Conversations in Critical Psychiatry is an interview series aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.
CONVERSATIONS IN CRITICAL PSYCHIATRY
Paul R. McHugh, MD, is University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine. He was the Henry Phipps Professor and Director of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine and Psychiatrist-in-Chief at Johns Hopkins Hospital for 26 years. He is also the inaugural Director of the Paul R. McHugh Program for Human Flourishing. Dr McHugh is a nationally recognized figure: he was elected a member of the National Academy of Medicine in 1992, and from 2002 to 2009, he was a member of the President’s Council on Bioethics. He is the author of many books, most popularly of The Perspectives of Psychiatry (co-written with Phillip Slavney, MD), which presents a conceptual framework for the proper evaluation and understanding of psychiatric disorders.
Building on the philosophical work of forerunners such as Adolf Meyer and Karl Jaspers, The Perspectives of Psychiatry identifies four explanatory methods underlying the practice of the profession. In Perspectives, generations of psychiatrists have found a nuanced, unifying approach to the field, which the biopsychosocial model and the DSM had promised but never delivered. Although the Perspectives approach was not formally taught during my residency, I was fortunate to work with several attendings who exposed me to the book, which led me to delve into the ideas on my own. The Perspectives approach demonstrates to me what a mature, pluralistic psychiatry can look like. It is my honor that Dr McHugh accepted my request to engage in a conversation regarding his ideas.
Awais Aftab, MD: It is a rare feat for a conceptual book on psychiatry to generate as much acclaim, influence, longevity, and readership within the profession as has The Perspectives of Psychiatry. When the first edition was published in 1983, did you expect that the book would be such a hit and that people would still be reading and recommending it nearly four decades later? Why do you think the book has endured for so long?
Paul McHugh, MD: When Phillip Slavney and I conceived and wrote The Perspectives of Psychiatry, we certainly expected it to be noticed because it strove to make explicit what was often implicit (and, to patients, mysterious) in psychiatric thought. And, we expected it in some way to endure in that it identified fundamentals of mental life that would not change. We didn’t expect it to be a hit given its challenges to several established views and, for that matter, we do not think it is a hit now given that few departments of psychiatry teach from it. Although it may not have boomed, it certainly did survive—this year it is being translated and published in Japan—and mainly for the reason I mentioned: both psychiatrists and patients recognize that it clarifies the clinical enterprise by identifying, distinguishing, and reflecting on the methods psychiatrists employ in making sense of mental distress and disorder. It also heuristically directs treatment and research gives it practical value.
Aftab: As popular as the Perspectives approach is, the biopsychosocial model remains the closest thing to an officially accepted conceptual framework in the field. From the nuanced viewpoint of Perspectives, the biopsychosocial model appears very vacuous and eclectic. Perhaps it’s the very vacuousness and eclecticism that explain the model’s widespread acceptability?
McHugh: You’re certainly correct in noting the common acceptance of the biopsychosocial model that George Engel was describing (and deriving from Adolf Meyer) just at about the time we were composing Perspectives. We think the biopsychosocial model survives because it can act as a slogan justifying any practice. It falters because it is neither refutable nor heuristic. By solemnly noting the obvious underpinnings of human life but providing no way to derive mental distresses and disorders from them—essentially offering ingredients without recipes—it’s sophistry.
Aftab: You have outlined in detail four perspectives (ie, brain diseases, personality dimensions, motivated behaviors, and life encounters), and the list has remained unchanged over your career so far. Are you open to the idea that there are valid perspectives other than these four? For instance, I can think of at least two. First, the evolutionary perspective, particularly situations of design-environment mismatch in which a brain mechanism that has evolved via natural selection thousands of years ago is now placed in a modern 21st century environment for which it was not designed, leading to distress or impairment. (There is no internal broken part, hence no disease). Second, the sociological perspective, which sees mental health issues in a population as a response to various social forces (for instance, Allan Horwitz’s work on depression). The sociological perspective is different from the individual life story perspective because it deals with complex phenomenon at the social level that cannot be described in terms of individual psychology.
McHugh: Although we believe that together the four perspectives we’ve outlined broadly and inclusively address the clinical explanatory problems of psychiatrists, we are open to the idea of other perspectives. We certainly have had many such proposed to us, including a developmental perspective, a neurobiological perspective, a sociological perspective, and many others, but we have usually concluded that the proposers have not grasped what we mean when we speak about psychiatric perspectives and what we were doing in choosing these four.
