The Mind has Mountains: Reflections on Society and Psychiatry
by Paul R. McHugh
Johns Hopkins. 272 pp. $25.00
Psychiatry has long been the sick man of medicine—a science without a laboratory, a discipline without a method, a field without boundaries. In an area of medicine like cardiology or dermatology, such confusion would present a danger primarily to those who suffered from heart disease or eczema. But in a therapeutic culture like our own, psychiatry’s maladies infect everyone. Whether through the lingering fog of Freudianism or the invention of fashionable but medically dubious diagnoses, the psychiatrist disseminates ideas that are eagerly seized upon by a population lacking a rich alternative for describing inner life.
Throughout much of his career, Paul McHugh has called upon psychiatry to heal itself. In his former post as director of psychiatry at Johns Hopkins, and in his many essays and reviews, he has appealed to his peers to examine their methods and presumptions and to shun the sort of overreaching that has produced library shelves groaning with volumes of junk psychiatry. Much of what he has learned and taught along the way is distilled in this collection, which includes several pieces first published in COMMENTARY.
The cure for psychiatry, McHugh contends, is fairly simple: more science. It is a measure of the poor health of psychiatry that this should even need to be stated. But psychiatrists, as he tirelessly points out, have been less inclined to seek out treatments for distinct conditions like dementia, depression, retardation, or schizophrenia than to theorize about them, sometimes wildly.
Chief among the sources of this theorizing has been Freudianism, and especially what McHugh calls its “romanticist” tendencies. Instead of using the scientific method to determine what ails their patients, psychiatrists “rely upon feelings for evidence, on metaphors for reality, on inspiration and myth for guidance.” Nor do they show the slightest interest in empirical research to prove their intuitions. “[I] nfatuated with their own thought,” they spin narratives about the childhood sources of their patients’ suffering and pride themselves on their “depth.”
They can do this, McHugh writes, because, like Freud and Jung before them, they prefer to treat patients who are most like themselves and to keep a safe distance from the worst cases. This allows them to view the symptoms of the schizophrenic or paranoid person as merely heightened versions of ordinary experience, “differing only in degree, not in kind.”
Patients suffering from depression have been especially victimized by the romanticist fallacy. McHugh hardly denies that depression can sometimes be a symptom of commonplace “demoralization,” on a continuum with normal psychological life. But in many cases, he insists, it is a sign of a true medical disease, an external “it” like cancer or epilepsy, “a thing unto itself and not just the dark side of human emotion.” As such, it is not remotely susceptible of treatment by “evocative insight psychotherapy” of the kind practiced by one therapist, steeped in orthodox Freudianism, whose disastrous handling of a suicidal Harvard student is the subject of a chapter here. (The therapist was ultimately brought up on charges—but, tragically, only after the patient had killed himself.)
The romantic fallacy has tarnished psychiatry for a long time. But in the 1980’s and 90’s, it mutated into a particularly vulgar form. McHugh’s name for this is “Manneristic Freudianism,” and its manifestations absorb several of the essays in The Mind Has Mountains. Egged on by radical feminists, the Mannerists took Freud’s idea of the unconscious sexual roots of personality and from it wove a bizarre theory of rampant childhood sexual abuse (usually by a relative) that remains repressed deep in the victim’s memory. Unable to integrate the trauma into conscious experience, the abused patient, in the Mannerists’ reading, “dissociates,” or disintegrates, into separate personalities known as “alters”; some therapists claimed to have had patients with as many as 80 alters.
In its heyday, this psychiatric fad wrought untold damage on patients and their families. If the memory wars—as the debate over Repressed Memory Syndrome and Multiple Personality Disorder has been called—have finally come to an end, it is not because psychiatry has healed itself but because of negative publicity and legal action by incensed—and innocent—parents.
For all its mischief, Freudian romanticism has been only one source of psychiatry’s present-day ills. In general medicine, McHugh says, doctors know to distinguish symptoms from the underlying disease. But psychiatrists, with their lack of true scientific rigor, are easily duped into pseudo-scientific simplifications, and especially into “classifying mental disorders by their appearances.” The official guidebook of the American Psychiatric Association—known as the Diagnostic and Statistical Manual of Mental Disorders—has swelled into a nearly thousand-page catalogue of supposed diseases, many of them invented to satisfy a particular group of psychiatric experts and their newly empowered clients.
Whether it is Vietnam veterans lobbying for the inclusion of Post Traumatic Stress Disorder or devotees of Multiple Personality Disorder, patients now arrive at the therapist’s office announcing their own diagnoses—OCD (Obsessive Compulsive Disorder), ADD (Attention Deficit Disorder), social phobia (painful embarrassment in social situations), or the like—and demanding the drugs to treat them. Yet many of these are merely descriptions, not diseases; in the case of ADD, writes McHugh, “it is simply not true that most individuals deficient in [attentiveness and confidence] are sick.”
Adding to the general confusion are medical ethicists, who, in focusing on patients’ rights, have muddied traditional understandings of the struggle against disease and death. Not so long ago, new doctors graduating from Harvard pledged their “respect for human life”; these days, they refer to upholding patients’ “dignity”—in other words, the right to die. Yet the rallying cry of dignity often leads to its opposite, as in the case of the victims of Jack Kevorkian, or in the case of Terri Schiavo, whose death by starvation, McHugh argues, represented a radical deviation from traditional hospice and medical care. For their part, psychiatrists have abetted this new “culture of death” by, once again, failing properly to define mental diseases like depression.
