Source URL: http://www.lhup.edu/~dsimanek/mchugh.htm

Psychiatric Misadventures
by Paul R. McHugh

I.

_PSYCHIATRY IS A RUDIMENTARY MEDICAL ART._ It lacks easy access to proof of its proposals even as it deals with disorders of the most complex features of human life--mind and behaviour. Yet, probably because of the earlier examples of Freud and Jung, a belief persists that psychiatrists are entitled to special privileges-that they know the secret of human nature--and thus can venture beyond their clinic-based competencies to instruct on non-medical matters: interpreting literature, counselling the electorate, prescribing for the millennium.

At The Johns Hopkins University, my better days are spent teaching psychiatry to residents and medical students. As I attempt to make clear to them what psychiatrists actually do know and how they know it, I am often aware that I am drawing them back from trendy thought, redirecting them from Salvationist aspirations toward the traditional concerns of psychiatry, which is about the differentiation, understanding, and treatment of the mentally ill.

Part of my justification for curbing my students' expansive impulses is that they have enough to learn, and several things to unlearn, about patients. Such sciences as epidemiology, genetics, and neuropharmacology, which support and surround psychiatry today, are bringing new power to our practice just as science did for internal medicine and surgery earlier in this century. Only those physicians with critical capacities--who see the conceptual structure of this discipline and can distinguish valid from invalid opinions--will be competent to make use of these new scientific concepts and technologies in productive ways. I want my students to number among those who will transform psychiatry in the future.

But my other justification for corralling their enthusiasms is the sense that the intermingling of psychiatry with contemporary culture is excessive and injures both parties. During the thirty years of my professional experience, I have witnessed the power of cultural fashion to lead psychiatric thought and practice off in false, eve disastrous, directions. I have become familiar with how these fashions and their consequences caused psychiatry to lose its moorings. Roughly every ten years, from the mid-1960s on, psychiatric practice has condoned some bizarre misdirection, proving how all too often the discipline has been the captive of the culture.

Each misdirection was the consequence of one of three common medical mistakes--oversimplification, misplaced emphasis, or pure invention. Psychiatry may be more vulnerable to such errors than other clinical endeavours, given its lack of checks and correctives, such as the autopsies and laboratory tests that protect other medical specialties. But for each error, cultural fashion provided the inclination and the impetus. When caught up by the social suppositions of their time, psychiatrists can do much harm.

II.

The most conspicuous misdirection of psychiatric practice-- the precipitate dismissal of patients with severe, chronic mental disorders such as schizophrenia from psychiatric hospitals-- certainly required a vastly oversimplified view of mental illness. These actions were defended as efforts to bring "freedom" to these people, sounding a typical 1960s theme, as though it were not their illnesses but society that deprived them of freedom in the first place.

There were several collaborators in this sad enterprise-- prominent among them the state governments looking for release from the traditional but heavy fiscal burden of housing the mentally ill. Crucial to the process were the fashionable opinions of the time about society's institutions and, specifically, the oversimplified opinions about schizophrenia and other mental illnesses generated by the so-called "anti-psychiatrists": Thomas Szasz, R. D. Laing, Erving Goffman, Michael Foucault, and the rest. These men provided an acid commentary on psychiatric thought and practice, which in turn eroded confidence in the spirit of psychiatric concern for the mentally ill that had previously generated, and regularly regenerated, advocacy on the part of mainstream psychiatry for their welfare. This traditional concern had lasted for more than 120 years in America, or ever since the 1840s crusades led by Dorothea Dix to provide professional services and humane conditions for the mentally ill.

The "anti-psychiatry" school depicted mental institutions as medically useless, self-serving institutions run for the management, and quite unnecessary for patients. These commentators scorned social attitudes about the mentally ill and the contemporary psychiatric practice, but not one of them described the impairments of mind in patients with schizophrenia, manic-depressive illness, or with mental retardation or senility. Data about these impairments were what Dix and an enlightened public came to emphasize when founding psychiatrically supervised, state-supported hospitals. These hospitals rescued the mentally ill from destitution, jails, and the mean streets of cities.

Description of the mental problems of psychiatric patients was not the style of the popular 1960s commentators. They were more interested in painting a picture of their own devising that would provoke first suspicion and then disdain for contemporary psychiatric practices and did so, not by producing new standards or reforming specific practices, but by ridiculing and caricaturing efforts of the institutions and people at hand just as fashion directed. The power of their scorn was surprising and had amazing results, leading many to believe that it was the institutions that provoked the patients' illnesses rather than the illnesses that called out for shelter and treatment.

