Do No Harm: Q&A with Paul McHugh

Author of “Try to Remember”

by Aalok Mehta

November 10, 2008

In the mid-1990s, some psychiatrists seemed to forget the Hippocratic Oath as they oversaw an “epidemic” of serious and devastating allegations of childhood sexual abuse and satanic cult worship, says Paul McHugh, a prominent professor of psychiatry at the Johns Hopkins School of Medicine. Often with no evidence to support them, psychiatrists would prescribe suggestive treatments that dredged up false memories and multiple personalities, sundered daughter from father, sent innocent men to jail and wreaked widespread financial and social ruin, he says.

Author Paul R. McHugh, M.D. - Feature Image
Paul R. McHugh, M.D. 
McHugh outlines his leading role in fighting—and eventually winning against—this recovered memory movement in the Dana Press book Try to Remember: Psychiatry’s Clash Over Meaning, Memory, and Mind. But as he points out in this Q&A with Dana journalist Aalok Mehta, psychiatry is beginning to repeat its mistakes, and both the public and the medical community should take heed of why things went so badly awry 15 years ago.

AM: Why did you write this book?

PM: The problem was that although psychiatry in the 1970s and early ’80s had moved away from thinking in terms of hidden causes for mental disorders, particularly hidden conflicts as Freudian theory held, these new Freudians concluded that in fact the conflicts were still the generative sources of mental disorder.

Recovered memory disorders and multiple personality disorders were being generated by these people’s ideas about patients rather than being natural occurrences. From a number of cases, I could demonstrate that these were misdirections of conception and therapy. I wanted to try to explain how that came about, what should be done about it, how it fit into other ways of thinking about psychiatric matters and how even today in conditions like post-traumatic stress disorder (PTSD) you can see this reappear.

In what ways do you think the book is controversial?

It’s making a number of statements about the direction psychiatry is taking. It is saying that psychiatry is moving away from conflict-oriented psychotherapy towards cognitive behavior psychotherapy. That’s the first way.

The second way is saying the Freudian era really is over.

And finally it’s saying that the classification system we’re using now in psychiatry played a role in generating this error and needs to be replaced. That’s also very controversial.

How did you become so involved in this topic, both on a judicial level and a clinical level?

It quickly became clear that opposing it locally wouldn’t do much; that I had to write about it and join others who were involved in it in order to put an end to what I thought was a terrible misdirection of my discipline.

I had a very important position at the time—I was chairman of the Johns Hopkins department of psychiatry—and it was my responsibility to put things aright. Here was something that was devastating families and growing in influence, and I couldn’t stand around and ignore it. I think I wrote the first paper actually calling attention to this misdirection, in the American Scholar back in 1992.

I also felt that this kind of thinking about psychiatric explanation had once disappeared. Now it had reappeared in a new guise, and I wanted to play a role in reminding people just what proper scientific psychiatry should be like.

Why do you think this problem resurfaced?

I don’t have a complete explanation, but I can tell you that there were several themes that were in play. One of the most important themes was the idea that psychiatry was neglecting the role of the unconscious in generating mental disorder as we’d moved away from Freudian thinking. Many psychiatrists felt that we were impoverishing our field, and they wanted to reinvigorate the idea that unconscious conflict was the explanation of many mental illnesses.

Secondly, in this case was the concept related to the contemporary [thinking] that children and other people, particularly women, were being abused by men, even in the most respectable families.

And thirdly, I think it was very, very exciting to see people act in multiple personality ways. It was very dramatic and provoked enthusiastic responses on the part of spectators.

Do you think this incident irreparably harmed the perception of psychiatry?

I don’t know whether it was irreparable, but it certainly did great damage to psychiatry’s reputation that some of the most distinguished institutions in our country could fall into this trap and slander good families out of theory about psychiatric matters.

I think the second thing that did great harm to our discipline was the fact that the discipline itself didn’t correct this. The theory and its practice continued until there were major lawsuits, so that the courts rather than the profession put an end to this.

And it made people of good judgment shy away from psychotherapy. Probably people who needed psychotherapy avoided it because they saw that this kind of misdirection could be generated.

But you still believe psychotherapy is extremely helpful, and these cases were just a failure of its application?

I think psychotherapy is extremely helpful. I do it. And I believe that moving in the direction of cognitive behavior psychotherapy is a real positive. We’re moving towards working to help people with deficits in their thinking rather than resolving some hidden conflict as psychotherapy. I think that all needs to be explained to patients.

The mystery has to be taken out of this field so people can approach psychiatry the same way they approach medicine, surgery or pediatrics. Understanding how psychiatrists think and work and what to expect from them in the future, that’s what is coming now. It will improve the reputation of the field and make people much more comfortable and ready to come into psychotherapy when they need it. And plenty of people do.

You’ve talked about cognitive behavioral therapy. Do you think there is also a role for psychoanalysis?

