Dr.Iconoclast Psychiatrist Paul McHugh has waged a ceaseless campaign to restore sanity to his own profession. He wants psychiatrists to pay less attention to intellectual fads and more to the hard realities of science.

THE BALTIMORE SUN

The ancient folk had a name for him. They called him Momus. He was the licensed critic who sprayed the gods with ridicule.

Is Paul Rodney McHugh a modern, flesh-and-blood Momus? A persistent faultfinder of the wannabe gods in psychiatry?

He hardly seems the type: He's not cranky; he doesn't go around preoccupied all the time. For someone who spends so much time among the depressed and insane, he's suspiciously happy.

Probably his reputation has less to do with the way he is than with his annihilating opinions on everything from doctor-assisted suicide (utterly wrong) to multiple personality disorder (it doesn't exist).

McHugh speak outs about the dubious practices -- and practitioners -- in the medical profession. People like Dr. Jack Kevorkian, whom McHugh regards as "insane" and "dangerous to others." Or Dr. Bruno Bettelheim, a renowned expert on children, who was "a habitual liar, thankless friend, vicious bully and brazen plagiarist. He died in 1990. Why not just forget him?"

But McHugh is always toughest on his own specialty, psychiatry, which he believes enjoys entirely too much credibility with the public and in the official world of courts and the law.

"Psychiatry," he writes, "is a rudimentary medical art." It is full of people who say things they can't prove about why human beings do what they do. Though all psychiatrists are medical doctors, psychiatry is largely bereft of the certainties that general medicine or chemistry or biology can claim. This is where it is most vulnerable to attack.

McHugh does not say most psychiatrists are irresponsible. He would admit many are.

He mentions an incident that occurred during the 1964 presidential campaign. It involved Barry Goldwater, the Republican nominee, considered by some to be reckless on the issue of nuclear war, and a gambit by an obscure magazine titled Fact.

The editors of this journal sent questionnaires to psychiatrists all across the country asking them to assess Goldwater's mental state. Many, having never even met the senator, declared him unfit to be president.

"Scandalous and wrong," McHugh calls it.

This is the sort of thing that has always upset Paul McHugh, Henry Phipps Professor and director of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins' School of Medicine.

This is an Olympian position in the world of psychiatry, one which McHugh seems to occupy without taking himself too seriously. He is an amiable man, with many interests, prepared ++ to talk knowledgeably on subjects as diverse as Evelyn Waugh's novels and Japan's post-war drug-abuse crisis. His recreations are almost entirely intellectual.

"I engage in conversation with friends. I read a lot of books [fiction, biographies and philosophy, mainly]. I travel with my dear wife [Jean, from Shropshire, England, whom he met in Boston and married 38 years ago]."

McHugh reveals his New England origins (Lawrence, Mass.) the moment he opens his mouth and launches those flat, large-tongued aaa's into the conversation. He is the son of a high-school teacher, father of three grown children: a journalist, an athletic director at a private school, a banker.

He earned his medical degree from Harvard in 1956 and completed residencies in psychiatry in Maudsley Hospital, London, and in neurology in Massachusetts General Hospital in Boston. He taught at Cornell and the University of Oregon before coming to Hopkins more than 20 years ago.

McHugh has an expressive, slightly cherubic, pale-pinkish face, a large forehead beneath not too much gray hair. He is 65, a man of many words and few gestures. Usually, when lecturing he just holds his hands before him, palms up, and raises and lowers them like somebody weighing a baby.

Over the years, he has trained hundreds of psychiatrists. Many remember their time with him as one of the high points in their professional lives.

"Paul teaches you how to think. How to take a stand in a world filled with ambiguity. He teaches you to think scientifically," says Michael A. Schwartz, professor of psychiatry at Case Western Reserve University who studied under McHugh 30 years ago and has followed his career ever since.

Patient interview

On Friday rounds at Hopkins, McHugh gathers 20 psychiatric residents in a room to interview a patient, a young man suffering from schizophrenia. The doctor is wearing a blue-striped Oxford shirt, black trousers and blazer. His students are in white lab coats.

First McHugh interviews the resident who has selected the young man. "Are you sufficiently interested in this patient?" he asks. "Or are you doing this pro forma?"

When McHugh has satisfied himself about the doctor's intentions, the patient is brought in. He hears voices, finds the world about him "unreal."