Here, from Szasz's book, Schizophrenia: The Sacred Symbol of Psychiatry, is a typical comment:

"The sense in which I mean that Psychiatry creates schizophrenia is readily illustrated by the analogy between institutional psychiatry and involuntary servitude. If there is no slavery there can be no slaves.... Similarly if there is no psychiatry there can be no schizophrenics. In other words, the identity of an individual as a schizophrenic depends on the existence of the social system of [institutional] psychiatry."

The only reply to such commentary is to know the patients for what they are-in schizophrenia, people disabled by delusions, hallucinations, and disruptions of thinking capacities-and to reject an approach that would trivialize their impairments and deny them their frequent need for hospital care.

On one occasion in the early 1970s, when I was working at Cornell University Medical Center in New York, a friend and senior member of the biochemistry faculty called me about a medical student who was balking over a term paper because his career plan was to become a champion of the "psychiatrically oppressed." Biochemistry term papers seemed "irrelevant." Could I offer him a project with psychiatric patients that might be developed into a term paper satisfying the requirements of her department? "He's a neat guy," she said, "but he is stubborn about this and full of views about contemporary psychiatry." "Send him over," I said, but I awaited his arrival with some apprehension. I needn't have feared the encounter because, in contrast to many other students of those times, he was not looking for a fight. "It's just that I know what I want to do--understand the people who are isolated by the label schizophrenia--and help them achieve what they want in life. I've written enough irrelevant papers in my life," he said. He had graduated summa cum laude from Princeton, with a concentration i philosophy, so he certainly had placed a large number of words o paper.

"Have you ever seen anyone with schizophrenia?" I asked. "Not in the flesh," he said, "but I think I know what you do with them." "Well," I replied, "I will be glad to have you see one, and let you tell me how to appreciate his choice of an eccentric way of life that he could be released to express it."

I had plenty of patients under my care at the time and chose one who was the same age as the student but who had a severe disruption in his thought processes. Even to talk with him was a distressing experience because few of his thoughts were connected, and all of them were vaguely tied to delusional beliefs about the world, his family, and our society. He wasn't aggressive or in any way threatening. He was just bewilderingly incoherent. I left the student with the patient, promising to return in half an hour to learn what he thought.

On my return, I found the student subdued. I started, in a slightly teasing way, to ask where he suggested I might send the patient to start his new life-but was quickly cut off by the student who, finding his voice, said, "That was nothing like what I expected and nothing like what I've read about. Obviously you can't send this poor fellow out of the hospital. Please tell me how you're treating him."

With this evidence confirming my colleague's judgment of the student's basic good nature in what, after all, had been a heartfelt if inexperienced opinion, we went on to talk about the impairments and disabilities of patients with serious mental illnesses, their partial responses to combinations of medication and psychological management, and, finally, to the meretricious ideas about their treatment that had been promulgated by contemporary fashion and the anti-psychiatry critics without making an effort to examine patients.

The student wrote his biochemistry paper on emerging concepts of the neurochemistry of mental disorders. He buckled down in medical school, and he came, after graduation, to join me as a resident psychiatrist and eventually proved to be one of the best doctors I ever taught. We had overcome something together--all out of going to see a patient, recognizing his burdens, and avoiding assumptions about what fashion said we should find.

A saving grace for any medical theory or practice--the thing that spares it perpetual thraldom to the gusty winds of fashion-- is the patients. They are real, they are around, and a knowledge of their distressing symptoms guards against oversimplification.

III.

The claim that schizophrenic patients are in any sense living a alternative "life style" that our institutions were inhibiting was of course fatuous. It is now obvious to every citizen of our cities that these patients have impaired capacities to comprehend the world and that they need protection and serious active treatment. Without such help, they drift back to precisely the place Dorothea Dix found them 150 years ago.

From the faddish idea of institutions as essentially oppressive emerged a nuance that became more dominant as the 1970s progressed. This was that social custom was itself oppressive. In fact, according to this view, all standards by which behaviours are judged are simply matters of opinion--and emotional opinions at that, likely to be enforced but never justified. In the 1970s, this antinomian idea fuelled several psychiatric misdirections.

A challenge to standards can affect at least the discourse in a psychiatric clinic, if not the practice. These challenges are expressed in such slogans as "Do your own thing," "Whose life is it anyway?" "Be sure to get your own," or Joseph Campbell's "Follow your bliss." All of these slogans are familiar to psychiatrists trying to redirect confused, depressed, and often self-belittling patients. Such is their pervasiveness in the culture that they may even divert psychiatrists into misplaced emphases in their understanding of patients.

