Every age produces its own metaphors. The present age has been marked by a disturbing trend to externalize blame, show signs of brazen arrogance when challenged by opposing views and look to escape into the ephemeral trends and crazes of the day (which shift like the weather) as temporal balm to avoid facing reality. A growing dogmatism currently informs many branches of human knowledge, rather than an enlightened rationality informed by morality, where drama and sensationalism are pushed to their limits. These trends are both common place and disturbing, as they have affected the field of mental health where both therapists and patients alike are more than eager to accept the fads and fashions of the age, as they attempt to distract themselves by seeking refuge in highly abstract and abstruse theories of human nature with the pretence of alleviating human suffering.
These transient solutions to life's challenges, which are part of the human condition and adversely affect many aspects of our current cultural climate, as one observer noted, shape our own identity and in turn tell us about ourselves. Cultural critics from Christopher Lasch to Rochelle Gurnstein, whose books The Culture of Narcissism and The Repeal of Reticence respectively, seem as timely now as when they were first written to characterize the self-absorption and lack of modesty that so dominates public morals and discourse. A recent book called The Narcissistic Epidemic: Living in the Age of Entitlement by Twenge and Campbell seems to suggest that certain attitudes and characterizations of our culture never fully change.
And this brings us to our present challenge where the field of psychiatry and more broadly the psychotherapy arena are influenced by the cultural assumptions of the age. I have to confess that in carefully reading Paul McHugh's recent offering Try to Remember on how a cadre of myopic therapists in the name of promoting mental health in their patients tried to highjack the questionable diagnosis of multiple personality disorder to begin with and turn sufferers into victims and loved ones into alleged predators caught me off guard. The fact that it took so many individuals to come forward after being accused of maltreatment and threatened, in many cases, with lawsuits by their relatives marks one of the saddest chapters in the history of psychotherapy. These accusations of the most egregious types of abuse by primarily their own adult children after years of silence are only part of the larger story of "misdirections" that plagued psychiatry and the practice of psychotherapy in McHugh's personal and firsthand account of this cult like phenomena. I must also admit that this compelling, informative and enlightening book is also a profoundly upsetting and unsettling one. It is inconceivable to think that so much harm can be done to patients, their families, friends and the larger society in the name of human endeavors, like mental health, aimed to ideally ameliorate suffering. Yet, that is part of the problem -- that practitioners, according to McHugh, often portray themselves as all knowing, possessed of special knowledge about the mysteries of life and are not mindful enough that psychotherapy can be a force for good and bad. McHugh is one of this country's preeminent psychiatrists and observers of the human condition.
He writes with the experience of leadership, but tempered by moderation, gained from having been both the Director of the Department of Psychiatry and Behavioral Science at the Johns Hopkins School of Medicine and Psychiatrist-in-chief at the Johns Hopkins Hospital for three decades. However, there are many in the mental health field with impeccable credentials that still lack the means to express their thoughts in a prose that is reminiscent of some of our best essayists, which is profound, witty and accessible to the novice and seasoned reader. What is even rarer in a man of science, like McHugh, is not just the clinical authority he brings to bear on his subjects that comes from having treated a multitude of patients over the course of a highly distinguished career, but an even more uncommon moral sensibility.
In reality the larger ramifications of McHugh's claims starts with his magnum opus, The Perspectives of Psychiatry - a work that has shaped the thinking of generations of psychiatrists and other mental health professionals. In this work McHugh breaks down mental disorders into "four well-defined families", 1) Diseases -- structural/functional injuries to the brain (i.e. schizophrenia, bipolar disorder, dementia), 2) Dimensional disorders -- psychological makeup or constitution of the patient, 3) Behavioral disorders such as alcoholism, eating disorders, multiple personality disorder, and 4) Life Story disorders which can include grief, homesickness, posttraumatic stress disorder and jealousy, to name a few. Diseases are defined by "what the patient has", dimensional disorders by "who the patient is", behavioral disorders by "what the patient is doing", and life story disorders by "what the person encounters". This novel classification system is in marked contrast to the DSM (the Diagnostic Statistical Manual of Mental Disorders which is the so-called bible for classifying mental disorders for students/clinicians in the mental health field) which speaks only about symptoms to meet particular diagnostic criteria. The DSM does not delineate that similar disorders can have different provocations and causes, just like different symptoms can have diverse sources. It is by nature a-theoretical and not geared towards coming up with the etiology of mental disorders. McHugh struggles himself with the DSM, viewing it as an accomplishment in lieu of a single theory driven classification system, but also paving the way for unwarranted diagnoses to enter like the ones to be discussed in more detail to follow just because they manifest in a symptomatic way. McHugh writes, "In deferring to 'experts' for their diagnostic criteria, the authors of DSM-III had to put their trust in two things: first, that the 'experts' really did know the symptomatic identifying features of a disorder, and second, that the disorder the 'experts' described really did exist as they believed". He adds that, "By organizing disorders according to symptomatic 'appearances' the authors of DSM-III/IV (whether they realized it or not) produced a field guide indistinguishable from field guides used by naturalists". Yet, McHugh's book, rather than the DSM, served as a guide to my own conceptual entrance into the mental health field and has continued to help me and others in the field look past "the appearances of things" in order to confirm clinical acumen with evidence to support one's diagnostic conclusions. It is a challenge, but not an insurmountable one, to honestly read Try to Remember without this earlier and seminal work in mind.
