Psychiatry’s Healer

Hanging prominently at the Johns Hopkins Meyer library is the portrait of Dr. Paul McHugh. McHugh served as the Chairman and Henry Phipps Professor of Psychiatry at Hopkins from 1975 to 1992, transforming the program into the best in the nation. His placement on the wall, among neurologists and neurosurgeons, is especially appropriate. McHugh began his training in neurology and spent his career directing psychiatry away from its “misadventures” toward a more empirical approach in the manner of other medical disciplines. His training in neurology and psychiatry prefigured the widespread view that increasingly the two fields will overlap. As we learn more about the workings of the brain, the vagaries of the mind will become more concrete and subject to empirical scrutiny.

Yet McHugh is much more than a champion of psychiatry rooted in science; he is also a probing student of the human soul in all its variety and complexity, and he knows that it is the poets, not the biologists, who best understand the lived realities of being human. In this exciting and thoughtful collection of essays, McHugh devotes himself first to the question of how psychiatry understands itself vis-à-vis the difficulties inherent in the distinction between mind and brain, then goes on to address larger questions such as medical education, physician-assisted suicide, and what it means to be a doctor. What emerges is a portrait of the physician par excellence: one grounded in practical wisdom cultivated at the bedside, with an eye to man’s aspirations and greatness, his passions and imperfections, and the limited but significant role doctors can play alongside their patients’ lives.

McHugh, like many other great figures in medicine, stands on the shoulders of past giants. In his introduction to Karl Jaspers’s General Psychopathology (one of the essays in this new book), McHugh introduces a man and his ideas — ideas important for anyone attempting to negotiate the difficult terrain of modern psychiatry, especially the pathways between mind and brain. In pre-war Germany, the distinction between the brain (the physical substrate of consciousness) and the mind (the inner warehouse of ideas which inform thoughts and emotions) was a dialectic in search of resolution. Under the guidance of Franz Nissl (known for the Nissl stain of neurons) at the University of Heidelberg in 1913, Jaspers explored and organized two distinct understandings of psychiatry. Building on the improving techniques in neuropathology, coupled with the identification of specific brain disorders such as schizophrenia and Alzheimer’s disease, Jaspers saw the empirical investigation into the workings of the brain as central to psychiatry. But Freud (himself a neurologist) and his technique of psychoanalysis were also gaining steam; in Freud’s footsteps we came to expect that the inner life of the mind could be made accessible to others in a manner that captured purpose and meaning. At that point, neurologists and psychiatrists saw themselves as largely sharing the domains of mind and brain, whereas later the mind would become the domain of the psychiatrists and the brain that of the neurologists.

From early on, Jaspers was concerned that psychiatry lacked a systematic approach to patients. As new camps within psychiatry drew idiosyncratically on various empirical, epidemiological, or psychoanalytical sources, the result was an ever-increasing number of self-referential schools without a common language or method. To a large degree, despite the fact that Freudian psychoanalysis became the preeminent doctrine of psychiatry, this sort of factionalism continued.

The period of Freudian reign lasted more than a generation, from 1935 to 1975. As a trainee in psychiatry in the 1950s, McHugh became well-versed in Freud and his descendents. Like others, McHugh credited Freudian theory with expanding psychiatry’s range of insight into the inner life, circumstances and humanity of particular patients via psychoanalysis. But he also traced much of what ailed psychiatry to the prevalence of Freudian ideas. And so McHugh made a career of shrugging off the dominance of the analysts, and bringing psychiatry back into the fold of medicine. He did so by developing a model of mental disorders based on reliable and measurable descriptions — descriptions that accounted for both brain and mind, for embodied and purposive beings. While never fully abandoning psychoanalysis, McHugh is largely credited with saving psychiatry from its worst mandarin tendencies. In attempting to bring together neuroscience with psychiatry, McHugh picked up where Jaspers left off.

Healing psychiatry was no easy task, and the deep-rooted problems within the field led to various “misadventures,” as McHugh aptly describes them. The 1980s and 1990s were marked by an increasing awareness of childhood sexual abuse. Not surprisingly, it was also increasingly apparent that such abuse could result in psychiatric symptoms. The surprise came with the inference that today’s more garden-variety unhappiness could likely be traced to yesterday’s hidden, forgotten, traumatic events — memories which needed to be “recovered.” This was the origin of the recovered memory movement of the 1980s and 1990s, in which numerous people — typically family members — were wrongly accused of sexual abuse. It derived from the presumption that “where there is smoke, there is fire.” Typically, a young patient with routine complaints such as demoralization and depression would begin therapy; over time previously undisclosed memories presented themselves. Suddenly, “in a flash,” a memory of abuse would emerge and serve as the explanation for the patient’s struggles. It was thought that because the memories were so horrifying, they were repressed and could lead to distorted and dissociated forms of the self, a claim that also resulted in a vast increase in the number of cases diagnosed as “Multiple Personality Disorder.” These were not patients who arrived with complaints of childhood sexual abuse. Rather, these were cases in which more standard psychiatric complaints such as anxiety and depression were traced to previously unrecognized sources of “unresolved conflict” due to repressed memories of sexual abuse.