This interrelationship of cultural antinomianism and a psychiatric misplaced emphasis is seen at its grimmest in the practice known as sex-reassignment surgery. I happen to know about this because Johns Hopkins was one of the places in the United States where this practice was given its start. It was part of my intention, when I arrived in Baltimore in 1975, to help end it.

Not uncommonly, a person comes to the clinic and says something like, "As long as I can remember, I've thought I was in the wrong body. True, I've married and had a couple of kids, and I've had a number of homosexual encounters, but always, in the back and now more often in the front of my mind, there's this idea that actually I'm more a woman than a man."

When we ask what he has done about this, the man often says, "I've tried dressing like a woman and feel quite comfortable. I've eve made myself up and gone out in public. I can get away with it because it's all so natural to me. I'm here because all this male equipment is disgusting to me. I want medical help to change my body: hormone treatments, silicone implants, surgical amputation of my genitalia, and the construction of a vagina. Will you do it?" The patient claims it is a torture for him to live as a man, especially now that he has read in the newspapers about the possibility of switching surgically to womanhood. Upon examination it is not difficult to identify other mental and personality difficulties in him, but he is primarily disquieted because of his intrusive thoughts that his sex is not a settled issue in his life.

Experts say that "gender identity," a sense of one's own maleness or femaleness, is complicated. They believe that it will emerge through the step-like features of most complex developmental processes in which nature and nurture combine. They venture that, although their research on those born with genital and hormonal abnormalities may not apply to a person with normal bodily structures, something must have gone wrong in this patient's early and formative life to cause him to feel as he does. Why not help him look more like what he says he feels? Our surgeons can do it. What the hell!

The skills of our plastic surgeons, particularly on the genito-urinary system, are impressive. They were obtained, however, not to treat the gender identity problem, but to repair congenital defects, injuries, and the effects of destructive diseases such as cancer in this region of the body.

That you can get something done doesn't always mean that you should do it. In sex reassignment cases, there are so many problems right at the start. The patient's claim that this has been a lifelong problem is seldom checked with others who have known him since childhood. It seems so intrusive and untrusting to discuss the problem with others, even though they might provide a better gage of the seriousness of the problem, how it emerged, its fluctuations of intensity over time, and its connection with other experiences. When you discuss what the patient means by "feeling like a woman," you often get a sex stereotype in return--something that woman physicians note immediately is a male caricature of women's attitudes and interests. One of our patients, for example, said that, as a woman, he would be more "invested with being than with doing."

It is not obvious how this patient's feeling that he is a woman trapped in a man's body differs from the feeling of a patient with anorexia nervosa that she is obese despite her emaciated, cachectic state. We don't do liposuction on anorexics. Why amputate the genitals of these poor men? Surely, the fault is in the mind not the member.

Yet, if you justify augmenting breasts for women who feel underendowed, why not do it and more for the man who wants to be a woman? A plastic surgeon at Johns Hopkins provided the voice of reality for me on this matter based on his practice and his natural awe at the mystery of the body. One day while we were talking about it, he said to me: "Imagine what it's like to get up at dawn and think about spending the day slashing with a knife at perfectly well-formed organs, because you psychiatrists do not understand what is the problem here but hope surgery may do the poor wretch some good."

The zeal for this sex-change surgery--perhaps, with the exception of frontal lobotomy, the most radical therapy ever encouraged by twentieth century psychiatrists--did not derive from critical reasoning or thoughtful assessments. These were so faulty that no one holds them up anymore as standards for launching any therapeutic exercise, let alone one so irretrievable as a sex-change operation. The energy came from the fashions of the seventies that invaded the clinic--if you can do it and he wants it, why not do it? It was all tied up with the spirit of doing your thing, following your bliss, an aesthetic that sees diversity as everything and can accept any idea, including that of permanent sex change, as interesting and that views resistance to such ideas as uptight if not oppressive. Moral matters should have some salience here. These include the waste of human resources; the confusions imposed on society where these men/women insist on acceptance, even in athletic competition, with women; the encouragement of the "illusion of technique," which assumes that the body is like a suit of clothes to be hemmed and stitched to style; and, finally, the ghastliness of the mutilated anatomy.

But lay these strong moral objections aside and consider only that this surgical practice has distracted effort from genuine investigations attempting to find out just what has gone wrong for these people--what has, by their testimony, given them years of torment and psychological distress and prompted them to accept these grim and disfiguring surgical procedures.