Given all this, there would seem little reason to be hopeful about the future of psychiatry. But McHugh is guardedly optimistic. If the theory that gave us the Oedipus complex and castration anxiety has gone the way of Soviet-style Marxism, advances in neuropharmacology, genetics, and epidemiology—and, McHugh posits more controversially, the accountability imposed by managed care—are helping to discipline therapeutic practice. As neuropharmacologists successfully prescribe different categories of drugs to different sorts of patients, and as neurologists locate brain-based mechanisms that drive certain behaviors, it has become increasingly impossible to maintain that “mental illness is all one, à la Freudianism.”
Some have worried that the shift to an empirically based psychiatry would lead practitioners to become unsympathetic, disinterested pillpushers, but McHugh believes this has not happened. Psychiatrists are learning to make crucial distinctions between patients afflicted by illnesses that “rest upon bodily disease” and those whose suffering is caused by life situations. In short, after an extended adolescence, psychiatry may finally be growing up.
Paul McHugh writes with a wit and elegance almost extinct in his professional neighborhood. At their best, his essays, though considerably more polemical, bring to mind the graceful prose of Lewis Thomas or Oliver Sacks. The comparison works to his disadvantage in one respect: because McHugh avoids the anecdotal approach that has allowed many of his peers to evade scientific rigor, The Mind Has Mountains is often abstract in a way that, for example, Thomas’s Lives of the Cell is not, and some readers will undoubtedly wish for more case studies. Still, McHugh’s pithiness, lucidity, and professional modesty are themselves a tonic to psychiatry’s usual oversimplifications, confusions, and grandiosity. The psychiatrist is a man of medicine, not a poet or a sage, McHugh reminds his readers. “We psychiatrists don’t know the secret of human nature. We cannot build a New Jerusalem.”
This raises an interesting issue. One secret that psychiatrists do not know, as McHugh observes on several occasions, is the answer to the “mind/brain problem.” In recent decades, neuropsychiatry has made great leaps in understanding the brain as a medical organ, but it is still “unable to demonstrate how symptoms emerge directly from activity in, or changes to, the organ that generates them—namely the brain.” The common vocabulary we use to describe inner states—fear, belief, consciousness, self—do not necessarily correspond to brain events. Nor does the brain tell us much—yet, anyway—about why or even how our self-destructive friend is different from our well-adjusted cousin.
“I can’t point to a single neuroscience discovery that would explain the most obvious psychological differences between people,” McHugh writes. The brains of geniuses and ordinary people, of extroverts and introverts, do not vary in any significant way. Nor can science tell us very much about “selfness and intentionality.” That is why some neuroscientists reject talk of the self altogether as an “expression of primitive thinking.”
McHugh is far from that mindset. His is a humane sensibility. He clearly brings to his craft a belief that human beings have souls, minds, and intentions worthy of respect. No friend to Freudian psychoanalysis, he nevertheless does endorse the narrative, psychotherapeutic approach—what he calls the “life story perspective”—as a necessary part of the doctor’s inventory, especially in treating “ordinary” grief, isolation, and demoralization. Yes, this approach can fall prey to “missionary zeal”; but when it is working properly, patients can find help through being “understood by some authority who is prepared to provide assistance in restructuring his or her thoughts and intentions into a story with more promising meanings.”
In what sense, though, can psychotherapy as McHugh here describes it be considered medicine? He is entirely convincing that science is the route to understanding and treating diseases of the brain like schizophrenia, autism, dementia, and many forms of depression. But what about the sort of commonplace unhappiness that brings throngs of sufferers to consulting rooms not just at Johns Hopkins or on the Upper West Side of Manhattan but to offices all over the country?
About these sorts of patients, McHugh is less clear. On the one hand, he declares himself a proponent of the “cognitive-behavioral approach,” which sets out to reorder the (presumably conscious) thoughts that (presumably) cause our feelings. On the other hand, he implies at several points that he also believes in the unconscious—though he makes no mention of its contents, its role in human psychology, or, for that matter, its part in the therapeutic enterprise. Yet surely if a therapist sets out to “restructure” unconscious as well as conscious thoughts, he is treading dangerously close to the sort of unempirical speculation that is otherwise the object of McHugh’s censure.
More importantly, the therapist inevitably brings something of his own personal vision to his office—and, with that vision, unspoken assumptions about how to live a good life, about the limits of self-fulfillment, and about just what defines a “story with more promising meanings.” In one of the few vignettes of actual treatment that he gives us, McHugh tells about a young female patient whose boyfriends have a habit of fleeing after sexual affairs. He tries to explain to her “how contemporary sexual mores, supported by easy contraception, tend to emphasize what one receives from an intimate relationship rather than what one brings to it,” and “that she has been cooperating with a cultural system that permits males to remain perpetual adolescents.” This is, assuredly, wisdom; but is it medicine?
For better or worse, America’s middle classes turn to psychotherapists to make sense of their unhappy relationships, their failures, and their everyday miseries. One can only hope that some of these therapists are like McHugh himself. For if one thing is clear, it is that he has a humanistic vision, inspired by wide reading, deep reflection, and, one suspects, religious feeling, and nourished by thinkers ranging from Shakespeare (the subject of one chapter) to the philosopher Karl Jaspers (the subject of another). This learning cannot cure what ails psychiatry. But how lucky for McHugh’s own patients, many of them otherwise bereft of the wisdom that he has plumbed and that is so movingly evident throughout The Mind Has Mountains.