If the best mind doctors of the 20th century have, at last, outlived psychiatry's magical times and the tyranny of ideologues, then the future will be far kinder to Paul McHugh.
The pugnacious Bostonian is characteristically optimistic.
As chief of Psychiatry at The Johns Hopkins Hospital, McHugh recently passed the high-water mark of a thrillingly public, often contentious career-long campaign against psychiatric pomp and doctrinal influences. Never one to shrink from skewering the cults of Freud and Jung or bow to the post-modern cant of an amorphous discipline, he is at the crest of his profession. The controversies he once embraced have now left him thriving at a new level of eminence.
Two weeks ago, the Department of Psychiatry hosted a two-day conference in his honor, attracting financial donations totaling more than $1.76 million from friends, colleagues and alumni to create the Paul R. McHugh Chair in Psychiatry. In time, the endowment will support a position devoted to research in "motivated behaviors," including eating, sex and drug addictions. At the event, it was announced that McHugh, the Henry Phipps Professor of Psychiatry, has been named University Distinguished Service Professor.
Acclaimed author Tom Wolfe attended the fete, having just dedicated his best-selling novel, A Man In Full, to McHugh. Joseph Epstein, essayist and former editor of The American Scholar, echoed sentiments heard throughout the two-day event, calling McHugh "a manic impressive" because of his extraordinary flow of energy. Wolfe, who claims the psychiatrist pulled him out of a disastrous depression so he could complete his novel, commended the man's "voice and laugh and personality," but made particular note of his "extraordinary kindness."
As the world beyond the university awakens more fully to the contributions of a psychiatrist who has been perhaps the most vocal proponent of the profession's redemption into rationalism, McHugh expressed no desire to slow down or moderate his efforts. To the contrary, after 30 years in psychiatry, he indicated that he will continue to toss the gauntlet down, challenging the profession to shape up, to be more structured and more coherent.
One of his goals remains to use his position at Hopkins as a soap box, encouraging the field "to drive error out."
A few days after the "McHugh celebration," reflecting on the arc of change across the past three decades, he noted that psychiatry has, at times, been so malleable that essentially "it could go almost anywhere if somebody spoke well enough."
The lack of definition and structure in the discipline has occasionally left it captive to irrational ideas that led psychiatrists to follow their own salvationist impulses, regardless of good sense or regard for the discipline's foundation in science. In particular, McHugh has condemned the practice of sex reassignment surgery, the untested acceptance of "recovered memories" and multiple personality disorders, the dangerous influence of Jack Kevorkian and the tragic, massive "liberation" from hospitals of masses of psychologically impaired people who eventually became America's most desperate population of homeless people.
"At Hopkins, our department has said, 'Look, this is the way medicine used to be in more magical times," he observed. "Prior to the scientific approach in medicine, everyone talked about the flow of humors; all illnesses were humoral: too much black bile, too much hot bile, too much of some other kind of bile. Disease was all of one kind--an imbalance of humors. Well, the same thing happened to psychiatry. At one time it was all about how you felt about your sexuality, or all the way you dealt with power, or all the way you dealt with archetypes, or all the way you've been trained or conditioned in life.
"Without developing a more explicit structure--without saying, Now, listen, we have to be more coherent in how we know what we know and how we claim to know what we know--we just won't be able to drive error out. That's the real problem with psychiatry. You have to differentiate between cause and effects, between symptoms and syndromes, between observations and interpretations.
"Medicine has the autopsy and the laboratory to confirm its opinions. But since there is nothing of the sort in psychiatry--the mental life is only mysteriously connected to the body, so we can't rely entirely on biology--our discourse must be much tougher before forming an opinion."
When he first came to Hopkins in 1975, McHugh inherited a department enervated by disunity and flagging spirits. The confusion, reflected throughout the field, only stimulated the young doctor. The department became a test bed for ideas about structuring the discipline that had stirred in his mind since he had graduated from Harvard Medical School.
By 1983, he had produced a blueprint for reengineering psychiatry, which he published with colleague Philip Slavney, titled The Perspectives of Psychiatry. A reviewer for the New England Journal of Medicine commented that the book illuminated the discipline more clearly than anything previously written.
