shamans and priestesses and artists because they are mad, although artists may possibly be more successful if they are (mildly) manic-depressive. (This is an important distinction. Being mad probably does not make you creative, but if you are creative, glimpsing the depths of human despair and then reaching the heights of confidence with infinite energy probably enhances your ability to use your gift.@@@[[#19SeeKayRedfieldJamisonss|19]]$$$) Crazy people cannot fend for themselves when they are sick. They struggle to survive with the generosity and protection of others. There is no reasonable doubt that madness is an intrinsic feature of human life, not a by-product of asylum building or of a shift in religious practice.

At the same time, it is true that madness is involved with our social fabric. To return to the sociological point, the way illness is socially conceived does seem to alter the way it is individually expressed and experienced. It is true, as Sue Estroff wrote in her classic ethnography of psychiatric clients, that “being a full-time crazy person is becoming an occupation among a certain population in our midst.”@@@[[#20SueEstroffMakingItCrazy|20]]$$$ Our psychiatric professionals, as well as the rest of us, have expectations of the psychiatrically ill, and we institutionalize those expectations in subtle and unsubtle ways that can lead people to mimic the symptoms we think that they should have. If a homeless veteran wants a warm bed for the night, he can learn what words and gestures will persuade the psychiatrist on call to admit him to the hospital. If a woman receives a disability check each month for her psychiatric diagnosis, she will learn how to avoid having the support curtailed. When Erving Goffman wrote in ''Asylums'' of an institution’s “direct assault on the self,” he was describing the reality that, both inside the hospital and without, the psychiatrically ill learn to play roles our society has designed for them.@@@[[#21ErvingGoffmanAsylumsp|21]]$$$ One of the unintended consequences of social assistance is that we reward people for becoming and remaining ill. Sometimes we trap them in their illness.

This is where much of the good psychiatric anthropology has been focused. These anthropologists have shown us that there is a complex dance between what a clinician learns to treat and how a patient learns to be treated. For example, Allan Young describes the gradual construction of “posttraumatic stress disorder” out of the lives of traumatized Vietnam veterans, the way the clinicians used the diagnostic criteria to include people they felt ought to be seen as sick, and the way patients began to present themselves in order to fit into that diagnostic structure.@@@[[#22AllanYoungTheHarmonyof|22]]$$$ It has now become apparent that not all women diagnosed with multiple personality disorder had that disorder before they walked into the psychiatric consulting room. That many of them had major emotional and behavioral problems seems clear. Many seem to have struggled with dissociation, a long-term consequence of a childhood escape mechanism used when a child confronts bullying or abuse she cannot physically flee. Such a child learned to “check out” when the distress began. She would no longer be there, in the same way you can “check out” when the dentist’s drill begins to whir. As adults, these women had difficulties with concentrating, keeping track of time, being effective and reliable in human relationships. Some learned—from popular best-sellers such as ''The Courage to Heal'', from support groups, from Internet chat groups, and from therapists sensitized by feminism to the dangers of male sexual authority—to understand their pain as caused by male transgression and to experience their disconnectedness as the result of a fragmented self. Dissociation is a skill, and the use of that skill can be learned. Some learn involuntarily, and their dissociation is pathological: unwanted, intrusive, uncontrollable. Some learn willingly to go into trance, possession, out-of-body states, and, for that matter, channeling. And the content is manipulable. Someone can dissociate by zoning out and then learn to experience that sensation as possession. In the 1980s, many women learned to handle their dissociation and general distress by learning to experience multiple personalities that switched on and off in disturbing ways.@@@[[#23SeeJoanAcocellaThePoli|23]]$$$ By that point, a therapist who helped a woman to gain control over a disturbing, unwanted dissociation by teaching her how to “call” her “alters” (alternative personalities) was acting appropriately and effectively to help her. But the therapist may not have been doing what she thought she was.

History shapes the kind of madness people experience and the frequency with which it occurs. Poverty, war, and dislocation are bad for people—an obvious point, but important if you are tempted to think of psychiatric illness as purely hereditary. A recent survey on world mental health observed that in all different age, gender, and cultural categories everywhere, the most important risk factor for mental health is social disruption.@@@[[#24RobertDesjarlaisetalWo|24]]$$$ Social isolation also seems to exact a high cost. Depression, and mood disorders in general, may be more common in the twentieth century than ever before, because in no other time of human history have so many people been so isolated.@@@[[#25RobertWrightTheEvolutio|25]]$$$ (It is, however, extremely difficult to figure out what would count as evidence here—it is very difficult to judge the rate of mental illness in earlier centuries.) More people live alone in America than ever before—a quarter of all Americans, compared to less than 10 percent in 1940 and probably almost none in our ancestral past. Mothers who work hand their children over to strangers for long periods of time. Mothers who don’t work are at home alone with small children. From a human evolutionary perspective, this is bizarre. In hunter-gatherer societies, child rearing is extensively social, as are work and life in general. In modern societies, isolation is a leading risk factor for suicide.@@@[[#26KaplanandSadockPocketHa|26]]$$$

Historical and cultural conditions also seem to affect significantly the way mental anguish is internally experienced and socially expressed. For instance, people in non-Western societies are likely to report somatic symptoms—aches, pains, problems of the body—as the primary difficulty of being abnormally sad, while Westerners are more likely to report psychological symptoms—feeling down, guilty, suicidal, having difficulty concentrating. Are they suffering from the same psychiatric difficulty? When Arthur Kleinman went to China as an American psychiatrist in the 1970s, he thought that the Chinese who came to the clinic complaining of aches and anxieties often looked depressed. Moreover, most of them met the American psychiatric criteria for major depression. But they called their difficulties neurasthenia, the major symptoms were not those of depression, and the meaning and explanation of the difficulties were quite distinct. Neurasthenia was (conceived as) a physical problem having to do with nerves, not an emotional problem with sadness. And it became apparent that neurasthenia was also a role for people whose lives had been crippled by the Cultural Revolution, which had left a generation terrorized and humiliated and then stranded them without any way to compete professionally with the next generation. This is not to say that people pretended to have neurasthenia: they experienced neurasthenia, and not all victims of the Cultural Revolution had it. But Kleinman, whose 1986 study has become a classic, came to believe that to understand these patients, you had to understand their difficulties as part of a social suffering, as part of a culture’s history, not as a series of unrelated personal complaints.

There is no medical test for a specific disease pathology for any major psychiatric illness. You cannot know whether there really is an underlying “disease” in psychiatric illness. There is no way to determine, once and for all, whether someone has depression or not, and there is no reason to suppose—despite occasional claims to the contrary—that we will have any way to do so anytime soon. No one can say whether Chinese neurasthenia is “really” the same as American depression. It ''is'' clear that, no matter how you slice the research, psychiatric problems involve genetic vulnerability, bodily stress, social milieu, cultural interpretation, family history, and individual temperament. (The unwieldy term that was supposed to sum this up was “biopsychosocial,” but even that refers to too few factors.@@@[[#30GeorgeEngelTheClinical|30]]$$$) As a result, it is particularly important to understand how psychiatrists look at these illnesses and thus how we in turn understand them (psychiatric knowledge seeps into popular culture like the dye from a red shirt in hot water). The way we understand these illnesses affects not only the way they are treated but the way they are experienced, their outcomes, and our sense of responsibility toward those who suffer.

