Try to Remember: Psychiatry’s Clash Over Meaning, Memory, and Mind
Dr Paul McHugh continues to be a creative teacher and critical thinker who never avoids confronting problems or mistakes in our field. Try To Remember is a book that should be read by both mental health professionals and patients, both past and potential. His newest contribution expands a series of his essays, contained in The Mind Has Mountains, into a riveting narrative of "psychiatric misadventures."1 Dr McHugh’s educational path in psychiatry was different, which explains his recognition of different perspectives and championing empiricism. When he was a Harvard medical student, his mentor, Dr George Thorn, the Physician-in-Chief at the Peter Bent Brigham Hospital, counseled him to eschew the traditional psychiatric residency that emphasized Freudian theories. Instead, McHugh completed a neurology residency in which he honed his skills as a clinical observer who utilized inductive reasoning from accessible data. This was in direct contradistinction to Freudian theory and practice in which the clinician deductively organizes data from theoretical biases. He cites Elvin Semrad, who represented the psychoanalytic zeitgeist at the time, as a "pseudo guru" who would cite aphorisms that today sound like psychoanalytic haikus.
The central theme of the book is the sorry history of the recovered memory scandals. Therapists with tenaciously held beliefs about malevolent parental abuse that were completely unfounded were able to induce suggestible patients under their influence into believing that terrible abuse occurred during their childhood. The author terms these psychiatrists manneristic Freudians. They practiced "classical psychoanalytic techniques" but differed from traditional psychoanalysts in that such multiple personality experts viewed patients’ symptoms as the residues of victimization that was long forgotten, rather than the classical psychoanalytic approach of seeing symptoms as the residues of the patients’ own conflicted desires towards their parents. McHugh’s clinical approach was careful examination of the patient, but also an active search for corollary information from family and other sources. The book draws upon clinical examples that are fascinating, yet profoundly disquieting. Disturbed psychiatric patients evoke stories of abuse and trauma that were never substantiated. Family members were actually jailed on the basis of therapeutic zealots who were convinced that recovered memories were absolutely true despite obvious inconsistencies. Clinical programs developed for such multiple personalities reinforced and expanded the false memories from early abuse to broader satanic ritual abuse. McHugh never denies that child abuse does occur, but reminds the reader that such traumatic incidents are generally remembered by its victims. In response to such clinical atrocities, the False Memory Syndrome Foundation was established to help lead the legal fight for diagnostic accuracy and truth in rebutting such iatrogenic symptoms and stories. The story has a happy ending, as multiple personality disorder units were often discredited, and patients and families were often able to reconcile.
The second part of the book moves to the current focus on posttraumatic disorders, which have significant political issues as many veterans return from Iraq and Afghanistan. Dr McHugh has previously questioned the validity of this category.2 Nevertheless, he urges a systematic approach that reviews the patient’s life prior to the trauma and urges understanding of concurrent or coexisting issues that may make the individual more vulnerable. He correctly points out that trauma is a common human experience and that negative reactions, such as recurrent memories and sleep disturbance, are understandable in the face of terrible adversity. Negative emotions related to such traumatic events are emotions of adjustment and vary in intensity, depending on the perception of threats and premorbid vulnerabilities. As with the false memory fads, Dr McHugh warns us to be cautious in overdiagnosing individuals who have experienced bad things as always suffering from posttraumatic stress disorder.
The final section is an elegant overview of psychotherapies utilized in our field. McHugh reviews the common elements in all psychotherapies that include restoration of morale by a socially sanctioned healer. For psychiatrists, our white coats and diplomas give our patients trust and confidence in our healing abilities. Some might label this phenomenon as transference. Second, all therapies promote some emotional arousal in patients, such as evoking hope and attempting reversal of demoralization. Third, effective psychotherapists offer patients suggestions for coping with circumstances. McHugh then dichotomizes psychotherapies into those that are based on conflict models and those that are based on deficit models. The conflict models are common psychodynamic approaches that look at early life conflicts as causes of current symptomatology. Conflict models also utilize discussions between patient and therapist about their interactions since such interactions, as reflected in dreams and verbalizations, may reproduce habitual attitudes of dealing with important figures in the patient’s early development. The deficit model is best characterized by cognitive-behavioral therapy, an active approach dealing with thoughts and behaviors that are maladaptive and are challenged by the therapist through the work of therapy toward self-efficacy.
Dr McHugh closes with a very brief overview of the perspectives of psychiatry that allow a broader understanding of each patient.3 By reviewing the strengths and weaknesses of categorical disease models, life stories, dimensions, and behaviors, psychiatric physicians can utilize each via empirical observations, collateral information, and inductive reasoning to do what is best for each patient. It is this approach that is powerful and necessary for psychiatry to move forward from a field influenced by "revealed truths" of theories that explain everything and lead to deductive methods that are contradicted by valid observations. Try to Remember may well upset clinicians who solely utilize such theories to organize their clinical strategies, but these clinicians should read this beautifully written volume with an open mind and consider the intellectual challenges that Dr McHugh offers.
References
1. McHugh PR. The Mind Has Mountains: Reflections on Society and Psychiatry. Baltimore, MD: Johns Hopkins; 2006:249.
2. McHugh PR, Treisman G. PTSD: a problematic diagnostic category. J Anxiety Disord. 2007;21(2):211-222. PubMed doi:10.1016/j.janxdis.2006.09.003
3. McHugh PR, Slavney PR. The Perspectives of Psychiatry. 2nd ed. Baltimore, MD: Johns Hopkins; 1998:332.
Author affiliation: George Washington University School of Medicine, Washington, DC. Financial disclosure: Dr Wise is a member of the speakers/advisory boards for Pfizer and Eli Lilly.
doi:10.4088/JCP.09bk05252
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