We need to know how to prevent such sadness, indeed horror. We have to learn how to manage this condition as a mental disorder when we fail to prevent it. If it depends on child rearing, then let's hear about its inner dynamics so that parents can be taught to guide their children properly. If it is an aspect of confusion tied to homosexuality, we need to understand its nature and exactly how to manage it as a manifestation of serious mental disorder among homosexual individuals. But instead of attempting to learn enough to accomplish these worthy goals, psychiatrists collaborated in a exercise of folly with distressed people during a time when "do your own thing" had something akin to the force of a command. As physicians, psychiatrists, when they give in to this, abandon the role of protecting patients from their symptoms and become little more than technicians working on behalf of a cultural force.

IV.

Medical errors of oversimplification and misplaced emphasis usually play themselves out for all to see. But the pure inventions bring out a darker, hateful potential when psychiatric thought goes awry. The invention of entities of mind and then their elaborate description, usually fuelled by the energy from some social attitude they amplify, is a recurring event in the history of psychiatry.

Most psychiatric histories choose to describe such invention by detailing its most vivid example--witches. The experience in Salem, Massachusetts, of three hundred years ago is prototypical. Briefly, in 1692, several young women and girls who had for some weeks been secretly listening to tales of spells, voodoo, and illicit cultic practices from a Barbados slave suddenly displayed a set of mystifying mental and behavioural changes. They developed trance-like states, falling on the ground and flailing away, and screaming at night and at prayer, seemingly in great distress and in need of help. The local physician, who witnessed this, was as bewildered as anyone else and eventually made a diagnosis of "bewitchment." "The evil hand is on them," he said and turned them over to the local officials for care.

The clergy and magistrates, regarding the young people as victims and pampering them by showing much attention to their symptoms, assumed that local agents of Satan were at work and, using as grounds the answers to leading questions, indicted several citizens. The accepted proof of guilt was bizarre. The young women spoke of visions of the accused, of sensing their presence at night by pains and torments and of ghostly visitations to their homes, all occurring while the accused were known to be elsewhere. The victims even screeched out in court that they felt pinches and pains provoked by the accused, even while they were sitting quietly across the room. Judges believed this "spectral" evidence because it conformed to contemporary thought about the capacities of witches; they dismissed all denials of the accused and promptly executed them.

The whole exercise should have been discredited when, after the executions, there was no change in the distraught behaviour of the young women. Instead more and more citizens were indicted. A prosecution depending on "spectral evidence" was at last seen as capricious--as irrefutable as it was undemonstrable. The trials ceased, and eventually several of the young women admitted that their beliefs had been "delusions" and their accusations false.

The modern diagnosis for these young women is, of course, hysteria not bewitchment. Psychiatrists use the term hysteria to identify behavioural displays in which physical or mental disorders are imitated. The reasons for the behaviour vary with the person displaying the disorder but are derived from that person's more or less unconscious effort to appear more significant to others and to be more entitled to their interest and support. The status of the putatively bewitched in Salem of 1692 brought both attentive concern and license to indict to young women previously scarcely noticed by the community. The forms of hysterical behavior--whether they be physical activities, such as falling and shaking, or mental phenomena, such as pains, visions, or memories--are shaped by unintended suggestions from others and sustained by the attention of onlookers--especially such onlookers as doctors who are socially empowered to assign, by affixing a diagnosis, the status of "patient" to a person. Whenever these diagnosticians mistake hysteria for what it is attempting to imitate-misidentifying it either as a physical illness or inventing some psychological explanation such as bewitchment--then the behavioural display will continue, expand, and, in certain settings, spread to others. The usual result is trouble for everyone.

During the last seven or eight years, another example of misidentified hysterical behaviour has surfaced and again has been bolstered by an invented view of its cause that fits a cultural fashion. This condition is "multiple personality disorder" (MPD, as it has come to be abbreviated). The majority of the patients who eventually receive this diagnosis come to therapists with standard psychiatric complaints, such as depression or difficulty in relationships. Some therapists see much more in these symptoms and suggest to the patient and to others that they represent the subtle actions of several alternative personalities, or "alters," co-existing in the patient's mental life. These suggestions encourage many patients to see their problems in a fresh and, to them, remarkably interesting way. Suddenly they are transformed into odd people with repeated shifts of demeanour and deportment that they display on command.