For example, Hugh Gusterson, another anthropologist of science, described the way politically liberal young men at Lawrence Livermore Laboratory turned into weapons scientists. They graduated with doctorates in physics from elite universities. Not all of them were politically liberal, but many were, and many were hesitant about contributing to the nuclear arms race. But they didn’t believe in unilateral disarmament, and these jobs paid well and were more secure than the precarious world of up-or-out university tenure decisions. So the men took these jobs and years later found themselves committed to the importance of nuclear weapons with a passion that matched that of the antinuclear protestors. Why? This anthropologist argued that through the process of living in their skins at work, coming to terms with their fear of radiation and annihilation, and feeling pride in their skill, they came to feel powerfully and deeply that their work was morally important and necessary to human survival. He saw three features of their everyday environment that were crucial to that unintended transformation. First, there was the thrill of being in a secret group, with the sense of specialness but also of constant panopticon surveillance, and the slow corrosive impact of that separate, secret world on the intimacies of private life, as a result of which the laboratory loomed ever larger in the scientists’ sense of self. Then there was the way the men handled their fears by jokes in which they identified with the machines and not with fleshly corpses—they were powerful, like the bombs, not weak, like the bodies burned by them. He described the way they learned from laboratory culture to experience excitement and not desperation at the violence of explosion. (At least, those who stayed in the lab did. The others left.) Finally, they felt a sense of mastery when the nuclear tests actually worked, and in the joy of a job well done, those tests became fun for the scientists and seemed reasonable, ordinary, and intrinsic to the proper functioning of the lab.@@@[[#31HughGustersonNuclearRite|31]]$$$ And so these Berkeley doctoral students grew into the men the Berkeley radicals came to protest.

No person is simple. We hear their sorrows through the din of our occluding pasts, and we can grasp only the sounds to which we are attuned. Psychiatrists are taught to listen to people in particular ways: they listen for signals most of us cannot hear, and they look for patterns most of us cannot see. Their two primary tasks, however—diagnosis and psychopharmacology, on the one hand, and psychodynamic psychotherapy, on the other—teach them to listen and look in different ways. As an anthropologist, I could see what young psychiatrists had to achieve in diagnosis and in psychotherapy, and I could see what they learned to do in order to achieve it. I could see how they learned to perceive the patient in order to do their task, and I could see that what they had learned was inherent in the tasks themselves, not due to the style or personality of the doctor. I could also see how they learned to anticipate patients in the settings of their different tasks, how they learned to fear or hate or love them, and I could see what counted as appropriate behavior on the units dominated by either biomedical or psychodynamic concerns. Again, these differences were part of the tasks, not the result of the doctor’s personality, although certainly different tasks did seem to draw different kinds of people for keeps. And I could see who was admired in these different domains, so that one could ask, when a young doctor was with a patient, not only what he saw in the patient but whom he should aspire to be in response. All this is part of the way young psychiatrists learn to be doctors with patients, focused on two different tasks. That is the anatomy this book sets out to describe.

There is also a more subtle risk. Psychiatry is inevitably entangled with our deepest moral concerns: what makes a person human, what it means to suffer, what it means to be a good and caring person. By the word “moral” here I do not mean a code of right behavior so much as our instinctive sense of what it is to be responsible, when to assign blame, how we come to see our ambitions as fundamentally right and good. The biomedical and psychodynamic approaches nurture two very different moral instincts by shaping differently the fundamental categories that are the tools of the way we reason about our responsibilities in caring for those in pain: who is a person (not an obvious question), what constitutes that person’s pain, who are we to intervene, what intervention is good. These two approaches teach their practitioners to look at people differently. They have different contradictions and different bottom lines. Both have their strengths and their weaknesses. Each changes the way doctors perceive patients, the way society perceives patients, and the way patients perceive themselves. The irony is that while Freud perhaps saw himself as demonstrating that human nature was shackled by its own design, his legacy has been to create a moral expectation of human agency and self-determination that we do ill to jettison.

== {{anchor|CHAPTERONE}} {{anchor|TopofLuhr9780307791900epubc2}} CHAPTER ONE: WHAT’S WRONG WITH THE PATIENT? ==

=== {{anchor|INTHEHOSPITAL}} IN THE HOSPITAL ===

Gertrude was one of nine new residents I met on July 1, 1992, in the oak-paneled room the hospital reserved for its occasional formal events, such as board meetings and residency orientation. She seemed young and wary, determined not to look nervous. This was her first day of psychiatric training (the medical year runs from July to July). She had graduated from medical school one year previously. Her first year after graduation from medical school had been spent in internship, an intensive, lived-in-the-guts, all-consuming apprenticeship in a general hospital. Some psychiatrists-to-be take a rotating internship, with several months on a psychiatric or neurological service. But the more elite internships are a rigorous, focused, sleep-deprived, and thoroughly medical experience. Gertrude had been such an elite intern. Her only experience of psychiatry had been as a medical student, as an insubstantial presence on a psychiatry unit for some weeks, assigned to residents only marginally less naive than she, whom she and her fellow students had followed around like abandoned puppies. She had good reason to be anxious.

Medicine trains its students by having them act as if they are competent doctors from their first days on the job. Although psychiatric residents are “in training,” they are also acting—from the day they arrive—as psychiatrists. Gertrude was assigned to a hospital unit as one of its psychiatrists. She was immediately assigned patients to care for. As the year progressed, she needed less supervision, but she was still doing the same tasks. As is common in medicine, she learned by doing. She was expected to be able to manage the hospital’s entire psychiatric service after hours by herself in a matter of weeks: doing emergency admissions, signing orders that only doctors can authorize, prescribing emergency medications to calm unexpectedly agitated patients. During that summer I sat through two months of orientation, the “summer seminar,” some analogue of which is held at every psychiatric residency in the country. It taught the basic survival skills of psychiatry. In the summer seminar, Gertrude and her peers were taught by residents one or two years older—psychiatric residency is a three-year training in which senior residents train junior ones—with a kind of in-group coaching meant to get them up to speed rapidly so that they could pull their own weight in caring for patients and dispense with step-by-step supervision. There were lectures for a few hours a day. The rest of the time the residents spent doing their jobs with patients. “These are basic lectures,” the chief resident said during the first class on psychopharmacology. (The chief resident is the young doctor in charge of all the other residents.) “When it gets down to gamma-2 level receptors, then it’s religion, not science.” He meant that the psychiatrist’s basic skill is knowing how to use medications, that only the overzealous care exactly how they work. The new psychiatrists were expected to understand this, to come prepared with the pragmatic expectation that they must avoid disaster but not strive for perfection. “I can tell who the weak residents are already,” the chief resident said to me after a week. “They’re the people who are taking this too seriously. Those are the ones who will have trouble.”

The summer seminar series aimed to teach Gertrude and her fellow students how to avoid egregious errors, not how to become excellent psychiatrists. What it taught, then, teaches us what counts as basic adequacy. The lecture list went as follows:

<div style="margin-left:0.423cm;">''Week one:'' On call in the hospital; psychiatric emergencies; introduction to psychopharmacology; process notes and supervision.</div>

<div style="margin-left:0.423cm;">''Week two:'' Antipsychotics; the dangerous patient; mental status examination; diagnosis.</div>

<div style="margin-left:0.423cm;">''Week three:'' Antipsychotics; beginning psychotherapy (1); beginning psychotherapy (2); medical issues in psychiatric care.</div>

<div style="margin-left:0.423cm;">''Week four:'' Sedatives, hypnotics, and stimulants; overview of substance abuse; introduction to interviewing; violent patients.</div>

<div style="margin-left:0.423cm;">''Week five:'' Tricyclic antidepressants, overview of sleep disorders; legal issues in psychiatry; suicidal patients.</div>

<div style="margin-left:0.423cm;">''Week six:'' MAOIs [monoamine oxidase inhibitors, a kind of antidepressant medication] and novel antidepressants; overview of cognitive/behavioral treatment; psychological testing; rating scales.</div>

<div style="margin-left:0.423cm;">''Week seven:'' Mood stabilizers; neurologic emergencies; sexual issues in psychiatry; case presentations.</div>

<div style="margin-left:0.423cm;">''Week eight:'' ECT [electroconvulsive therapy]; history of psychiatry; case formulation; case presentation.</div>

<div style="margin-left:0.423cm;">''Week nine:'' Psychopharmacology of Axis II disorders; wrap-up.</div>

The first lectures were on psychiatric emergencies and the dangerous patient, then the admissions process and an overview of various medications. Eventually they moved to psychotherapy but really focused on hospital psychiatry. What the young psychiatrist has to know—and immediately—is how to handle psychiatric emergencies and admissions. New apprentices must know how to cope with people who may be violent or intensely suicidal, people who are brought in by the police or by a distraught family, people who have intentionally sliced their wrists or necks, spent seven hours in surgery, and been transferred by ambulance to the psychiatric hospital. It is the resident’s job formally to admit the patients and to make the first decisions about treatment—whether to prescribe medications and the kind and dose, whether the patient should be on a locked or unlocked unit, and so forth.