"How do you feel?" McHugh asks gently. "How's your mood?"

"Not good," says the young man.

"Not good? Not good, but not dismal," says the doctor, engaging, close but not too close. He has, in situations like these, a dynamic overtness about him: McHugh is never passive, or indifferent.

The doctor picks his ear, plays with his glasses, now and then pulls on his chin. He worries about the patient's reaction to him.

"Am I making you nervous?"

"No," says the young man, even though he obviously is nervous.

After the patient leaves, with McHugh's assurance that he is "in the very best of hands," the doctor questions the students, probes their knowledge of current theory on mental illness, especially schizophrenia, assesses the quality of the questions they had put to the patient.

Then McHugh departs for Penn Station; he's testifying as an expert witness in a criminal trial in Philadelphia. He is much in demand. He lectures, reviews popular books on psychiatry and psychology, and appears on television. He's a veritable quote machine for reporters. They call him often, asking for his reaction to therapists who want to medicate boys for being, well, boys, or his take on the latest big award to someone who dredged up a memory of sexual abuse, at age 3, by a heretofore beloved uncle.

Within his profession, the doctor's standing is so formidable that one specialist in abnormal psychology grew suddenly faint-hearted when she learned she might have her name appear in print contesting McHugh on repressed memory and multiple personality syndromes.

To appreciate McHugh and the place he occupies in psychiatry, one must know the ideas he endorses and those he sets himself against. These are not hard to learn, for McHugh has managed to break out of the circle of academic medical and scientific journals most psychiatrists are confined to. He writes clearly, with edge.

He first came to wider notice through a 1994 article titled "Psychiatric Misadventures" in the American Scholar, a general interest journal not nearly so popular as, say, Time, but far more accessible to the average person than the Annals of Internal Medicine. The point of the essay is that psychiatrists too often, and for too long, have violated the first duty of all physicians: to do no harm.

They have done plenty, not with intent perhaps, but owing to their weakness for the intellectual fashions of contemporary life.

What McHugh described as the most "conspicuous misdirection psychiatric practice" in his career occurred in the 1970s when, at the urgings of such "anti-psychiatrists" as Thomas Szasz, R. D. Laing, Erving Goffman, Michel Foucault and others, thousands of schizophrenics, manic-depressives, other mad people, were turned out of the institutions where they were being treated, set free to sleep under bridges and wander the streets like restless ghosts. A generation later, their "children" (sometimes literally) are still out there screaming at their reflections in store windows, trapped in never-ending dialogues with themselves.

The anti-psychiatrists believe mental illness does not really exist, that psychiatry is a fraudulent trade that refuses to accept that some people are simply more idiosyncratic than others. So they hear voices? So what's wrong with hearing voices? Hallucinations and delusions? It takes all kinds. This all began in the decade of "do your own thing," and "finding one's self." Some people sought themselves in another gender: You're uncomfortable as a guy? Be a girl! Or vice-versa. Many psychiatrists encouraged it. Johns Hopkins was a pioneer in sex-change surgery.

Along came Paul McHugh, hired in 1975 from the University of Oregon, to run the Hopkins' department of psychiatry. He was determined to put an end to sex-change surgery, which he did.

"I was greatly supported by people in the department," he recalls, "mainly because the patients didn't seem much better for their operations."

McHugh likens the zeal for sex-change surgery to that once evident for frontal lobotomies, the most "radical therapy ever encouraged by twentieth-century psychiatrists." Both were the fruit of muddled thinking by psychiatrists, whose influence was strong enough to override objections from those not so eager to embrace these grotesque surgical fashions.

But fashion being another name for the ephemeral, sexual reassignment surgery is no longer a growth industry. Lobotomies are a thing of the past. The mentally maimed are still being de-institutionalized, but not in the numbers they once were.

Which is not to say no new psychiatric misadventures have presented themselves. Currently most conspicuous among them is, in McHugh's opinion, multiple personality disorder and its attendant repressed memory syndrome.

McHugh does not believe more than one personality can inhabit a single mind.

"We have one mind. We have one personality" he says sourly. "We have one head."

He thinks repressed memories are excavated with the eager help of therapists; that is, suggested by them. Especially those memories that lead grown children to condemn parents, once thought loving and caring, as sexual abusers.