Psychoanalysis is predicated on the idea that our current selves are the products of earlier experiences. These experiences are often hidden but nonetheless active in shaping our conscious thoughts and decisions. Beneath the surface, a “dynamic unconscious” informs our mental life. A principal task of psychoanalysis is to access these sometimes hidden, more fundamental, and often conflicting animating forces. If the seeds of today’s unhappiness were planted early in life and took root, then unearthing early personal history is crucial to understanding and overcoming today’s struggles. Over time, between the work of analyst and patient, a story of the patient’s life emerges. In many ways, the goal of psychoanalysis is to liberate the self from the tyranny of an unexamined life. Unexamined ideas tyrannize our minds if they operate unrecognized, and psychoanalysis attempts to identify what is at work within the patient. This it shares with the philosophical view of the life of the mind. But unlike the philosophical life, which attempts to thrash out what is through competing efforts to apprehend the whole, psychoanalysis attempts to locate an intelligible story, i.e. to examine which experiences, ideas, or emotions are at work in an individual life. Psychoanalysis can give the sort of account that literature does — of particular people in particular places. When a good story brings us close to the source of human action, it serves as its own evidence; it is its own argument. The reader is compelled to say “This is how it really is.” Conversely, stories that exist only to demonstrate an abstract philosophical point are typically bad stories; they seek to capture universal truths but fail to capture the particulars of life as really lived. But telling stories and psychoanalysis itself have inherent risks. The chief risk is getting the story wrong. And disproving a bad story is no easy task.

McHugh recounts the recovered memory episode as illustrative of two tendencies within psychoanalysis. The first is to “romanticize” the life of the mind, that is, to rely too much on feelings and metaphor instead of observation and method. The other is a tendency for the analyst to see himself as possessing unique powers of insight. McHugh’s first response to these tendencies in psychiatry was an insistence on empirical research. Such research, he hoped, would serve as a corrective to the more unruly psychoanalytic model and allow psychiatry to develop along the same lines as medicine. He was interested in what can be observed and confirmed: “What we know and how we know it.” In the 1960s and beyond, the application of medications such as lithium and the first antipsychotics had provided evidence that material manipulation of the brain could have favorable outcomes on the mind. And later the discovery of the gene for Huntington’s disease provided more evidence that disorders of the brain could clearly give rise to psychiatric symptoms.

Yet even with such discoveries and the explosion of research in neuroscience over the past twenty years, how the brain is related to normal consciousness remains fundamentally unknown to science. Nevertheless, as McHugh notes, many neuroscientists expect to replace the psychiatrist’s speculations about consciousness with hard data about “brain states.” With increased understanding of neural networks, synaptic plasticity, and functional mapping of the brain’s geography, the expectation in much of neurology is that today’s “folk psychology” of the mind will ultimately be replaced with an empirical understanding of the brain.

But McHugh, in his wisdom, also recognizes the permanent limits of neuroscience even as he seeks a more scientific psychiatry. Of the neuroscientists, he says, “The toughest among them may say such things as ‘science shows there is no soul’ and then classify your views upon these matters [as] … one small step from the ‘flat-earth’ crowd.” The mind is thought to be a mere epiphenomenon of the brain — the brain causes the mind. No one would argue with the claim that the brain is the necessary substrate for the mind. But how a material event of the brain (the phenomenon) can give rise to a thought (the epiphenomenon), which in turn leads to further thought remains an enigma in need of explanation. As yet, neuroscience cannot account for the causal efficacy required for one epiphenomenon (a thought) to be the source and proximate cause of either a second epiphenomenon or a succeeding phenomenon (brain event). Still, the neuroscientists remain largely unbowed.

Something more was needed in psychiatry to integrate the advances in neuroscience without surrendering to an entirely material conception of consciousness. In an effort to account for the multiple and complementary views of the mind/brain problem, McHugh proposed four integrated views or “Perspectives,” which also served as the title for his seminal textbook in psychiatry, first published in 1987. The four perspectives are: Disease, Dimensional, Behavior, and Life-story.

The Disease perspective is what one would expect — some signs and symptoms group together in a manner typical of disease, and some diagnoses in psychiatry are most suitable to a biological understanding. This is the perspective most akin to the standard medical model.