The most unnerving time for the new residents was when they were “on call.” Then they were the psychiatrist in charge of the entire psychiatric service in the evening and throughout the night, when the senior psychiatrists had departed and only the night staff—some nurses, some mental health workers—stayed on. After only a month of experience in psychiatry, the on-call doctor might be the only doctor in a hospital with more than a hundred patients (other doctors were available by phone, but it is hard to call a senior in the middle of the night to ask him a question he thinks you ought to be able to answer yourself). If a patient went out of control, the nurses needed the doctor to prescribe a tranquilizer or sign an order to use physical restraints. If a patient arrived—that is, had showed up in some urban hospital’s emergency room and a transfer had been arranged—the doctor admitted the patient and signed the orders. If a person showed up crazy, on grounds, the doctor had to decide whether to commit him. If a patient suddenly developed an acute allergic reaction to antipsychotic medication, that doctor had to know what to do. Depending on the level of anticipated work, there might be other residents on call as well, to help with admissions or to advise the nervous newcomer. Often in those first few months, a somewhat more senior resident would also stay on to help out. But not always. The resident had to act like a knowledgeable doctor despite the newness of the patients, the circumstances, and his task. “So you’re on call,” the chief resident said, “and some guy has come into the entrance [a lonely house, set far back from the main admissions building] and he’s punched the emergency number into the hospital phone. You and Sergeant Carter go over [all forays to distant buildings at night are accompanied by the security guard], and you ask this guy why he rang in an emergency. He says he thought he might want to be admitted, but now he’s not sure. Sergeant Carter is getting bored. You ask the guy why he wanted to come in, and he says, ‘Just …’ and trails off. Sergeant Carter says that you seem to have this under control and can he leave? You say ''‘No.’'' Why? Because you don’t know. You don’t know. When the guy trails off into silence, he might just be hearing a voice that says, ‘Eliminate this fool.’ ”

In August, I went on call with Gertrude. She was noticeably uneasy. This was her first night as DOC, “doctor on call.” She was one month into her training, and she was legally liable (although covered by the hospital’s malpractice plan) for every decision she made. Although she had some help—another resident, one year her senior, joined her for part of the evening—she was alone (apart from the watchful anthropologist) for much of the night, running back and forth from building to building, holding the walkie-talkie that enabled the switchboard operator to reach her, assigning admissions to the one or two other residents who remained in the hospital, covering orders for psychopharmacological and physical restraints, doing admissions herself, trying to get enough time to eat and, if possible, change into the casual clothes that a doctor is allowed to wear on call but never during the day.

At night the hospital was an eerie place. Located as it was in the suburbs, this hospital had many “scheduled” admissions, patients whose doctors called up to arrange for hospitalization and who then arrived on the subdued afternoons of the regular workweek. But often the patients arrived unexpectedly and after hours, brought in by police or despairing relatives to a city emergency room and shipped out to the suburban hospital because the city hospitals were full. Even a large urban hospital is strange after midnight, as the acoustics of the long, empty corridors change markedly when there are no people in them. This hospital, with its strung-out buildings, each containing different units, was so much like a small liberal arts college that in the day I would have to stop myself from referring to the patients as students. At night it became forbidding. The grounds felt deserted, and the distances between the buildings were dark fields broken by inadequate pools of light. No matter how many residents there were in the early part of the evening, spread out in the great stretches of the hospital grounds, the night was still desolate. The security guard told me that the most dangerous creatures at the hospital at night were the raccoons. But it is nerve-racking to be alone at midnight by the dark woods of an asylum. When I was there I found myself repeating the guard’s words sternly to myself.

Gertrude made it through the night without mishap, but her personality style, like that of many doctors, did not sit comfortably with the sudden demand to care for people in ways she did not understand. She seemed as if she had always been competent, that she was a responsible older sister who had baby-sat her younger brother and washed the dishes. She did not like the model of good-enough adequacy; she was not laissez-faire; she worried that if she pretended to be competent without having full knowledge, one of her patients would develop a strange undiagnosed disease and die. She had been a solid, successful undergraduate—the kind who’d been accepted by many medical schools—and had done it by working until she became one of the best in her class. Like many psychiatrists, she was shy and had always been reserved. She loved parties but was vaguely embarrassed when standing around in a chattering group. She seemed to manage well, but that was because she did what other people told her to do, and it left her cynical and distrustful. It bothered her intensely to cut so many corners and to have to depend on other people to give her a sheen of adequacy in doing a job she had not yet been taught to do well.

“It’s all politics,” she said bitterly. “That’s what you learn—how to talk on rounds, how to talk to patients, how to talk to nurses. You’re taught by mistakes and by apprenticeship coaching, not all of which are consistent. Sometimes people give completely different advice. You start out so idealistic. Then you begin to cut your losses.

“Because the nurses will call and say, ‘We’ve put so-and-so in restraints [leather cuffs for ankles and wrists], please write the order,’ or ‘We’ve just given so-and-so Ativan [a minor tranquilizer used to calm agitated patients], please write the order.’ And in three months it won’t matter, I’ll know people, know whether I can trust their judgment. Still, I’m the one who takes the legal responsibility now. And where’s my legitimacy? What is it like to be the nurse who’s worked here for twenty years and calls up a new resident in July and has to persuade him to do something? They ''have'' to push me into agreeing with them, but the whole mess seems kind of inappropriate. Like, as DOC I need to be a protective watchdog on the phone. I need to protect the nurses by not taking patients that will make them feel uncomfortable. But I need to protect the hospital from bankruptcy. There’s no way of doing it well.”

This practical, rapid apprenticeship remains the primary teaching method throughout the residency period (as is typical in medicine). During the three-year training period, residents usually spend their first year in inpatient care, their second in outpatient, and their final year either in administrative positions (as “chief resident” for various services in the hospital) or in some other elective pursuit: research or in further specialized training. Often, what the resident does in the third year tends to mimic her first, the difference being that in her third she tends to have supervisory responsibilities. The second year, the outpatient year, is unusual because the resident is working not in the hospital but in a clinic, sometimes some distance from the hospital to which it is attached. That is when residents commonly have the greatest exposure to psychotherapy.

Gertrude’s program was in a large psychiatric hospital. At the time I was visiting, there were nine units, each oriented to a different patient population: patients who were depressed or traumatized or had eating disorders and so forth. Gertrude and her peers would rotate through three units for four months apiece. While in the rotation, they would be assigned one or more patients on the unit as their primary responsibility. Gertrude would attend most meetings concerning her patients—meetings to discuss the patient’s treatment, meetings with family members—and most meetings of the unit. In addition, she was expected to work in the admissions building, admitting patients, one afternoon a week, to be on call one or two evenings a week, to attend four hours of lectures a week, to participate in a group therapy session for the entire class of residents, and to begin to follow at least one outpatient for psychotherapy. In fact, residents often attended lectures sporadically after the first few months. In one residency, faculty resorted to attendance sheets and still the residents refused to show up; they pointed out irritably that their responsibility was to care for their current patients, not to sit dutifully in a class. What residents actually learn is to do what they have to do: admit, diagnose, and medicate patients, and—less pressing these days—see them in psychotherapy.