Psychiatric Polarities, a sequel to Paul McHugh's earlier work The Perspectives of Psychiatry is another foundational text that gives the interested reader added context and weight to McHugh's armamentarium and the overarching purpose of psychiatry and its place in society. This work addresses several of the inherent tensions in the psychiatry field, the most salient being the brain/mind problem and the ongoing factionalism between feuding enclaves. The book is highly philosophical, but provides a backdrop on how important the need for balance is in the psychotherapeutic enterprise as measured by the Hebraic vision with its emphasis on the particular person (not an ideal, but actual individual) and active moral engagement with others, combined with the need for detachment so emblematic of the Hellenistic approach to life. These elements in the right balance are what shape the competent and compassionate therapist and certainly inform McHugh's worldview. Much of this balance and perspective is lacking in those therapists and their treatment of patients discussed in Try to Remember. They justify their own version of therapy without the actual real live patient's welfare kept as sacrosanct or the openness to others views as part of the corrective so central to the therapeutic process.
So why all the cultural digressions and asides in a book review on Paul McHugh's newest publication Try to Remember? First, historical and cultural substrates shape all human endeavors including psychiatric practice, and this author's encounters with McHugh's works over the years have given me no reason to think that his claims, like his detractors argue, are "strong on opinion and weak on evidence". Second, Try to Remember has been a book that has elicited a great deal of controversy given its delicate subject matter and due to McHugh taking on some of the established pieties and orthodoxies (albeit in reality crazes and fads/fashions currently still in vogue) in psychiatry and psychotherapy. In other words, there has been a blatant arrogance and "culture of suspicion" created in mental health for decades (most notably dating back to Freud's original contributions/ascendency in the 1950's in academic circles and continuing in veiled disguises of current offshoots in select psychoanalytic circles).
McHugh's biggest axe to grind in Try to Remember is his taking on not only the diagnosis of multiple personality disorder (MPD), which he accurately labels a "social artifact" (that is a behavioral disorder akin to hysteria), but challenging its validity as a legitimate mental disorder based on empirical evidence into how the mechanics of memory actually work and the misguided attempts of a herd of overly doctrinaire and close-minded therapists to push forward unsubstantiated claims of victimhood. McHugh asserts that, "Certain disorders -- one of them being MPD are artifacts constructed by enterprising advocates". He rightfully refers to this particular brand of advocates/analysts as "Manneristic Freudians". This label is based on their desire to mimic the master's genius for understanding psychopathology from the vantage point of a single causation model. However, they expanded on Freud's notion of sexual conflict as the harbinger of most mental illness for their patients' past and ongoing distress, and replaced it with "actual sexual abuse". MPD, according to this view, was brought on by memories of these incidences buried deeply in the recesses of the unconscious via defense mechanisms of repression due to betrayal by significant others early in life and only manifest by elusive processes of dissociation. In eliciting the assistance of the late Martin Orne and memory experts Drs. Richard McNally, Elizabeth Loftus, and Richard Ofshe, McHugh came to the conclusion, based on empirical support by his colleagues that MPD is induced by hypnosis, highly suggestive psychotherapy, heavy doses of mind altering medications such as benzodiazepines, the desire of the patient to be accepted by clinicians in positions of authority as "ill" and linear causation (i.e. only A causes B) for varied manifestations of human distress. This is all aimed to bring out the "alters" (the multiple personalities geared toward helping the host/traumatized main personality recover from the abuse). Empirical studies on memory seem to contradict what the Manneristics report about the workings of repression and dissociation. Individuals that experience trauma and abuse do not have to try and remember, as they do not forget these events unless some type of brain injury, infantile amnesia before the ages of 4-5 or fading (not forgetting of memory) occurs with advancing years or the elapsing of time. Holocaust survivors and war veterans do not report the loss of memories, rather they consciously desire to either avoid talking about it because it is painful and/or they do not feel it will bring any relief from suffering. McNally confirms the idea that the mind does not drive trauma from recall by stating, "The notion that the mind protects itself by repressing or dissociating memories of trauma, rendering them inaccessible to awareness, is a piece of psychiatric folklore devoid of empirical support". Yet, McHugh does sound a cautionary note, "In the battles over false memory syndrome, none of us was claiming that child abuse does not happen. We were claiming that accusations of child abuse derived from suggestive psychotherapy had to have more support than the plausibility of the therapists or the compelling stamp of emotional displays".
