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Tanya Luhrman

I came across a piece about this Stanford professor and her new book on how evangelicals and others seem to talk to God. I was more intrigued with her earlier book on psychiatry and found this quote from a review by Dr. Rieder.

“Her argument is that psychodynamic psychotherapy holds patients responsible for their actions, whereas the biomedical view, which regards psychiatric disorders as illnesses and patients as victims, does not.

Biology is the great moral loophole of our age.…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. (p. 8)

Does the psychodynamic approach indeed see the mind as “choice-making and responsible?” In her view, yes. “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.” It would be very possible to argue the opposite, that the psychoanalytic point of view is quite deterministic with “choice” only a metaphor for immutable unconscious motivation.

Why is the issue of agency and self-determination of such concern? As a nonpsychiatrist, Luhrmann is as much focused on the society at large as on the realm of psychiatric disorders. She sees a danger of this biological “moral loophole” being expanded: “Psychiatric knowledge seeps into popular culture like the dye from a red shirt in hot water.” Also, she has embraced the position of patient (consumer) groups that resent the view that their actions stem from illness rather than from “themselves.” In her final chapter, “Madness and Moral Responsibility,” Luhrmann states that the different psychiatric approaches to agency have “profound consequences for the way we feel compassion for the person we need to help.” The empathy stemming from the biomedical model is “simple empathy,” whereas the psychodynamic model, by assuming intentionality in illness, leads to “complex empathy,” “empathizing with the patient’s self-destructiveness as well as with his despair.” The psychiatrist’s choice between these two views of patients is for Luhrmann a moral decision in itself. At the very end of her book this is stated in stark terms: a choice between understanding patients “only as the detritus of a broken brain” or as “engaged in the struggle to be decent, responsible people.” If we choose the former, “the loss of our souls is a high price to pay.” In other words, the biologically minded psychiatrist falls into this great moral loophole, even when treating patients humanely, if he or she “constructs” the patient as an incapacitated victim of illness.

It has been said that adopting the medical model risks a mindless psychiatry. Luhrmann warns that it might make our field, through the attitude of our trainees, soulless as well. This book itself, however, has a lot of heart. Reading it will make you smile, laugh, frown, and think.”

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