Of all the skills that Gertrude had to master, the most important, most tested, and most public was her ability to admit patients to a hospital service. An “admission” is a ritual-filled process that identifies an ill person as a patient and produces a few pages that are the single most consistently read document about the person as a patient throughout the hospitalization and beyond. As the hospitalization goes on, more and more pages are added: nursing notes, psychiatrists’ notes, notes from the occupational therapist and the social worker and so forth. Each subsequent admission adds more paper. Soon the patient’s chart—the folder with his name on it—bulges out to one inch, then to three; patients from the old psychiatric units, where stays were long and note taking was extensive, have charts that are literally feet in width. You see residents carrying these older charts out of Medical Records with hunched, strained shoulders. Every time a hospital staff member sees a patient, every time a doctor consults or a nurse takes over a shift or an occupational therapist drops by, a note is added to the chart. To read such a massive dog-eared volume, you turn first and foremost to the admission notes: clean, typed summaries that explain why the patient came into the hospital and what the doctor thought about that person at that time. To write that note, the doctor interviews the patient and dictates several paragraphs, which are the medical and legal justification for the patient’s presence in the hospital and which provide the evidence and argument for the identification of the illness.

During my summer at the oak-paneled hospital, I saw Gertrude prepare her first psychiatric admission note. It took four hours. By the end of the year, it would take her no more than an hour to interview the patient and dictate the admission note to the chart, but the afternoon I sat with her she was paralyzed. She had been a highly effective intern at her prestigious internship. She knew, she said, what to do about chest pain. At the end of her internship she knew which patient would “code” that night—who would slip into cardiac or respiratory arrest and need to be resuscitated. But now she was panicked.

What I found fascinating about her panic was that she had all the intellectual knowledge she needed. She had interviewed her first patient with a senior resident, and they had concluded that the patient had obsessive-compulsive disorder. She had the official diagnostic handbook for psychiatry, which she’d opened to the page on obsessive-compulsive disorder. She had a copy of another admission note for a patient with obsessive-compulsive disorder. She had a mass of notes on the patient she’d just interviewed. But after the patient had gone she stood behind the desk, her body tight and clenched, swaying slightly, desperate and terrified in her neat suit.

She understood that she had to provide, for the section marked “History of the Present Illness,” a chronological account of the illness, with generalizations backed up by specifics that provided evidence for one or more diagnoses. The admission note, she said, was not an account of what the patient had said; it was what the doctor, who supposedly excludes irrelevant details, interpreted the patient to have been saying. The note was supposed to demonstrate that the patient met the criteria for the diagnosis of obsessive-compulsive disorder. (There might later be a longer note detailing the entire course of the patient’s history.) These criteria basically are the following:# ''The patient must have'' obsessions ''(recurrent thoughts or impulses that are intrusive and distressing; they are not simply excessive worries about real-life problems; the person attempts to suppress them; the person knows the thoughts are a product of his own mind; e.g., he is not psychotic) or'' compulsions ''(repetitive behaviors such as hand washing, door checking, and so on, or mental acts such as praying, that the person feels driven to perform; these acts are aimed at preventing some dreaded event but are not realistically connected to its prevention)''.

# ''The obsessions or compulsions cause marked distress, are time-consuming (requiring more than an hour a day), or significantly interfere with the person’s life''.

# ''The obsessions or compulsions are not due to another psychiatric illness (such as obsessing about food in anorexia nervosa)''.

# ''Nor are they due to some other medical or drug-related condition''.@@@[[#1Thisisadaptedwithmoreuse|1]]$$$

An appropriate admissions note would probably have looked like this example from a psychiatric textbook:

===== The patient is a 24-year-old white single man who comes to the clinic, referred by and accompanied by his mother, for consultation about compulsions and obsessions. He presents with a history of rituals starting in childhood and becoming more disabling over time. He reports that after college he began checking the locks on his house repeatedly and checking his car for break-ins, then checking household appliances repetitively for safety. He developed excessive grooming rituals and became so obsessive at his work as an accountant that he was forced to quit. He then became fearful of losing control and of public aggression, fearful of acquiring AIDS, and concerned about the symmetry of objects. He has recently moved back into his parents’ home, where his rituals have become so extensive that they consume the entire day, and he is no longer able to bathe or groom himself in consequence. The patient is aware that these behaviors are excessive and unreasonable, but when he attempts to stop them he becomes so overwhelmed with anxiety that he ends up redoubling his ritual efforts. There appears to be no precipitating cause for these behaviors in medical illness or any other psychiatric illness. There also appears to be no family history of this condition. The patient presents as an unkempt, poorly groomed man who is intellectually intact and without symptoms of psychosis.@@@[[#2NancyAndreasenandDonaldBl|2]]$$$ =====

<div style="margin-left:0.508cm;margin-right:0.508cm;">diagnosis: obsessive-compulsive disorder 300.3</div>

But Gertrude’s patient hadn’t produced a story much like that: organized, abstract, distant from the minutiae of the facts. Patients never do, unless they have been through many, many admissions, and then only if they want to cooperate with the doctor. In psychiatry, patients don’t produce information as easily as they do in other medical settings. Most patients with physical disorders are frightened by their pain and eager to give information about it. Psychiatric patients have a very different relationship to their symptoms and don’t always want to answer questions. Gertrude’s patient probably found his rituals deeply embarrassing. He probably wanted the help, but he also probably wanted to tell this stranger as little as possible to get it. The paranoid patient, who has an unrealistic fixed belief that people are out to get him, may not feel, at the time, that it is of any relevance to the doctor that there is a conspiracy of aliens against him. The manic-depressive patient, whose judgment is usually quite poor during periods of illness, may take a dislike to the doctor and say that she has been behaving perfectly normally. Interviewing a psychiatric patient can be like trying to catch fish with your hands.

Moreover, while Gertrude had a clear, abstract idea about obsessive-compulsive disorder (all those notes), she had no “intuition.” The diagnosis didn’t feel ingrained, at her fingertips. “In internship,” she said, “at the beginning of the year, I remember the senior resident rotating around the floors checking out how things were going for the intern who was there all night. What would happen would be that the nurses would pull him aside and say, ‘You know, this patient in room 114 doesn’t look too good to me.’ So the senior resident would, in a very nonchalant way, saunter over and say, ‘How’s it going, how is that patient in 114 doing?’ and the intern might say, ‘Oh, not so bad,’ and the senior would say, ‘Oh, let me look at the vital signs [blood pressure, temperature, etc.]. Oh, that looks kind of funny, let’s go take a look at him together.’ As a beginner, you miss a lot of things, because you haven’t seen the volume of patients. As the year progresses, you find that by even walking into the room and just ''looking'', you can tell, this patient does not look good. That’s intuition.”

Clinical intuition is what doctors develop when they become what other doctors call “good.” It is their expertise. Intuition is the capacity to recognize patterns in body and behavior that are relevant to clinical problems, to see what is wrong with a patient, to judge the severity of the problem, and to choose an intervention that leads as quickly as possible to the patient’s recovery. When the average person walks through fields with a birder, he or she sees flowers and grass; the birder sees twenty species of birds and a complex range of their habitats. In bird-watching as in medicine, intuition means being able to pick up little, unobvious details, such as a type of grass or a smell or a little phrase, that helps you to know what you are seeing. But in medicine, the field guides to disease have an oblique relationship to sick people. It is rarely the case that a particular symptom (dizziness, for example) is produced by one and only one disease. Physicians learn how to diagnose from clusters of related symptoms so that they recognize patterns even when many of the pieces aren’t manifest. Part of their skill involves making helpful guesses about which disease the pattern of symptoms suggests. A “good” or “classic” case of hypothyroidism is a depressed-looking, overweight woman with a thick tongue and dry, scaly arms. If you were a senior doctor, you might teach “hypothyroidism” to your medical students with such a case, but the hypothyroidism you diagnose in your office might have very few of those classic features. Luckily, for some illnesses, there is a simple test—a “pathognomonic test”—that confirms the diagnosis, such as a brain scan that reveals a tumor that has been causing headaches. Even in medicine this is often not true: Alzheimer’s disease, for example, can be diagnosed definitively only by autopsy. In psychiatry, of course, there are no such tests—no blood tests, no X rays, no urine samples apart from those used to detect alcohol or drugs.