"Our department stepped up and said, 'We want to offer a structure to this discipline,'" McHugh said, crediting his students and colleagues at Hopkins rather than taking personal notice for the work. "We needed a structure that would make sense in treatment, that would provide differential diagnosis and expand our understanding of the commitment to research. We said, 'Sure, it's true that some of our problems are due to our sexuality. Some of our problems are due to power. Some people have trouble with their biochemistry. But psychiatry must differentiate them according to the nature of the disorder and then treat them rationally. Rational treatment will come from understanding how disorders have fundamentally different natures. And in that way, psychiatry will be more like medicine.'"
Over the years, McHugh not only commandeered a restructuring of the discipline at Hopkins, but he also published trenchant, occasionally sassy essays in The American Scholar and elsewhere that forced psychiatrists to reconsider questionable practices and conceptual errors that denigrated the profession and damaged patients' lives. Under such titles as "Psychiatric Misadventures," "Psychotherapy Awry," "The Kevorkian Epidemic" and "Hippocrates a la Mode," he earned a reputation as psychiatry's H.L. Mencken. He persistently used his platforms to tweak colleagues for lashing themselves to trends and for giving in to what he called "thralldom to the gusty winds of fashion."
The backlash against him has, at times, been ferocious. His critiques have been labeled simplistic, narrow-minded, facile, self-serving and hysterical. When one of his pieces was included in a collection of The Best Essays of 1993, his notoriety spread. The venomous nature of personal attacks that resulted sometimes caught him off guard.
"It was wild," McHugh recalled. "I'd say, 'You know, I think when you accuse a man or a woman of sexually abusing somebody 30 years ago and that claim came out during hypnosis, that sounds like witches to me--and by the way, you ought to try to prove it before you make the accusations public.' And the response would be either, 'Dr. McHugh must be abusing children,' or 'Dr. McHugh must be defending some pedophile.' They would say, 'He hates women ... he hates children.'
"I'd think, my gosh, here are all these people who don't know anything about me accusing me of such awful things--where is that coming from? I didn't lose sleep over it, but it was illuminating to me about what it must be like to stop a lynch mob. You know, if you want to stop a lynch mob, you better bring an army and be in a good, strong position to do it."
As it so happened, McHugh said, "Well, it turned out, I'm in a pretty good position."
Today, he sees changes taking place in psychiatry that he had hoped for specifically at Hopkins 20 years ago. A new edition of The Perspectives of Psychiatry was just re-released a couple of weeks ago by The Johns Hopkins University Press, and his most notable essays have been compiled privately by the medical school. Ideology is dead; empirical reasoning is celebrated. And he is preparing to write his own history of the struggle.
At the cusp of the next decade, McHugh happily predicts that psychiatry is primed for a revolution. In the 21st century, he says, the field will look more like a science infused with Enlightenment values than with post-modern philosophies that often dimmed its vision in the past.
The fact is, he is passionately convinced that human beings are not fundamentally irrational creatures, as the post-modernists believed, but fundamentally coherent and rational. "The challenge for psychiatry," he said, "is to differentiate how, at different times, different people are thwarted in their capacity to use their reason. And let's not think of the incapacity as fundamental to humankind, but really the result of impositions made upon people that we as psychiatrists can, in an enlightened way, free them from."
It's no wonder that during the recent celebration, university president William R. Brody said McHugh "epitomizes the Hopkins ideal of the triple threat: doctor, researcher and teacher."
Add to that "field commando," and the list is complete.
"You know, I have the best chair in American psychiatry," McHugh said recently. "So if you've got this position, you're supposed to talk. Especially if you think the field is going awry, you're supposed to speak up. I don't want somebody 30 years from now to write about our history and say, 'Gosh, there were all these horrible things going on like lobotomies and sex-change operations and this guy McHugh, he had a most important job but he was silent, he was doing his own thing while patients were being hurt and the reputation of psychiatry was being destroyed. I would much rather have them say he took a number of positions about fads and fashions, and his batting average was such-and-such. That's what I'd like them to say--"He was out there swinging.' That's why Johns Hopkins hired me, and that's what I've done.
"Now I just want to continue to try to correct the errors that I've made and persuade the rest of America to look at things my way. I want to be engaged in an active, progressive discipline so we're all smarter a year from now than we are this year. Smarter. Fewer mistakes. Driving error out. That's what everybody in my department is trying to do."