Yet, with the evidence behind him from investigative scientists in what became known as the "memory wars" and the founding of a support group for those allegedly accused of abuse (called the False Memory Syndrome Foundation (FMSF)), it was not until the courts, rather than well established psychiatric institutions and journals took up the fight for families torn asunder by false memories. One of the ironies of this internecine feud between McHugh and his proponents and the Manneristic Freudians, is that the latter not only co-opted Freud's conceptions of sexual conflict into actual sexual abuse, they infected many other clinicians into believing their unsupported claims leading to a literal epidemic of false memory alarms and what McHugh calls "social madness". The contagion effect that occurred from these analysts with supposed outstanding academic pedigrees and inhabiting leading positions/citadels in academia and specialized treatment centers for MPD, misleading the neophytes down the wrong road, exacted an enormous and immeasurable human toll. To this day, in spite of financial settlements that at least implied sub-standard practice and even wrong doing by those who were treated by the Manneristic Freudians and those accused of abuse, this non-remorseful group of elitists have shifted their attention to other areas. One of these areas is the movement away from MPD to Posttraumatic Stress Disorder (PTSD), where a model of being a victim can still be maintained with the replacement of sexual abuse to the more generic and socially acceptable term called "trauma". Yet, trauma is often a part of life and once again Paul McHugh feels its overdiagnosis and being placed in a separate diagnostic category gives the Manneristics Freudians the benefit of using a politically correct title "traumatologists" to further their ongoing commitment to repression and similar unfounded claims about memory and trauma. According to McHugh and his evidence-based supporters, "These actions all served to call attention to their new goal of treating the various forms of PTSD and reconstituting minds shattered by 'traumatic memories'". In many ways their agendas have now shifted to give the same level of legitimacy to PTSD, as they had in their treatment of MPD. McHugh writes the following regarding PTSD, "PTSD is not a separate 'entity' or 'malady', but a natural emotional response provoked by frightening events and varying in intensity from patient to patient depending on several factors". He also adds, "PTSD is not a disorder of memory, nor is it caused by some failure of memory. Rather, with its symptoms of fear and dread, it is one of the normal emotions of adjustment".
The critics still abound, as patients in turmoil led by therapists who continue to look for the holy grail -- that is a single cause to what is much more often a confluence of factors that contribute to mental disorders - become frustrated that therapy ideally should be focused on the here and now and address present life circumstances. The past has its place in therapy and clearly abuse and trauma can cast long shadows for some, but the subjective reports of patients and collusion of therapists without empirical support of some kind, according to McHugh, can make all of us vulnerable to accusations of being abusers without due cause. This has been referred to by McHugh as the "unfettered imagination", where theories are insubstantial, imagination is given too central a place and responsibility is surrendered. Whether one is a behaviorist, psychodynamic or pharmacologically inclined is beside the point, as McHugh writes about his tenure at Johns Hopkins, "I did not expel anyone from the conversations. I didn't stop anyone from presenting ideas, and in particular I didn't eliminate any theories, such as Freudian psychoanalysis or Skinnerian behaviorism, from being taught in these places. I just began to ask all practitioners to explain, with each patient they presented at rounds, the basis for their options so that everyone could decide whether that foundation was really as strong as was claimed or as appropriate to the matter at hand".
However, these were the early years at Johns Hopkins for McHugh and with the MPD craze, the over diagnosis of PTSD and its questionable place in the DSM, McHugh began to realize that for psychiatry and psychotherapy to regain coherence and the public's trust again, therapies with greater empirical support (that is evidence-based), such as Cognitive-Behavioral Therapy (CBT) needed to take center stage. Cleary, CBT has passed the litmus test of being the most empirically supported psychotherapy, but there are many versions of CBT and no one size fits all. In my own experience as a clinician and researcher, therapists now have the added benefits of looking to many "CBT hybrids" that integrate the best of CBT with components of other approaches. This is not the place for an extended discussion of all these diverse models and approaches. However, the advantages of using CBT as a first line treatment are manifold. First of all, the treatment has a psycho-educational piece (roles and goals of the treatment are made explicit). It is collaborative, structured, goal-oriented, relatively brief, focuses on modifying unhealthy cognitions, emotions and behaviors in the present and ultimately helps the patient self-discover on their own what needs to be corrected by weighing the evidence. McHugh accurately writes, "No one is 'the master;' both are working to make sense of circumstances and to find ways of responding that can relieve the feelings of demoralization that accompany them".