Because none of the psychiatric categories (at least, none of the ones that count as truly psychiatric) can be diagnosed by a test or a telltale symptom, most of the diagnoses are presented as a checklist of criteria, in which the patient has to have some but not all of the items on the list to qualify for the diagnosis. This, for example, is the diagnostic checklist for major depression:

===== Five or more of the following symptoms have been present during the same two-week period, and at least one of them is depressed mood or loss of interest and pleasure: =====

# ''Feelings of worthlessness or guilt''

The obsessive-compulsive disorder checklist is more straightforward, but there is still a gulf between what a patient says and the abstract itemized diagnosis. The reason the admissions process for Gertrude’s first admission took so long was that Gertrude kept trying to match up what the patient had said with what the diagnostic criteria stated. She had difficulty remembering the details in the patient’s account because they didn’t really yet seem like part of a story. Washing one’s hands a hundred times a day seems frankly incomprehensible to most of us, a weird Borgesian exaggeration, not evidence of “excessive grooming.” Ditto for checking the house lock thirty times before leaving for work or not taking out the garbage for six months. The young psychiatrist’s pen hesitates at that thought: What does the place really look like? What makes it an illness, not a Hollywood fantasy? Admissions notes seem so calm and measured. Those first interviews are alien.

To new psychiatrists, fresh from treating cardiovascular disorders and lung cancer, diagnoses for which you need five of nine symptoms seem strange, despite the fact that certain medical diseases, such as lupus, are also diagnosed by checklist. These diagnoses become particularly suspect when the criteria include items such as “feelings of detachment or estrangement from others” or “feelings of worthlessness or guilt.” These complaints do not seem like “real” diseases; they do not feel “organic.” They suggest that a committee sat down one afternoon and voted on what “depression” should include. Which, of course, some committee did. To a young psychiatrist like Gertrude, this committee work initially has the look of whim. It is not clear to her that she is dealing with distinctly different physical processes in the body. “It was very different being an intern,” she said in her first summer. “As an intern you had an agenda. You knew much more precisely what to ask. And there was always something ''organically wrong'', even if it presented with a variety of symptoms. There was none of this five of nine of this or that.”

Through the process of psychiatric training, those doubts disappear in practice, even among those who remain vociferously skeptical to the end. By the time young psychiatrists have finished training they can recognize the disorders immediately, the way plane spotters can spot Boeing 747s, the way bird-watchers can spot great snowy owls, the way dog lovers know the difference between a Jack Russell terrier and a beagle. Often, they talk and act as if the diagnoses pick out diseases that are as clear and distinct from one another as Jack Russells and beagles. That first year, when Gertrude learned to diagnose quickly and accurately, she began to behave as if there were psychiatric diseases that people came down with, just as they came down with meningitis. “You’re sizing up the patient right away,” Gertrude told me some months later, “just like in medicine. After a year of seeing people and doing countless admissions, two to five or more a week, you walk into a room, you see how they address you, and you’re already thinking the diagnosis.”

That summer I watched the new residents do admissions. Each was assigned one case at one o’clock and another at three. The resident would walk over to the Admissions Building after lunch, pick up any previous medical chart in the main office, thumb through it, go out to meet the patient in the waiting room, and take him or her to an interview room. Usually, the resident spent an hour interviewing the patient, and then, after a quick physical exam, the patient would be sent out to wait for an escort to the unit. One resident said to me after her first admission interview, “My job, in the admission interview, is first that I’m the primary contact with the hospital, and I want that to be a good and healing experience for the patient, and I want to convey interest in her life. But what I ''have'' to do is to collect information. ''That’s'' what goes into the admission note. The art is to produce the information in a seamless way, as if you were naturally having a conversation. But that’s hard. I haven’t learned it, and so I fire streams of questions at the poor patient.” As the doctor you want to behave “normally” in an initial interview, in a trustworthy and compassionate way, both because you want to be helpful and because the patient won’t talk unless he trusts you. At the same time, your real job is to probe with specific questions into areas the patient may find embarrassing, humiliating, or distressing.

There are two distinct kinds of questions. First, there are direct questions about illness, like those medical doctors ask about medical diseases. A psychiatrist “probes” for obsessive-compulsive illness by asking questions such as “Do you wash your hands very often?” He probes for psychosis with questions such as “Do you feel that the television has special messages for you?” He probes for depression with questions such as “Have you thought recently about killing yourself?” The younger the clinician, the more likely he is to pursue the full range of possible questions with the medical student’s studious anxiety, regardless of what the patient thought he came in to talk about. I once saw a second-year resident interview a nineteen-year-old man who had made the appointment because he’d decided to tell his mother that he was gay and it happened to be the one-year anniversary of his father’s death from AIDS. People who lose someone close to them often feel a return of acute grief on the anniversary of the death. It was very likely that the young man had come in for psychotherapeutic counseling. He probably wanted to talk about his grief, his anxiety, and his need to be honest but not to hurt his mother. The young psychiatrist asked him all the diagnostic questions for psychosis (Do you think that you can read my mind? Do you have special thoughts about the cosmos?), for depression (Have you lost weight recently? Do you have difficulty concentrating?), and for antisocial personality disorder (Did you ever set fires before you were sixteen?). The adolescent, who had clearly cinched up his courage to come talk about his decision, sat in baffled astonishment. More often the clinician will ask a series of targeted questions around the diagnosis the psychiatrist thinks will fit the patient, and those questions will focus on the defining characteristics of that category. If a psychiatrist suspects that the patient became manic, she will ask: Were you talking very quickly? Did you spend a lot of money? Was it a great weekend for sex?

Then there are questions that are essentially indirect ways of getting information the patient may not want to, or cannot, give. Often the psychiatrist asks some everyday questions and gives small tests to judge whether there is anything bizarrely amiss in the patient’s thinking. A patient may, for example, be asked to count backward from one hundred by sevens; to remember the words “car,” “book,” and “umbrella” and repeat them a few minutes later; who the president is; what day it is; what “A stitch in time saves nine” means; what he would do if he saw a stamped, addressed envelope lying on the sidewalk. There are at least two versions of this last test of common sense, the other being “What would you do if you saw a fire?” In the summer seminar session on the mental status exam, one of the senior residents described a patient, bored at the end of his admission interview, who when asked what he would do if he saw a fire said that he would put it in the mailbox. That, said the resident, was a patient of many admissions.

<div style="margin-left:0.423cm;">''Patient name:''</div>

<div style="margin-left:0.423cm;">''Identifying data:'' Age, ethnic group, sex, marital status, employment status, referral source.</div>

<div style="margin-left:0.423cm;">''Chief complaint:'' Complaint in patient’s own words.</div>

<div style="margin-left:0.423cm;">''History of present illness:'' Use problem-oriented format. For each symptom/problem include age of onset, severity and duration of symptoms, precipitating and maintaining factors, presence or absence of neurovegetative signs, response to medications. Use back of page if necessary.</div>

<div style="margin-left:0.423cm;">''Past psychiatric history:''</div>

<div style="margin-left:0.423cm;">''Substance abuse:'' Number of drinks/day, last drink. History of DWIs, etc.</div>

<div style="margin-left:0.423cm;">''Medications:'' Current psychotropic and nonpsychotropic medications.</div>

<div style="margin-left:0.423cm;">''Allergies:''</div>

<div style="margin-left:0.423cm;">''Family history:'' List current and past family psychiatric disorders (including substance abuse) and medical disorders. List treatment received and effectiveness. Also include suicides in the family.</div>

<div style="margin-left:0.423cm;">''Medical history:'' Include history of head trauma, major illnesses, hospitalizations, and operations.</div>

<div style="margin-left:0.423cm;">''Current functioning:'' Indicate living arrangements, occupation, economic status, social and leisure activities, sexual orientation and functioning.</div>

<div style="margin-left:0.423cm;">''Past development:'' Describe sibling rank, relationships with family members and peers. Describe key relationships and dating, marital and sexual history (including sexual abuse). Describe educational history, highest grade completed, and work history.</div>

# ''General appearance and behavior''Examples: Appearance: in relation to age, grooming, clothing, eye contact; behavior: agitated, retarded, bizarre, abnormal movements, restlessness; attitude: cooperative, defensive, guarded, hostile.

