After three decades in the field, Dr. Paul R. McHugh believes several trends that have swept American psychiatry since the 1960s are wrong-headed outgrowths of popular culture.
In a recent magazine article, "Psychiatric Misadventures," Dr. McHugh outlines his distaste for three "fashions" -- the anti-psychiatry movement, sex-change surgery and the theory of multiple-personality disorder. None, in his view, addresses what really ails patients; the result has been prolonged treatment with dubious results.
The most conspicuous case, he says, is the anti-psychiatry movement, the view that psychiatrists have imposed labels like "schizophrenic" on people who are simply different. That movement, he says, is partly responsible for the deinstitutionalization of thousands of desperately ill patients onto the streets of America.
Dr. McHugh's article appears in the autumn issue of the American Scholar, a quarterly published by Phi Beta Kappa. He is chairman of psychiatry at the Johns Hopkins School of Medicine and a professor of mental hygiene at the Johns Hopkins School of Hygiene and Public Health -- positions he has held since 1975.
QUESTION: Your article says that every 10 years or so a new fashion sweeps over psychiatry, "proving how all too often the discipline has been held captive to culture." What is the current fad?
ANSWER: This whole idea of hidden child abuse, that somehow or another there are all kinds of victims who are not remembering their "victimhood."
Q.: Do you disagree with the idea that children who are sexually or physically abused can so thoroughly suppress the memory that it remains buried until emerging years later in adulthood?
A.: All I can tell you is that every time I come across such a case, the testimony is remarkably dubious. The mind can do all kinds of things. But one of the things that the mind can do more than anything else is take up a suggestion and run with it.
It's a contemporary view that many of us are victims. I don't think there's any malice involved in this. It's just an idea that's come to many therapists who have forgotten true abuse, and it's a total re-creation of just what Sigmund Freud ran into at the turn of the century.
Freud began his important work and suddenly came across a whole slew of claims about sexual abuse. And eventually, after going public and saying there was all this abuse going on, he came to realize that in the interactions between him and the patients, the ideas had been generated not out of historical reality as he said but out of psychic reality.
Q: But some patients are making specific statements about who abused them, what happened, and when. These aren't vague memories. How do such specific memories get formed if the events never really happened?
A.: When I had an opportunity to follow [these cases], they took the course of a person in distress going to a therapist who concluded quite early that sexual abuse had occurred.
Together, the patient and the therapist discuss the possibility. The patient says things like, "Well, you know, there are things in my background I can't quite remember, I feel uneasy about."
And after weeks and weeks of focusing on that, something quite concrete emerges.
Q.: It would seem a huge leap of faith for most people to accuse a father, uncle or brother of abuse. Wouldn't most people be loath to accuse a parent of sexual abuse unless they remembered specific abuse?
A.: Indeed, and the people who have recanted these things and have changed their mind, speak about how long it took for them to both come to that opinion and then change that opinion. The power of psychotherapy and the power of the therapist's even-unconscious suggestions are not to be underestimated.
Q.: What do you think is really going on with these patients?
A.: There's no one thing. I think these are people in a variety of forms of distress. They need to be understood for the nature of their distress, and we shouldn't pour them all into a category of post-traumatic stress sex abuse.
Don't get me wrong. I believe there's sex abuse of children. We know a lot more about sex abuse than we used to, and sex abuse has long-term effects on people. But they don't forget it. They don't forget it.
Q.: You've also debunked the theory of multiple-personality disorder, an idea popularized by such movies as "Sybil." The theory is that victims of sexual abuse invent alter egos to shelter RTC themselves from the trauma. The disorder is now recognized as an official diagnosis, and thousands of victims are being diagnosed every year. Is this a fad, too?
A.: Only in the sense that it's a hysterical symptom. The word "hysteria" is a professional one: an individual has developed a physical or a psychological state that is derived from conflict and suggestion.
What happens is that this phenomenon becomes more and more publicized as a set of events, so we have books and movies about them. Certain therapists become intrigued and begin to suggest [the diagnosis], to think about it and provoke it in their patients. So the person in trouble hears about [the diagnosis] from a variety of sources, and with some therapists, has sustained and amplified it.
Q.: What is the harm or the damage done when a therapist makes multiple-personality disorder the focus of therapy?
A.: You don't get on with treating the real problem. Hysterical behaviors are always a way to blind the patient to the need to solve something else in life.
Q.: And yet therapists will describe how in many cases they've been able to integrate the person into a single personality by allowing the different voices, "the alters," to talk to each other and resolve their differences.
A.: I just think there's an easier and quicker way: Not speaking to any alters. Just like you ignore a hysterical paralysis [a paralysis stemming from a psychological belief that one is paralyzed], you ignore the hysterical mental state to get to the root of the matter. If quickly you don't reward that behavior, it stops. Reward it, and you'll make 99 personalities.
Q.: You come down hard on the anti-psychiatry movement -- the 1960s view that psychiatrists impose the diagnosis of mental illness on people who are really just different. You say that movement was largely responsible for the neglect and discharge of seriously ill people from institutions, and now we're bearing the consequences: the homeless mentally ill. Are there strong remnants of this movement?
A.: They still live, but it's over.
The idea that schizophrenia is a disease and that people are victims of the disease is clear.
Thirty years ago, it was a legitimate point to make that schizophrenia and manic-depressive disorder might not be appropriately construed as diseases. That discussion in the profession was healthy.
Now, we have the evidence of disease in schizophrenia, and we have improving evidence of disease in manic-depressive disorder. Good, honest evidence.
Q: Is it a fair statement that some institutions may subscribe to a trend, while others may not -- that mental health centers have styles that influence how they treat patients?
A: Yes, and that's the essence of my article and the reason I'm speaking to the public. As long as there are different styles, the public should know that psychiatry is still a primitive discipline, and caveat emptor. I wrote this article to produce a better-informed public about psychiatric medicine. The public should expect that doctors make mistakes, and those mistakes in psychiatry have this awful potential of being swept up by a fashionable idea.
And you can find yourself for a decade producing what we produced in all of these cities -- the neglect of the seriously mentally ill.