CBT provides a much needed counter weight to the therapies that derive from Freud. This is not to say that there are not some gifted practitioners in the psychodynamic camp. Otto Kernberg, Nancy McWilliams and Stanley Messer are three excellent examples of analytically oriented clinicians who are open-minded, not rigid and appreciate the contributions made by Aaron Beck (the founder of cognitive behavioral therapy) and his students. Their influence has been felt in positive ways by many in the helping professions and they would view the MPD craze with outrage and abhorrence. This is the case in spite of the fact that they in are in agreement in many ways with Freud's conceptual explanation and understanding of human psychopathology and its treatment. However, Paul McHugh "fought the good fight" with many of these later day Manneristic Freudians (not the old school analysts, just mentioned, who are more gracious and open to new ideas and influences) and most likely would argue that the newer edifice their theories and practice of therapy rests on, which builds on Freud, needs to be demolished once and for all.
One area of contention in Try to Remember is that psychiatrists should be the first contact for patients seeking psychotherapy. This would make them the gatekeepers and arbiters of where patients should go to get optimal treatment. I must admit that this position is untenable for several reasons. For one, many psychiatrists, especially in America, neither conduct psychotherapy nor know anything about it. In addition, some of these psychiatrists still subscribe to the untested Manneristic conceptual foundations that McHugh found wanting, irresponsible and dangerous in the first place. Finally, even though psychiatrists ideally need training in CBT and other evidence-based therapies (i.e. interpersonal psychotherapy), until this happens their roles have been relegated to prescribing medications, and psychotherapists (mostly psychologists and clinical social workers) are responsible for the psychotherapy. What would be more practical, given present realities, is that patients become better informed about the types of therapies and therapists available to them, and stay away from clinicians that make sweeping promises of helping them "find themselves", use an approach that is not supported by evidence, keep family and others uninformed/uninvolved in their treatment, have questionable credentials and are not universally recognized as experts by clinicians from different theoretical orientations and disciplines.
There is a famous saying "people hear what they want to hear and disregard the rest". In the end there is no complete stopping of the true believers and ideologues. Many rationales have been provided for their short lived victories and how phenomena, like the craze of MPD and its proliferation, get started in the first place. We know generally after the fact what damage these rationalized and often well organized movements can do to wreak havoc on individuals, their loved ones and the social order. Those loyalists who remained involved in the cause have the capacity to retain their sense of identity through denial and, more often than not, when compromised by failure externalize blame on the "incompetents" in their rank and file. Psychiatrists and psychologists have studied and hypothesized on how the synergistic effects of multiple elements - promises of liberation from suffering in vulnerable, unstable and immature individuals, fanned by perceptions of mass betrayal/hysteria through a cult of personality led by prominent and powerful individuals - can be the catalysts for the next fad or fashion to emerge in psychiatry and mental health. Not only has Paul McHugh brought our attention to the utter disregard these so-called professionals had for their patient's care when ideology goes unchecked by evidence, but he actively entered the fray and dealt MPD a devastating blow in what could be considered a modern day witch hunt. We can all rest a little easier knowing that because of courageous individuals like McHugh and his supporters, psychiatry and the practice of psychotherapy are beginning to once again produce more light than darkness.
© 2009 Michael E. Portman
Michael E. Portman, DPhil, LISW-S, is a full-time staff clinical social worker at the Cleveland Veteran's Administration. He provides individual and group therapy to a patient population consisting of veterans with severe mental disorders. He is also a former adjunct faculty member at Case Western Reserve University, Mandel School of Applied Social Sciences, and has maintained a private practice specializing in the treatment of mood and anxiety disorders, especially Generalized Anxiety Disorder, for ten years. Dr. Portman is the author of Generalized Anxiety Disorder Across the Lifespan: An Integrative Approach. In addition to his clinical experience, Dr. Portman received a Doctorate of Philosophy in Social Work from The University of South Africa, a MSW from The Ohio State University, and a M.A. in Psychology from The New School for Social Research.