# ''Mood and affect'' (Mood: patient’s subjective description of feeling tone over time. Affect: the outward manifestation of the patient’s emotional state at the moment.)Examples: Mood: happy, sad, depressed, irritable, angry; affect: appropriate, flat, constricted, depressed, euphoric, anxious, elated, angry.

# ''Thought process and content''Examples: Tangential, circumstantial, loose associations, flight of ideas, thought blocking, delusions, paranoia, ideas of reference, intrusive thoughts, obsessions, compulsions, phobias, hallucinations, illusions, suicidal/homicidal ideation.

# ''Cognitive functions''Examples: Orientation, attention, memory, serial 7s, presidents, proverbs.

# ''Insight and judgment'' (Insight: awareness of being ill; judgment: ability to compare and assess facts and alternatives in deciding on a course of action).DSM ''diagnosis and code (five axes):Psychosocial assessment:Goals:Treatment plan:''

From Gertrude’s earliest days on the ward, as she prepared to take call and to do her first admissions, she memorized lists of diagnostic criteria, sometimes with mnemonic aids, such as SIGECAPS for depression (depressed mood plus four of these eight: sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation or agitation, suicidality). Medical students attend lectures on the differences between depression and psychotic depression, or between organic delusional disorder and schizophrenia, in which the resident who is teaching the class writes the criteria out on the board and explains them. During the first months of doing admissions, new residents will pick up the small ''DSM (Diagnostic and Statistical Manual)'' handbook while talking to a patient and turn to a specific diagnosis to make sure they’ve asked about all the criteria. And often the lore passed on to new residents about the admission process circles around the symptoms and the criteria. In the summer seminar series the chief resident advised Gertrude’s class, “Try to memorize the topic you always forget; I always used to forget about obsessive symptoms.” And the daily structure of hospital life creates a learning environment that is highly effective in persuading residents to memorize these complex categories by criteria, because the failure to be “good enough” becomes a public humiliation.

Medical rounds, for instance, often amount to a junior resident’s public performance of diagnostic knowledge. In a hospital, most of the important decisions are made or discussed in team meetings, or rounds, where all ward staff members—junior and senior psychiatric residents, psychiatric attendings, psychologists, nurses, social workers, and so forth—meet to discuss each patient assigned to their team. These meetings take place usually twice a week, although “sign-in rounds,” when the on-call doctors hand off responsibility to the day staff, meet every morning. Newly admitted patients are presented and discussed in detail, in discussions that may take more than half an hour each. Other patients are more briefly presented, and their progress is assessed. In most cases the presentations are done by a junior resident (or his or her medical student) who has been assigned as the responsible doctor on the case. When this is so, the job of the assembled ten people is to check the work of the most junior doctor. If the junior doctor gets the diagnosis or medication wrong, he is made to feel not only stupid but culpable. There is, after all, a patient’s life involved, and most residents and students feel guilty and embarrassed when they make mistakes. Sometimes the senior doctors deliberately humiliate them. I remember this happening most commonly over prescription errors. In one hospital, the resident did not want to place her patient on an antipsychotic. Her senior psychiatrist disagreed. When they got to her patient in the team meeting, he announced that she had made a mistake and insisted that she write the order in the chart during the meeting, so that everyone could see that she had done it. Shame is a common teaching tool in medical education.

In one hospital, each inpatient team had two junior residents, and each semiweekly team meeting ran through all of one resident’s eight to twelve patients. The resident would pull out his patient identification cards from his shirt pocket and begin to recite in a tired voice, “Mr. Jones is our fifty-one-year-old depressed divorced white male. He presented in the ER last Thursday with suicidal ideation, sleep disturbance, and appetite loss. We’ve started him on imipramine, and he’s now up to fifty milligrams t.i.d. [three times a day].” These are, of course, the criteria: depressed mood for at least two weeks and at least four out of eight further criteria, of which—and this is the clinical knowledge that accompanies the memorization of diagnostic criteria—suicidality, weight loss, and changed sleep patterns are really the most distinctive and important. When a patient has been admitted and is being presented for the first time, the resident develops the account more fully and presents the diagnosis as a conclusion. New presentations are an argument for a diagnosis: “Mr. Jones is a fifty-one-year-old divorced white male with the chief complaint ‘I don’t want to live anymore.’ He presented in the ER last night with intense suicidal ideation. He described feelings of hopelessness and guilt and reported a weight loss of ten pounds in the last three weeks. He reports extremely poor sleep with early-morning awakening.…”

By their second year, residents begin to talk about the “feel” of the disorders. They say that they “sense” or “intuit” psychosis. In her second year, Gertrude remarked, “There’s something to be said for having seen a thousand schizophrenics and a thousand bipolars. You begin to get a ‘feel.’ It’s kind of the art of medicine.” A classmate remarked around the same time that “if you’re doing your medical clerkship, your admission note is eight pages long and you have every detail under the sun. Then the intern comes along and writes a two-page note and the resident comes along and writes a one-page paragraph. Somehow that paragraph is able to distill what is important, pick it out much more clearly than the eight pages by the clinical students. Now, for me, diagnosis is more of a feel. You kind of have a feel for a patient. Someone just comes across to you as a schizophrenic or bipolar patient. I’ve come to appreciate what clinicians gain with time, that these people fifty and sixty years old have this wealth of experience and they really get to the heart of the problem in a way that I’m only beginning to understand.”

At some point in the first year, then, the resident moves from memorizing criteria to recognizing prototypes. By “prototype,” I mean a cluster of characteristics that constitute a “good example” of a class. When you use prototypes in your thinking, you ask whether the item in question resembles the best example of that class, not whether it meets specified rules or criteria of that category. Is an ostrich a bird or a grazing animal? A prototype user asks himself whether the ostrich is more like a sparrow or more like a cow, relying both on what he can see and on an array of background theory and assumptions. An impressive battery of work in cognitive science argues that for most of our everyday categories—particularly our “basic-level” categories such as “table, “chair,” and “dog”—we reason by prototype. When you look at a piece of furniture to decide whether it is a table or a chair, you do not list the rules of membership in the “table” and “chair” categories in your mind. That takes time. It also often does not work, since many category members do not have all the apparent criteria of the class. (A bird that cannot fly, like the penguin, is still a bird.) Instead, the evidence suggests, you call to mind the best examples of each category, and you decide which one the questionable object most resembles.@@@[[#4EleanorRoscheg197319|4]]$$$ You don’t ask yourself whether this chair meets the criteria for chairship. You look at it, and you know it’s a chair.

The great advantage of prototype use is that it is fast and efficient. You recognize rather than remember a list of membership rules. The cost is that the boundaries between categories become starker. Cognitive scientists use the phrase “prototype effects” to describe this phenomenon. People process information about prototypes more quickly than about nonprototypes, but they also tend to clump information around prototypes, so they are more likely to overinterpret similarity to a prototype.@@@[[#5Aclassicexampleofasomewh|5]]$$$ If a very new resident is asked whether a patient meets ''DSM'' 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 that 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 a simple identification task. Diagnoses begin to feel like real, distinct objects in the body.