Multiple personalities, recovered memories -- "These are artifacts," he says. "By that I mean they are created by human hands. Just like the difference between a stone shaped by wind and rain and an arrowhead." The arrowhead is not found; it is made.

These thrusts by McHugh invariably draw counter-thrusts.

"Dr. McHugh's opinion is an opinion," says Dr. Richard P. Kluft, of the Temple University School of Medicine and visiting lecturer at Harvard. "The fact of the matter is the American Psychiatric Association recognizes multiple personality disorder, the World Health Organization lists it as a condition. There are numerous articles on this syndrome."

Kluft formerly ran the multiple personality disorder program at the Institute of Pennsylvania Hospital. He has written many of these articles. "This is a highly political position Dr. McHugh holds," he says. "It is by no means mainstream."

McHugh has been especially vehement with regard to assisted suicide. Those who favor it see it as a personal choice made by people facing painful and certain death from terminal disease.

McHugh says people who choose suicide are invariably "depressed and demoralized," unable to make rational decisions. Those who assist them, such as Dr. Kevorkian, are in "collusion with insanity." McHugh sees legal suicide as a step toward officially countenanced euthanasia.

There are more than a few people in line to have at McHugh on this. One is Dax S. Cowart; he brings more than just an intellectual interest to the debate. In 1973 a gas explosion engulfed Cowart in flames, permanently blinded him and scarred 85 percent of his body. His pain was so intense that he begged to be allowed to die but was treated for 14 months against his will. His attempt at suicide failed: he was too weak to open his hospital window to jump out.

Cowart recovered and became a successful lawyer in Corpus Christi, Texas. He also became an active speaker on medical ethics. Suicide, he says, can indeed be a rational decision. It was with him, he insists, though no one would help him carry it out.

"I'm talking about a right that's about as fundamental as you can get," he says. Cowart believes McHugh, not having gone through what he did, just couldn't understand.

McHugh is not entirely comfortable as the institutional critic of psychiatry. This doesn't seem to discourage him, though, as he expresses disdain for lax practices on every side.

Last year he wrote a commentary in Nature Medicine called "Hippocrates a la Mode" criticizing graduating physicians at Hopkins and Harvard for re-writing parts of the Hippocratic Oath. Their revisions excused themselves from some of the more demanding responsibilities physicians through the centuries accepted.

In one case, McHugh notes, they wrote into the oath "a new and farcically self-centered tenet" that went as follows: "To serve others most effectively, I must maintain my own well-being."

A "sentiment suitable for a body-builder," McHugh writes, further evidence that physicians, along with everybody else, are caught up in what he regards as a widespread preoccupation with the self.

The doctor has thought a lot about this. It has led him to an interesting idea about anorexia nervosa. He has studied eating disorders for decades and has found no biological cause for anorexia. He now believes it is a manifest product of our culture and times -- this "Age of Self-Absorption," as he calls it, when people think only of themselves, their health, their looks. The distinguishing features of anorexia nervosa are that it almost always occurs among youthful females, usually in the higher income levels, and in developed countries.

McHugh might not like being perceived as the perennial complainer. But if he stopped doing it, who would take his place? And, more importantly, would the profession of psychiatry, the public in general, be better served if McHugh shut up?

Hardly. And if he did, who would provide us with the lovely acidic judgments of the sort McHugh specializes in -- such as that poured upon the head of Dr. Oliver Sacks, the neurologist and author who was portrayed by Robin Williams in the movie "Awakenings."

McHugh doesn't care much for the author of "The Man Who Mistook His Wife for a Hat." "I have a visceral antipathy toward psychiatric romantics and the stories they generate," he wrote in a commentary for this newspaper in 1995. "They have done much harm to patients and to my profession usually by inflating some half-baked idea into a practice that made fools of us all."

At a decorous institution like Hopkins, doctors rarely express themselves with such withering directness. But McHugh says it has never gotten him into trouble. In fact, there are many who cheer him on.

"Paul's the conscience of the medical school," says Patrick Walsh, head of the urology department. "We admire him immensely."

Which is not to say McHugh's career has not had its low moments. Probably the lowest occurred in 1995, when he began to think that maybe his time at Hopkins was up. He had been there 20 years and was approaching the traditional retirement time. His department needed money, more space, more wherewithal to do new things.