Conflict-focused psychotherapy [such as psychoanalysis] is useful in those people in whom you can really and truly demonstrate that there is a conflict in relationship to their upbringing. But I no longer believe in trolling in the unconscious in search of some conflict as though there must be one there if there are conscious mental problems. I don’t think that’s worthy anymore, and I think not only has it proven to be replaceable by cognitive behavior psychotherapy, it has produced this misdirection that we have here in recovered memory but I also think in PTSD.

So is there any such thing as recovered memory syndrome?

Of course there is such a thing. But it turns out that it’s an artifact. It’s generated just like multiple personality—it exists in relationship to the generative powers of the therapist that produced it. It exists just the same way as the Salem witches existed. It does not exist in nature.

PTSD is a topic that has been in the news a lot because of the Iraq conflict. What are some of your concerns about the disorder?

For a number of years we’ve generated the idea that every psychological problem that afflicts someone in the service or in harm’s way must be PTSD, and not only that, we have got the idea that many of these patients don’t even know that they have a PTSD syndrome and we need to draw out for them the kind of traumas they underwent. That’s why I think they’re producing artifactual PTSD.

In contrast to multiple personality, though, I think PTSD does exist. It exists in the same way as grief exists or homesickness exists. These are emotions of adjustment. But primarily again because of political reasons, we are amplifying all the psychological problems. They’re building up a big story around it and making it fundamentally an unconscious conflict.

You’ve also outlined several historical cases of hysteria where this sort of abuse of psychiatric power has resulted in what are essentially false diseases. Is this likely to continue?

Well, that’s one of the reasons for writing this book. It is intended to say that a very large number of these historical events and some of the events we’re talking about in the present were generated primarily because of the ignorance of the public about what psychiatry can do and what it can’t do. I believe if we get a much more sophisticated public, we will have much less of this kind of abuse of psychiatric authority and power.

In your book you expressed some concerns about the way psychiatric disorders are classified and diagnosed.

I’m saying in the book that because we now emphasize symptoms and symptoms alone as our diagnostic criteria, the Diagnostic and Statistical Manuals (DSM) III and IV  opened up the possibility for people to apply their recovered memory theory to it.

As long as you said all psychiatric disorders could have any cause and the only thing that will be used to differentiate them will be the symptoms they show, then that’s an open door for anyone to come along and say, well, I think the reasons for these kinds of symptoms is a recovered memory of conflict. There’s nothing that would hold people back from saying I produced several personalities in these patients, so they must exist in the same way as anything else exists in DSM.

If it weren’t for the fact that we have given up on anything supernatural, you could put witches in the DSM III and IV.

 We don’t have as good an understanding of the basic physiology behind many of these disorders. Is it possible to treat psychiatric disorders the same as other medical disorders?

Yes it is, as long as you begin to reorganize your psychiatric conditions into the things that can be explained by neurophysiology [and] the things that can’t be explained by neurophysiology.

This idea that somehow psychiatric classifications have to wait until we have evidence all the way down to carbon, nitrogen and hydrogen didn’t happen in medicine, and it doesn’t have to happen in psychiatry. Remember, we treated and ended the cholera epidemic long before we understood the cholera bacillus. This idea that all of medicine waited until we completely understood at the molecular level the nature of disease is wrong.

A lot of people are suspicious about science and technology, especially as it becomes harder to understand. Do your experiences offer any lessons about the misuses of scientific authority?

I wanted more science rather than less science involved. I think the problem with the recovered memory thing was not that there were scientists that were using their authority to abuse patients, like in the Tuskegee experiments. These were people who had very little understanding of science who had the cloak of mystery that psychiatry had gained from Freud and used that cloak and the authority it gave them as gurus to misdirect patients that came to them.

I say the more science, the better. I think it is my job as a doctor to explain the contemporary science to the patient. I don’t expect the patient will necessarily be completely up to speed on all the scientific matters, but I think I can explain it to them—and should explain it to them—in a way that they can comprehend.

Have you had problems stemming from your views on psychiatry?

I don’t think I’ve had difficulties. It’s hard to make difficulty for the Henry Phipps Professor of Psychiatry at Johns Hopkins—he’s pretty safe. But do I have people who tell me I’m dead wrong and that they disagree with me and they’re not sure I’ve done good? Yeah, I’ve had people say that.

Why did you decide to write this book now?

I thought that earlier the issues and the contentions had not really completely settled out enough, so I waited until the heat of battle had quieted down. But as well I thought that the other books that had been written on this subject were by scientists, and I thought what was needed now was a clinician to describe to how the problems emerge, because they don’t emerge in the laboratory—they emerge in a clinical office.

Who do you hope will read your book, and what do you hope they will get it of it?

Well, I hope that the general public will read the book, and learn from it not only the history of this era in the field and how it came about, but learn a bit about how to approach psychiatrists, how to expect psychiatrists to respond to them and to become in a sense better consumers of psychiatric teaching and practice.

I also hope other people will read the book because of the adventure that tells the course of psychiatric development. I think it’s hard to be boring about psychiatric matters, and in this area the drama of everything from the presentation to the courtrooms to the display of personalities, I hope they find it a good read.