Sexual politics in the 1980s and 1990s, particularly those connected with sexual oppression and victimization, galvanizes these inventions. Forgotten sexual mistreatment in childhood is the most frequently proffered explanation of MPD. Just as an epidemic of bewitchment served to prove the arrival of Satan in Salem, so in our day an epidemic of MPD is used to confirm that a vast number of adults were sexually abused by guardians during their childhood. Now I don't for a moment deny that children are sometimes victims of sexual abuse, or that a behavioural problem originating from such abuse can be a hidden feature in any life. Such realities are not at issue. What I am concerned with here is what has been imagined from these realities and inventively applied to others.

Adults with MPD, so the theory goes, were assaulted as young children by a trusted and beloved person--usually a father, but grandfathers, uncles, brothers, or others, often abetted by women in their power, are also possibilities. This sexual assault, the theory holds, is blocked from memory (repressed and dissociated) because it was so shocking. This dissociating blockade itself-- again according to the theory--destroys the integration of mind and evokes multiple personalities as separate, disconnected, sequestered, "alternative" collections of thought, memory, and feeling. These resultant distinct "personalities" produce a variety of what might seem standard psychiatric symptoms--depression, weight problems, panic states, demoralization, and so forth--that only careful review will reveal to be expressions of MPD that is the outcome of sexual abuse.

These patients have not come to treatment reporting a sexual assault in childhood. Only after therapy has promoted MPD behaviour is the possibility that they were sexually abused as children suggested to them. From recollections of the mists of childhood, a vague sense of vulnerability may slowly emerge, facilitated and encouraged by the treating group. This sense of vulnerability is thought a harbinger of clearer memories of victimization that, although buried, have been active for decades producing the different "personalities." The long supposedly forgotten abuse is finally "remembered" after months of "uncovering" therapy, during which long conversations by the therapist with "alter" personalities take place. Any other actual proof of the assault is thought unnecessary. Spectral evidence-developed through suggestions and just as irrefutable as that at Salem-once again is sanctioned.

Like bewitchment from Satan's local agents, the idea of MPD and its cause has caught on among large numbers of psychiatrists and psychotherapists. Its partisans see the patients as victims, cosset them in groups, encourage more expressions of "alters" (up to as many as eighty or ninety), and are ferocious toward any defenders of those they believe are perpetrators of the abuse. Just as the divines of Massachusetts were convinced that they were fighting Satan by recognizing bewitchment, so the contemporary divines--these are therapists--are confident that they are fighting perpetrators of a common expression of sexual oppression, child abuse, by recognizing MPD.

The incidence of MPD has of late indeed taken on epidemic proportions, particularly in certain treatment centers. Whereas its diagnosis was reported less than two hundred times from a variety of supposed causes in the last century, it has been applied to more than 20,000 people in the last decade and largely attributed to sexual abuse.

I have been involved in direct and indirect ways with five such cases in the past year alone. In every one, the very same story has been played out in a stereotyped script-like way. In each a young woman with a rather straightforward set of psychiatric symptoms--depression and demoralization--sought help and her case was stretched into a diagnosis of MPD. Eventually, in each example, an accusation of prior sexual abuse was levelled by her against her father. The accusation developed after months of therapy, first as vague feelings of a dream-like kind--childhood reminiscences of danger and darkness eventually crystallizing, sometimes "in a flash," into a recollection of father forcing sex upon the patient as a child. No other evidence of these events was presented but the memory, and plenty of refuting testimony, coming from former nursemaids and the mother, was available but dismissed.

On one occasion, the identity of the molester--forgotten for years and now first vaguely and then more surely remembered under the persuasive power of therapy--changed, but the change was as telling about the nature of evidence as was the emergence of the original charge. A woman called her mother to claim that she had come to realize that when she was young she was severely and repeatedly sexually molested by her uncle, the mother's brother. The mother questioned the daughter carefully about the dates and times of these incidents and then set about determining whether they were in fact possible. She soon discovered that her brother was on military service in Korea at the time of the alleged abuse. With this information, the mother went to her daughter with the hope of showing her that her therapist was misleading her in destructive ways. When she heard this new information, the daughter seemed momentarily taken aback, but then said, "I see, Mother. Yes. Well, let me think. If your dates are right, I suppose it must have been Dad." And with that, she began to claim that she had been a victim of her father's abusive attentions, and nothing could dissuade her.

The accused men whom I studied, denying the charges and amazed at their source, submitted to detailed reviews of their sexual lives and polygraphic testing to try to prove their innocence and thereby erase doubts about themselves. Professional requests by me to the daughters' therapists for better evidence of the abuse were dismissed as derived from the pleadings of the guilty and scorned as beneath contempt, given that the diagnosis of MPD and the testimony of the patients patently confirmed the assumptions.