Certainly young psychiatrists talk about the diagnostic manual as if they use it casually and as if the disorders are there in the person’s body regardless of what the manual says. As a second-year resident said, “I’m fairly sloppy about [DSM]. I use it to diagnose several broad categories, and I don’t worry much about the nuances.” Another, at the end of his first year, remarked, “PTSD [posttraumatic stress disorder].… I couldn’t give you every little ABCD, but I know what PTSD is. You have to experience one of these four things, ABCD. Category B, you have to have two of these seven things. I don’t know what these things are precisely, but I kind of know what it feels like. For generalized anxiety disorder you have to worry about things, and then you have to have, like, six out of the eighteen somatic symptoms—I have no idea of what those eighteen things are, but I know when someone’s anxious.” Sometimes the residents seem more interested in treating people who need help than finding out whether, strictly speaking, those patients meet the printed criteria. One second-year resident remarked, “There’s a lot of gray. They’re sad, they’re not sleeping too well, their wife just left them. Or they’re anxious and it sounds like a panic attack but it just doesn’t meet the criteria. If someone had to meet the diagnosis strictly before getting treated, a lot of people wouldn’t be treated.” Sometimes they think about the social impact of the diagnosis they choose, mostly preferring to give a diagnosis with a better prognosis for the long term (such as manic-depressive disorder) than one with a less good prognosis (such as schizophrenia) if there’s any ambiguity. And they will sometimes mention diagnostic characteristics not listed in the diagnostic handbook, such as clothing or makeup. “I once diagnosed someone as hypomanic by the way they listed their name in the phone book, with ''all'' their names,” someone told me. Or “If you ask a depressed woman whether she’s ever tried to kill herself and she says, ‘Fifty times,’ you’ve got a diagnosis [borderline personality disorder].”

Young psychiatrists also act with the speed that suggests that diagnosis is more like recognizing chairs and tables than it is like pulling out a manual and carefully double-checking the printed criteria. When I began this study, an anthropologist told me that University of Kentucky residents took thirty seconds to make a diagnosis.@@@[[#6ThiswasCharlesNuckollsfro|6]]$$$ I thought at the time that he was pulling my leg. Then I spent an evening with a resident at her night job. To entertain me, she would diagnose the patient after glancing at him through the plate-glass window that separated the staff room from the waiting area. We sat in the staff room; we looked at the patient as he or she walked in the door, and my friend would say, this one’s depressed, that one’s manic, that one’s high. Then we walked out together and she interviewed the patient, often in the presence of the police. The man she said was depressed had been picked up on a bridge, threatening to jump because he wanted to die. The man she said was manic had been running down the street half naked and was, when he began talking, clearly on a drugless high. The one she said was on drugs obviously was. That is, it was obvious to me when he began to speak; it was obvious to my psychiatric friend when she glanced at him. Shortly after I had seen Gertrude struggle through her four-hour marathon to admit ''one'' patient, I had lunch with a senior resident who merrily announced that he’d admitted seven patients the previous evening (in other words, after 5 p.m.) and been in bed by 1 a.m. That is less than an hour each to meet a patient, interview him or her, do a physical exam, and dictate the admission note for the chart. When I began to canvass people on the anthropologist’s provocative comment the senior faculty were alarmed and defensive—they took pains to explain how carefully diagnoses were made—but residents chuckled and wondered why those Kentucky residents were so slow. Of course, few patients who appear in the hospital are totally new to psychiatry, so in most cases the patient carries a prior diagnosis, but even so the quick assessment occurs. “It’s pattern recognition,” Gertrude explained. “Does this seem like somebody who as you sit with them seems psychotic? Do they seem depressed? Like a trauma patient? I kind of ask myself what are they making me feel, what sense am I getting, and then once I feel confident about what direction they’re heading, I’ll kind of go through a list more confirming what I already sense. Just in case I’m missing something, I’ll also ask about hallucinations even if they don’t seem psychotic, suicide even if they don’t seem suicidal. Things like that. But first I get this general gist, and then I confirm it.” Psychiatrists do treat these initial diagnoses like hypotheses that their interviews will support or overturn, but the point is that they are fast. I once stood in an elevator with a psychiatrist known for his work on the diagnostic categories, and I asked him how long it took him to make a diagnosis. He looked thoughtful and slightly troubled, and then he said, “Quickly. Very quickly.”

It doesn’t always work like this, of course. Once a week, a hospital (or a hospital unit) will hold a case conference, and usually the point of that conference is to have a senior clinician diagnose a “diagnostic difficulty,” a patient who doesn’t seem to fit any category well, as if he were part table, part chair, or both at once. For example, I attended one about a patient admitted to the hospital because of a dangerous suicide attempt. He didn’t really seem depressed. He “felt” psychotic to some of the doctors. When he talked about his life, it sounded schizophrenic to them. “He’s very isolated,” one psychiatrist said. “He has a lot of crazy ideas about the Internet, and when you talk to him, he comes across as disconnected and sort of affectless.” But the patient said he was bipolar, and he talked about being “manic” and “depressed” with accomplished ease. He’d been hospitalized several times, but the medical charts from the other hospitals probably wouldn’t arrive until after he’d been discharged, so it was impossible to know what he had looked like to other doctors then. He said he didn’t “like” lithium or the other mood stabilizers. He said they didn’t help. Was he a schizophrenic who had once been told he was bipolar and had since worked that up into a near delusion? Was he bipolar? Did he have a psychotic depression? When I saw him interviewed, the senior clinician was sure he was bipolar. But then, this senior clinician specialized in the treatment of bipolar patients. He more or less thought that most patients were bipolar. This is not that uncommon. One hospital has a PTSD (posttraumatic distress disorder) research unit with a charismatic leader, and in an admission interview the residents probe more deeply about abuse than they might elsewhere and diagnose PTSD more often. Another program is known for its schizophrenia research. There the eager residents are more likely to suspect schizophrenia than bipolar disorder in patients. In this case, the other two mature clinicians in the room thought the patient was schizophrenic.

Still, the cumulative effect of the learning process is to imply that for each diagnosis there is an underlying disease, a “stuff” the diagnosis names, and that the stuff trumps the diagnosis. That is, through the process of memorizing the criteria and learning to prototype the categories, psychiatrists learn to talk and act as if the disorders are there in the world, that they are instantly recognizable, and that the printed diagnostic criteria may only partially describe the real disorders. Young psychiatrists behave as if these categories are “natural kinds.” A “natural kind” is something real in the world, such as a zebra or a horse (but not a table). We know that there is a “natural” difference between a zebra and a horse, even if an albino zebra has no stripes and a troublesome philosopher has painted black stripes on a white horse. The difference between zebras and horses is genuine. It is not a matter of social convention, we didn’t invent it, and whatever makes the difference is intrinsically, even causally, related to the difference between categories. Gold is not the same as fool’s gold, even though both are golden, because it is made from a different chemical compound.@@@[[#7Thephilosophersperhapsmost|7]]$$$ We know that experts know the difference between the two, and we know that there is a real, underlying difference, even though we may not know what it is.

Doing a lot of diagnoses, using prototypes, and writing those admission notes tends to give one the sense that there ''are'' underlying essences that can be seen, named, and possibly controlled, even when the actual problem seems elusive and perplexing. One of the oldest ideas in human thought is that when you name something mysterious and out of control, you gain mastery over it. In magic and religion in cultures throughout history, to know the name for a tree or a person or a malicious spirit was to grasp its essence and so control it (unless you were too weak or impure, in which case uttering the sacred name might kill you). In medicine, of course, diagnosis gives a doctor control because it tells him how he might be able to help a patient. But something of the old magical echoes linger. To produce a name makes you feel that you have begun to master the reality of the problem and that there is, in fact, something there to master. And medical training has already persuaded the resident that diseases are natural kinds existing in the body. A viral infection is not the same as a bacterial infection, even if they sometimes produce similar symptoms and even if the difference between them is not easily explained, and the doctor’s job is to figure out which disease it is.

