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The Big Question

Paul McHugh, psychiatrist-in-chief at Hopkins from 1975 to 2001, is now a professor of psychiatry. His new book, The Mind Has Mountains (JHU Press, 2006), describes his experience of creating a "community of inquiry" at Hopkins and, he says, "some of the adventures on the way."
Photo by Sam Kittner

Q: Do Psychiatrists Need to Have Their Heads Examined?
A: "Although I would not irritate my colleagues with such teasing slang, I do know that many psychiatrists live in a different kind of intellectual community than other doctors. Neurologists, cardiologists, dermatologists, surgeons, pediatricians might best be described as living in a community of inquiry — they develop their practices, attitudes, and opinions through investigation accompanied by a certain dispassionate skepticism, the study of examples, challenging discourse, criticism, lively exchange, and think that mastery of their discipline derives from this approach.

"Psychiatrists tend to belong to a community of belief. They treat and explain human disorders by methods tied to these beliefs. Thus, in the past psychiatrists were taught to believe in the Freudian unconscious and the universality of the Oedipus complex so as to do acceptable psychotherapy. Now they are told to believe in the utility of the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association as the approach to making sense of disorders. With that commitment comes unchallenged support for such conditions as multiple personality and social phobia. Ultimately, belief-driven practice hinders the discipline's progress, therapeutic effectiveness, and mastery of its practitioners. 'You've gotta believe' may work well for a baseball team, but not for a medical discipline.

"About a decade ago, the most pernicious belief was that mental disorders such as anxiety, depression, or anorexia nervosa were all to be understood as being caused by sexual abuse — despite the fact that the patients had no memory of such abuse. The fact was to be 'recovered' in the process of doing psychotherapy. When psychiatrists who held this view were asked to prove that the sex abuse did happen, they rejected these queries, believing that the existence of the symptoms proved the sex abuse.

"This was not a trivial mistake. It swept over many psychiatric centers in America and was a destructive force in family life and now a huge embarrassment to the profession.

"Today, the belief mantra is disorders such as anxiety, depression, etc., represent expressions of post-traumatic stress. Trauma certainly produces mental unrest, but we are now being asked to believe that mental disorders with their own causes are produced by it.

"In 1975, I was made director of the Psychiatry Department with the purpose of transforming it into a community of inquiry. That's been the mission — to turn 'You've gotta believe' into 'You've gotta know.'"

Return to April 2006 Table of Contents

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