In Salem, the conviction depended on how judges thought witches behaved. In our day, the conviction depends on how some therapists think a child's memory of trauma works. In fact, severe traumas are not blocked out by children but remembered all too well. They are amplified in consciousness, remaining like grief to be reborn and reemphasized on anniversaries and in settings that can simulate the environments where they occurred. Good evidence for this is found in the memories of children from concentration camps. More recently, the children of Chowchilla, California, who were kidnapped in their school bus and buried in sand for many hours, remembered every detail of their traumatic experience and needed psychiatric assistance, not to bring out forgotten material that was repressed, but to help them move away from a constant ruminative preoccupation with the experience .

Many psychiatrists upon first hearing of these diagnostic formulations (MPD being the result of repressed memories of sexual abuse in childhood) have fallen back upon what they think is a evenhanded way of approaching it. "The mind is very mysterious in its ways," they say. "Anything is possible in a family." In fact, this credulous stance toward evidence and the failure to consider the alternative of hysterical behaviours and memories are what continue to support this crude psychiatric analysis.

The helpful clinical approach to the patient with putative MPD, as with any instance of hysterical display, is to direct attention away from the behaviour--one simply never talks to an "alter." Within a few days of a consistent therapeutic emphasis away from the MPD behaviour, it fades and generally useful psychotherapy on the presenting true problems begins. Real sexual traumas can be dealt with, if they are present, as can the ambivalent and confused feelings that many adults have about their parents.

Similarly, the proper approach to end epidemics of MPD and the assumptions of a vast prevalence of sexual abuse in ordinary families is for psychiatrists to be aware of the potential, whenever we are dealing with hysteria, to mistake it for something else. When it is so mistaken, this can lead to monstrous concepts defended by coincidence, the induction of memories, and a display of "spectral" evidence--all to justify a belief that the community is under siege. This belief, of course, is what releases the power of the witches' court and the Lynch mob.

As a corrective, psychiatrists need only review with a patient how the MPD behaviour was diagnosed and how the putative memories of sexual abuse were suggested. These practices will eventually be discredited, and this epidemic will end in the same way that the witch trials ended in Salem. But time is passing, many families are being hurt, and confidence in the competence and impartiality of psychiatry is eroding.

V.

Major psychiatric misdirections often share this intimidating mixture of a medical mistake lashed to a trendy idea. Any challenge to such a misdirection must confront simultaneously the professional authority of the proponents and the political power of fashionable convictions. Such challenges are not for the fainthearted or inexperienced. They seldom quickly succeed because they are often misrepresented as ignorant or, in the cant word of our day, uncaring. Each of the three misdirections I have dealt with in this essay ran for a full decade, despite vigorous criticism. Eventually the mischief became obvious to nearly everyone and fashion moved on to attach itself to something else.

In ten years much damage can be done and much effort over a longer period of time is required to repair it. Thus with the mentally-ill homeless, only a new crusade and social commitment will bring them adequate help again. Age accentuates the sad caricature of the sexual reassigned and saps their bravado. Some, pathetically, ask about re-reassignment. Groups of parents falsely accused of sexual mistreatment by their grown children are gathering together to fight back in ways that will produce dramatic but distressing spectacles. How good it would have been if in the first place all these misguided programs had been avoided or at least their spa abbreviated.

Psychiatry, it needs always to be remembered, is a medical discipline--capable of glorious medical triumphs and hideous medical mistakes. We psychiatrists don't know the secret of human nature. We cannot build a New Jerusalem. But we can teach the lessons of our past. We can describe how our explanations for mental disorders are devised and develop--where they are strong and where they are vulnerable to misuse. We can clarify the presumptions about what we know and how we know it. We can strive within the traditional responsibilities of our profession to build a sound relationship with people who consult us--placing them on more equal terms with us and encouraging them to approach us as they would any other medical specialists, by asking questions and expecting answers, based on science, about our assumptions, practices, and plans. With effort and good sense, we can construct a clinical discipline that, while delivering less to fashion, will bring more to patients and their families.

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PAUL R. McHUGH is Henry Phipps Professor and Director of the Department of Psychiatry and Behavioural Sciences at the Johns Hopkins University School of Medicine. He is the author (with Phillip R. Slavney) of _The Perspectives of Psychiatry and Psychiatric Polarities._ This article is from The _American Scholar,_ Autumn 1992.

 

 

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