The practical demands of psychiatric training lead young psychiatrists to speak and act as if the illnesses they diagnose in the hospital are diseases of inherently different kinds. As a result of the demands placed on them in this situation, they are told that the patient has an illness that they must identify. They are told as well by this situation that they can get the identification wrong, and if so they will be humiliated; the identification, in other words, is not trivial but meaningful. They are told that identifying a patient as having both bipolar disorder and schizophrenia, for example, is a mistake, whereas suggesting that a patient has either bipolar disorder or schizophrenia (or even schizoaffective disorder) can be understood as a reasonable identification.@@@[[#8Therearemanydiagnosesthat|8]]$$$ They learn to identify a category by clumping available information around good examples. They know that although the diagnostic handbooks are composed by committees, there are experts, revered within psychiatric culture, who believe that the basic diagnoses are diseases. They have already been deeply schooled in the disease model of medicine by their training in medicine. Psychiatric illness is probably more complicated than many medical diseases and certainly in many cases less well understood. The difference between the diagnostic categories is genuinely more ambiguous because there are no clear-cut medical tests that distinguish them unambiguously and there are genuine questions about whether there really are distinct underlying diseases or not. Yet because the disease model of illness is reinforced by the cognitive experience of psychiatric training in the hospital, the inherent ambiguity of psychiatric diagnosis can rapidly disappear from the young psychiatrist’s experience.

Gertrude started out skeptical and uncomfortable with the categories and their lists. By the end of the year she saw the illnesses as clearly as when we suddenly catch on to an optical trick and can no longer see the feature that makes it a puzzle for everyone else. And with that she became confident. She could do admissions quickly, manage night call easily, and she no longer looked fraught and tense at lectures. “The more you see,” she said over lunch one day, “the more you develop a sense for a problem. You do work with prototypes, you see a number of patients with OCD, you know what questions to ask, what’s important, you learn to ask for the HPI [history of the present illness], you learn what the clinician on the other end will be interested in knowing about the person’s presentation. That knowledge only comes from seeing people over and over again. With a patient with bipolar disorder, you know what to ask for: sleep is a ''major'' marker for what’s going on with this person. You’ll ask them why they are in the hospital. With bipolar disorder, they often exhibit no insight or judgment [i.e., they don’t perceive themselves as ill]. That helps you. You just learn certain—formulas, in a way. Okay, this is a person with bipolar disorder, these are the things I have to look at. But I also try, in my formulation, to raise a differential diagnosis [list other possible diagnoses for the condition]. The problem with prototypes is that you forget what other things might be happening. The person I admitted last night has only a three-year history of bipolar disorder and she’s forty-eight, so she got it when she was forty-five. So she’s presenting manic, but I’m not totally convinced, because it doesn’t really jive with what we know about bipolar disorder [which usually manifests itself before thirty-five]. It makes me think there might be something else. Does she have a tumor in her head? Does she have an occult cancer that’s metastasized to her brain and is causing this funny behavior? It makes you suspicious that something else could be going on, and that’s what we mean by differential diagnosis. Clinicians put a lot of emphasis on that.”

There are two important caveats here. The training experience that tends to encourage young psychiatrists to treat diagnoses like different underlying diseases is relevant, these days, only to some diagnoses. The organizing committee for the first postpsychoanalytic diagnostic manual (''DSM III'', in 1980) wanted the manual to bridge the field’s differences, to be accepted by everyone in the field, even while knowing that they were creating a revolutionary document. So they made an effort to be deferential to the psychoanalysts, and they created two kinds of diagnostic categories, Axis I and Axis II. (There were and are other axes as well: one for medical conditions, one for stressors such as divorce or moving, one for general level of functioning. The authors of ''DSM III'' seem to have envisioned a set of continua that located a patient precisely in some multidimensional descriptive world. For the most part, psychiatrists worry only about the first two axes.) Axis I, the first group of diagnoses, is thought of as being more “biological.” It was the product of the new psychiatric scientists who began to emerge in the 1970s and 1980s. In this group one finds schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder, panic disorders, posttraumatic stress disorder, dissociative disorder, and a great many other categories. These are supposed to be “clinical syndromes.” The thinking behind this was that one has such a disorder more or less for life but there are certain times when it becomes more “active.” Axis II, the second group, was developed by the psychodynamically oriented members of the committee. Here one finds “personality disorders” of various types: narcissistic, schizoid, obsessive-compulsive (as distinguished from the Axis I clinical syndrome), borderline, antisocial, and so forth. These are supposed to be long-standing problems of character. They are not supposed to become more active at one time than at another (although clinicians in fact treat them as if they do). They just are, like being a nervous person or an intense one. Sometimes psychiatrists say that Axis I disorders are like “states”—you go into and out of them—while Axis II disorders are like “traits,” such as having brown hair.

These days psychiatric researchers have heated debates about whether these clusters are fundamentally distinct. Certainly some of the personality disorders can be as deadly as Axis I disorders, in that people with personality disorders can be at significant risk for suicide. But—and here enters a social force—only Axis I diagnoses are learned with bird-watching acuity as distinct, clear-cut objects. Because the character disorders are supposed to imply long-standing, constant problems, most hospitals (or at least their insurers) insist on limiting psychiatric hospital admissions to patients who can be described as having an Axis I category in an acute phase. Hospital admissions are meant to be limited to those who are a danger to themselves or others or incapable of self-care. In the admission note, those states are usually attributed to an Axis I disorder, the patient is treated for the Axis I disorder, and the personality disorder becomes something that makes him more or less difficult to treat (he is dramatic, irritable, entitled, and so forth) and not the cause of his illness. Whether or not these Axis I disorders (or for that matter the Axis II disorders) turn out to have underlying diseases, they are already powerfully institutionalized as if they did and as if the personality disorders did not.

The second caveat is that there is a major contradiction in the learning process that challenges the naturalness of these distinctions. Psychopharmacology is the great, silent dominatrix of contemporary psychiatry. It is what psychiatrists do that other mental health professionals cannot do; and as mental health jobs become defined more by their professional specificity, more and more psychiatrists spend more of their time prescribing medication. This is where the weight of most psychiatric research is placed. More money is spent developing, testing, and analyzing psychopharmacological drugs than in any other area of psychiatry; more people are involved in the research; more patients (these days) are probably touched by these agents than by anything else the psychiatric profession does. And when a doctor medicates in psychiatry, he or she is thinking in a way that can cut across diagnostic categories and undermine the notion that there are separate underlying diseases that correlate with those categories.

Psychiatric medications treat symptoms, not diseases. They touch the way people act, not the underlying mechanisms. So when psychiatrists focus on medications, they sometimes behave as if the symptoms are the things in the world and the diagnostic categories have been invented by committees and reified by insurance companies. They say things such as “First you sort of break things down into gross categories. Are you dealing with a mood disorder? Is there more an anxiety component or an affective component? The bulk of what you treat, the question is psychotic spectrum versus biochemical depression or anxiety versus neurotic issues.” At the end of her first year, Gertrude said, “The first thing I’m trying to get a handle on is whether they will need medication. I’m kind of thinking ''DSM'', and, based on their chief complaint, they’re either going to go down a depression road, a psychotic road, or an anxiety road.” There are only a small number of symptoms that make up a wide variety of psychiatric illnesses, and even these symptoms are not straightforward. You can’t see them directly like a runny nose or test them objectively like a fever. There is the lead-dragging soul weariness of depression; the hallucinatory disconnectedness of psychosis; mood swings; and anxiety. There are, of course, many more particular symptoms—obsessiveness, impulsivity, addiction, and more—but depression, psychosis, mood swings, and anxiety are the most important. They are, however, inferred from behavior. Depression is inferred from lethargy, insomnia, poor appetite, suicidal thoughts, and other behaviors; psychosis is inferred from hallucinations, bizarre beliefs, and the like. You call someone “psychotic” when you ''interpret'' him as having a seriously and significantly distorted view of reality. You call someone depressed when you ''interpret'' her as having a seriously and significantly lower mood than is normal. Psychiatric disorders are inferred, in turn, from different combinations of these symptoms. Psychosis is a symptom of schizophrenia, bipolar disorder, delusional disorder, psychotic depression, and other disorders. Someone can be interpreted as being psychotic (he has told a doctor that she is the president’s sister), but that in itself is not enough to diagnose him as schizophrenic. Depression is a symptom of depressive illness but is also found in bipolar disorder, schizoaffective disorder, and others. And medication treats the symptom, not the disease.