Mind and Matter
To the Editor:
Paul R. McHugh’s “Romancing Depression” [December 2001] skillfully reveals the dangerous imprecision and lack of critical discrimination of Andrew Solomon’s much-touted Noonday Demon: An Atlas of Depression. But Dr. McHugh’s own historical account of how the importance of morality became recognized in psychiatry, and his picture of the current role of psychotherapy within the profession, both demand scrutiny.
Contrary to Dr. McHugh, long before Otto Kernberg’s work in the 1970’s, many others had recognized the tendency for psychiatric treatment to help people feel better by removing justified guilt over past misconduct, thus condoning future misconduct. Thomas S. Szasz’s The Myth of Mental Illness (1960) attacked the psychiatric redefinition of misconduct as “mental illness,” claiming that this undermined personal responsibility. And Aaron Beck’s “cognitive therapy” had for decades recognized the importance of moral standards.
More important is Dr. McHugh’s omission of the most profoundly harmful recent change in psychiatry: the almost total abandonment of psychotherapy in favor of drug treatment. In Out of Its Mind: Psychiatry in Crisis (reviewed by Kevin Shapiro in the January COMMENTARY), J. Allan Hobson and Jonathan A. Leonard maintain, rightly, that the field’s greatest problem is the profound gap between “biomedical treatment” and “humanistic therapy.” They point out how psychiatrists remaining in the health-care system have been transformed into “pill-pushers who hardly speak with patients.”
Dr. McHugh’s claim of major advances in the identification and treatment of the two major mental illnesses, manic-depression and schizophrenia, is undercut both by the increasing number of patients who continue on drugs and, at least for schizophrenia, by the steady worsening of treatment results over the past three decades. Most of the “empirical studies of mental illness and its treatment” praised by Dr. McHugh involve short-term drug administration. Follow-up studies years after the initial illness show, with respect to schizophrenia, that all the patients who recover fully have stopped taking medication.
Paul McHugh is correct that the “essential moral vision of human responsibility” is absent from Andrew Solomon’s ruminations on depression. But his own omissions reduce the value of his critique.
Nathaniel S. Lehrman, M.D.
Roslyn, New York
To the Editor:
Paul R. McHugh brings to light certain elements in the progress of psychiatry over the last several decades, but he creates distortions along the way. First, his characterization of “dogmatic” Freudianism (“with its guilt-assuaging visions . . . and its view that Oedipal anxiety explains all mental disorder”) is sweepingly simplistic. Nobody would deny that Freudianism had its heyday, but it is unfair to suggest that serious mental-health practitioners were blithely slotting everything into their Freudian paradigms with unquestioning complacency, especially where schizophrenia was concerned. Had that been the case, people like Otto Kernberg would not have struggled to find new approaches.
Dr. McHugh’s characterization of Kernberg’s contribution is also misleading. The idea that a therapist could “force” a “borderline” patient—that is, one who, in Dr. McHugh’s words, displays “a pervasive pattern of emotional and behavioral instability”—to do anything is extremely wishful. The innovation to which Kernberg lays claim is in identifying the borderline personality as a separate entity requiring a specialized approach. This did not, as Dr. McHugh claims, “liberate therapists from their own permissiveness.” It merely shifted the emphasis of their interpretive work from fantasy and the unconscious to the here and now, and entitled them to direct the patient to consider the impact of his own behavior.
Finally, it seems that Dr. McHugh confuses therapeutic neutrality with permissiveness. In the consulting room the therapist may try not to be judgmental about a patient’s adulterous behavior, and this may well result in the adultery’s going unchecked. But this does not mean, as Dr. McHugh puts it, that the therapist “tolerates” adultery or any other “self-indulgent, aggressive, and impulsive behavior.” Rather, the therapist believes that, before coming to a conclusion, it is necessary to look at the behavior as a symptom and understand more about it. This sidesteps the problem of morality but does not make psychotherapy more culpable than any other agent in our culture.