McHugh asked for these things and didn't get them. He sensed Hopkins preferred to wait until he retired and someone younger took his place. So McHugh accepted an offer to run the Friends Hospital in Philadelphia. Then Hopkins responded.

"They were even more generous than I expected. They came through. They asked me to stay."

In almost everything he does, McHugh follows his own intellectual inclinations. He sees himself as a defender of a tradition in psychiatry older than that established by Sigmund Freud, a tradition anchored in the principles of the Enlightenment. A broad intellectual movement in 17th- and 18th-century Europe, it propagated, among other things, a belief in human progress and perfectibility, the supremacy of reason and the scientific method.

During the Enlightenment, McHugh says, the idea took root that "The mentally afflicted, the psychotic, the retarded, the demented, the delirious, etc., were suffering from natural processes -- from diseases rather than curses of God or Satan."

Faith in science

This idea, central to modern psychiatry, was championed by people such as Emil Kraepelin and Eugen Bleuler in Europe, and Adolf Meyer in this country. Science, they believed, could cure the mentally ill, or at least illuminate the causes of their maladies. Medicines could be used to treat symptoms of insanity. Diagnostic training was essential. These men remain McHugh's heroes. These ideas animate him.

In the 19th century -- the age of Frederick Nietzsche, Freud and Carl Gustav Jung -- reason as a means of knowing the truth was devalued. The role of the sexual drive became important. Psychiatry began to splinter into cults and sects, competing therapies whose advocates had little to say to one another. The scientific rigor of modern psychiatry began to weaken.

Freudianism, McHugh says, gave birth to the idea in psychiatry that "the plausible is just as good as the proven. So we use many plausible explanations of things, and get away with it because no one calls us on it."

Owing to the dazzling celebrity of Freud and the preaching of his many disciples, a conviction embedded itself in the public mind that psychiatrists knew "the secret of human nature." This is nonsense, but nonsense widely accepted, McHugh says. It has caused much human suffering.

McHugh is not an anti-Freudian. He judges the Viennese doctor's approach as more art than science. "It introduced a lot of things about human mental life that are useful," he says. "But it hasn't explained mental illness. That's the reason it has fallen away in psychiatry."

One reason fuzzy and imprecise thinking continues in psychiatry, the doctor believes, is because teaching universities have failed to hold psychiatrists to the "same tests, the same values, to the same criteria for advancement and support they ask of neurologists, pediatricians and other people."

But McHugh believes a major change in psychiatry is coming. It will be similar, he says, to the revolution that occurred in general medicine in the last century.

Back then medicine was as splintered as psychiatry is today. Physicians pushed competing therapies. There were the homeopaths, the fresh-air and physical-culture advocates, the herbalists, you name it.

"The Civil War brought to light the fact that we educated plenty of doctors who couldn't do much about anything," McHugh says. "All they could do was chop people's legs off, and they didn't know how to do that very well. People were dying, from all kinds of things."

Change came in the 1870s and 1880s, inspired by this catastrophe of incompetence. Its advocates, William Osler of Hopkins among them, determined to teach student physicians certain things: more hard science, especially biology. They were taught to distinguish between diseases, their histories, how they progressed. They absorbed a core of empirical knowledge they could all agree upon, which they could use to determine the cause of a given malady, and which would help them find a cure for it.

It was an application of scientific rigor, and it came as a shock to an undisciplined profession. McHugh sees such a shock coming for psychiatry.

Today, he says, "The discourse in psychiatry is becoming steadily more logical, much more dependent upon careful definition, data and understanding of the reason behind an opinion."

Facts and proof are coming back into vogue in psychiatry. That's one fashion you'll never hear Paul McHugh complaining about.

The Skepticism of Paul McHugh

On anorexia nervosa: "Anerexia nervosa seems to follow the subscriptions of vogue. If Vougue gets to your country, anorexia nervosa will eventually follow."

On attention deficit disorder: "You can't just treat all these kids with Ritalin and then, because they slow down, declare that that was the problem all along. Ritalin will slow almost any kid down."

On author and neurologist Oliver Sacks: "A Wordsworth wannabe in the district of the sick."

On Harvard psychiatrist John Mack, who believes humans have been abducted by aliens: "He's a brilliant fellow who occasionally loses it, and this time he's lost it big-time."

Pub Date: 2/02/97

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