The Dimensional perspective emphasizes the fact that while all of us carry certain traits, they manifest themselves across a spectrum, much as height and intelligence do. For instance, while all of us have experienced anxiety, only some experience it to such a degree that it is disabling. This view illustrates that certain disorders are more a matter of degree within the spectrum of human variation than discrete disease entities.

The Behavior perspective highlights the fact that in certain disorders the patient’s behavior itself contributes to or is itself the disorder, e.g. alcoholism. The immediate goal is to stop the behavior, and only later to address co-morbid conditions such as depression. To do otherwise is to treat the symptoms and ignore the root disease. Because no cure can be offered in the absence of the minimum condition of stopping the behavior, the importance of behavior as distinct from the disease requires emphasis.

Finally, the Life-story perspective attempts to place the events of a patient’s life into a coherent narrative. It locates the role of the patient at the center of his own story and seeks to understand how he might restructure this role so as to bring about favorable outcomes. The good psychiatrist brings all four perspectives to bear in each case.It is a useful model that comes at mental illness from multiple angles, but also allows some standardization of vocabulary and approach.

McHugh the psychiatrist is also a great humanist. Many of the essays in The Mind has Mountains are devoted not to psychiatry but to broader issues within and beyond medicine, such as medical education, physician-assisted suicide, the Hippocratic Oath, Terri Schiavo, terrorism, stem cells, and even Shakespeare. There are frequent occasions for laughter and applause, such as his frank impatience with newer versions of the Hippocratic Oath, with their vague abstractions about “serving humanity” and hints of self-absorption (“I ask that my colleagues be attentive to my well-being, as I will be to theirs”). His prescription for the confused graduating medical students — enough with the New Age oaths, get to work learning the lessons of medicine in its day-to-day practice — is vintage McHugh. “They would do better to proceed in the service of the sick and so discover, during their quest to do that well, the ideals underlying the practice of medicine.” Similarly, his essay on Terri Schiavo — perhaps the best ever written on the subject — takes us to the bedside of Mrs. Schiavo. Here there is no morbid dwelling on her condition, nor a search for “solutions” to her “problem,” but concrete thoughts on caring for the impaired, the limits of medicine, and the misguided temptation toward full self-possession in the myth of the “good death.” Perhaps the one essay that misses the mark is his New England Journal of Medicine article on the “clonote,” a neologism for a human embryo produced by somatic cell nuclear transfer. Confusing the manner of a being’s origins with the reality of a being’s nature, McHugh argues that making and destroying cloned embryos is morally permissible, while destroying IVF embryos is not. The argument, unlike nearly everything else in this collection, is entirely unconvincing. But overall, one is left deeply impressed by Dr. McHugh’s combination of measured and lucid rendering of complicated ideas, sound judgment, and persistent good humor — all marks of a fine teacher.

This comes through in the genius of McHugh’s title, taken from a poem by Gerard Manley Hopkins. The mind has mountains: peaks which afford both broad vistas and impediments to our view. The metaphor captures the grandeur of the mind, but also suggests there may be inherent limits to our understanding of it. McHugh’s book serves as a cautionary tale, but one told with optimism. It recounts some of the recent history of psychiatry, with an emphasis on how things can go wrong, but also on how we can get things right if we recognize the limits of what we do and do not know. It is a story of possibility, but one that encourages the reader to be skeptical of grandiose claims about man’s understanding of the mind. The need for caution is hardly a thing of the past. It is only a matter of time, I fear, before my own field of neurology falls prey to the sorts of misadventures psychiatry has suffered. It is not just that neurology’s insistent materialism obviates the essential freedom of man, or that we too often take our cues from monkeys and tadpoles. Rather, because the mind is so closely linked to our identity, the temptation to reshape human nature will almost certainly express itself in part via the increasing capacities brought about in neuroscience.

As a guard against this temptation, McHugh’s book serves as a model for a kind of thinking that was once medicine’s bread and butter. This is the virtue of practical wisdom, the deliberative faculty which seeks out the good in our daily lives. It is a virtue that takes its bearings from daily life as it is lived and experienced in the flesh by whole human beings. This is the virtue that makes possible a second major concern of the book: exploring the larger ends of medicine in the face of our growing technical power and expertise. One suspects that McHugh is fortunate in his Catholic upbringing here. Such a mind is used to and undaunted by conflicts: reason vs. revelation, philosophy vs. theology, Athens vs. Jerusalem. He lacks the radical skepticism that marks so much of modern thought and modern science in particular, moving easily between fields as one who is accustomed to competing claims to the truth. He also has a nose for nihilism — especially the attempt to explain the high in terms of the low — however benign its appearance. McHugh’s is a lively mind well worth knowing, and this collection of essays serves as an excellent introduction.