To the Editor:
I appreciate much of what Paul R. McHugh has written, but his “Romancing Depression” contains more romance than fact. Although psychiatry is considered one of the “medical disciplines,” it should not be considered science. Dr. McHugh claims that Freudianism has been “replaced by . . . empirical studies.” But where are the biopsies, the blood tests, the x-rays—where, in short, is the hard science that would prove to us “the biomedical nature” of depression? He argues that depression is “like epilepsy.” I can demonstrate a seizure with an abnormal EEG reading. What objective test can demonstrate depression?
Carol K. Tharp, M.D.
To the Editor:
Paul McHugh provides a needed antidote for much sloppy thinking and writing about depression. But the distinction he makes between the person and the disease is a bit too neat. Dr. McHugh writes: “In depression, just as in any illness, including cardiac disease and cancer, ‘you’ and ‘it’ do exist together. You do not cause or control the disease, but you may make the expression of it stronger and weaker, the treatment of it easier or harder.”
I agree, but, along with varying degrees of genetic vulnerability, a sedentary lifestyle and a high-fat diet operate as causes in cardiac disease, just as smoking does in lung cancer. So, too, certain habitual attitudes and behavior, as well as perceived environmental deficiencies and traumatic life experiences, can operate as contributing causes of depression. Once the “it” develops, it is indeed a disease and, with minor variations, behaves stereotypically; but the “it” can, and often does, emerge from the “you.”
Paul R. McHugh writes:
As its title implied, my essay was not a discourse on morality but an effort to describe the historical turn in psychiatric assessment and treatment that began in the 1970’s: a turn away from fantasy and toward realism. That this enlightening move exposed moral as well as clinical lapses in prior psychiatric thought and practice simply indicates that morality, like health, is a part of the real world, and will be forsaken when realism itself is forgone.
Thus, in response to Nathaniel S. Lehrman, I do not deny that other psychiatrists before Kernberg had seen the “condoning” features of psychotherapy. So had many laymen, and perhaps none better than Stephen Sondheim in the patter song, “Gee, Officer Krupke” from West Side Story, wherein a gang of punks proclaims, “We ain’t no delinquents, we’re just misunderstood.” Kernberg, however, was first among psychoanalysts in demonstrating how to address this condoning of misbehavior.
All of us hate the reflexive medicating of patients who suffer from manic-depression and schizophrenia, but Dr. Lehrman seems to have forgotten how these patients were neglected therapeutically before the discoveries of lithium and chlorpromazine. Robin Roger appears to have a similar memory lapse, denying any past “slotting” of schizophrenics. During the Freudian “heyday,” schizophrenic patients were indeed slotted, and some of them were shoved, squeezed, and slammed into overcrowded and foul snake pits.
On the matter of “therapeutic neutrality,” whatever the therapists cited by Robin Roger may have believed they were transmitting to their patients, in practice their “neutrality” amounted to permissiveness—as realists like Kernberg ultimately made clear. Realistic therapists today do indeed “force” narcissistic, borderline patients to “take responsibility” for their feelings and behaviors—if they hope for recovery.
As Carol Tharp well knows, the empirical studies suggesting that manic depression is a disease are fragmentary; but exactly the same kind of studies first indicated that epilepsy was a brain disease and not a supernatural visitation. What sort of work is being conducted? Among other things: demonstrating the hereditary nature of many examples of manic depression; replicating its symptoms by means of such measures as depleting the brain’s biogenic amines; showing how it is provoked by brain injury (particularly stroke); and linking it clearly in some cases to DNA markers on chromosome 18.
I agree with Bernard MacKinnon that diseases are often provoked or worsened by personal behavior; venereal disease is the most obvious example. I thought I had made that clear in my essay. But something else should be equally clear: risk factors that promote, strengthen, or weaken the manifestations of a disease are distinct in nature from causes—i.e., necessary and sufficient factors. As the butter-and-egg diet of many healthy Frenchmen attests, a high-fat diet is not the cause of heart disease; by the same token, exercise is no certain cure of it, as the death by cardiac arrest of the running guru, James Fixx, tragically demonstrated.