Specifically, we were not writing a book that could carry the title “Causes of Psychiatric Disorder.” We were writing a treatise on the different methods psychiatrists need and use to make sense of mental disorders, and we were proposing that they derive those methods from what they can “see” of conscious mental life. We think psychiatrists are (or should be) aware of four basic, interactive, functional features of the mind that represent the compositional attributes structuring conscious mental life. Each of them can be viewed as a potential site of mental unrest. Those four are:
1. The intrinsic features—consciousness itself, memory, language, cognition, affect and the like;
2. The self-defining features—the individual’s intelligence, temperament, maturity, etc.;
3. The teleological features—hunger, thirst, sex, etc., and the wants and ‘needs’ tied thereto; and
4. The extrinsic/experiential features—responsivity to life events, social networks, education, etc.
Together, our four perspectives offer a way of making sense of mental disorders by drawing on these features and simultaneously offer a way of making sense of (ie, formulating) mental disorders in particular patients where a mix of perspectives can be expected. The disease perspective describes how psychiatrists strive to make sense of how neurobiological injuries can come to disrupt the functioning of one of the intrinsic features, as with delirium, dementia, or bipolar depression. The dimensional perspective describes how psychiatrists strive to make sense of the vulnerabilities of some individuals to emotional unrest tied to aspects of the self-defining features characterizing them, such as the intellectually disabled, the histrionic, or the compulsive. The behavior perspective describes how psychiatrists strive to make sense of such problematic, habit-sustained activities that arise from the teleological features, as with anorexia nervosa, alcohol dependency, or the sexual paraphilias. The life story perspective describes how psychiatrists strive to make sense of the emotional distresses that are generated by the play of events upon the extrinsic/experiential features of mind, as with grief, post-traumatic stress disorder, or demoralization.
This separation of the perspectives must not presume their independence of one another given that the functional features on which they rest interact. For example, an anxious patient (dimensional perspective) may develop an alcoholic dependency (behavior perspective) that could cause a demoralizing job loss (life story perspective) thereby prompting an increase in drinking, all leading to his clinical presentation with delirium tremens (disease perspective).
Given all this, we would view your two suggestions not as new or separate perspectives but as causal factors either shaping one of the mind’s basic features or an element in one of the four we describe. Thus, the evolutionary facts you identify as presenting problems in the contemporary era usually do so by altering the teleological features of mental life. So, for example, the genetic controls on food intake and calorie storage that evolved in some peoples and were useful for survival in times of shortage and deprivation can lead, if persisting amongst them, to overeating and obesity in times of plenty in today’s world. Still, the presenting problem of the patients would be behavioral in expression and emerge as alterations needing therapeutic attention in the drive, conditioning, and decisional aspects of their food intake. The social forces (including those studied by Allan Horwitz or Nicholas Christakis) provide the setting of the subject’s life experience and would be grasped in the life story perspective, where the triad of setting, sequence, and outcome make sense of the problems. While we are open to new perspectives, we argue, from what we mean by perspective, that a new one awaits the description of another compositional feature of the mind.
Aftab: What conceptual issues in psychiatry are the most important in your view? Issues that the new generation of psychiatrists and their conceptual comrades should focus on?
McHugh: The most important issue for psychiatrists to recognize today is that their discipline is at stalemate; it’s hesitating to come of age. This is an obvious problem of leadership. Officially, the discipline will only codify the disorders it takes for its concerns rather than strive to classify them by their presumed nature as does internal medicine. Many psychiatrists are at a loss as to what disorders their discipline should claim. Instead of boldly stating that this discipline takes responsibility for any expression of human mental disarray from Alzheimer disease to zoophilia, many psychiatrists wonder whether mental disorders with known brain derivations shouldn’t be surrendered to neurologists. They anticipate that the advance of neuroscience will deprive them of their professional position, rather than enhancing what they could know and do.
The solution? Psychiatrists must understand that all aspects of mental life (including the mental disorders) are derived in some way from the brain but not in the way urine is derived from the kidney or bile from the liver. The derivation of mind from brain takes the form of an emergent property with constituent features and functional rules that cannot be directly reduced to knowledge of the neural systems from which it, the mind, emerges. Psychiatry is thus an autonomous medical discipline dealing with the kinds of clinical problems that present within the emergent mind. It’s time for its practitioners to start thinking and acting accordingly, perhaps by officially noting the ways those clinical problems can be organized according to what’s known of their natures.
Aftab: In your opinion, what determines whether a particular condition is or is not a mental disorder? Is there an objective, fact-based answer to this (at least in part), or is it a thoroughly value-laden determination?
McHugh: We hold, and have specifically stated in our book, that because psychiatrists must employ several distinct methods to make sense of all the various disorders and distressful states they see, the definition of psychopathology, what is meant by normal, and the treatments that are suitable will differ with the perspective or perspectives that fit.
For example, the identification of a broken part or pathologic entity confirms the categorical designation of abnormality by the Disease Perspective. A patient here is somebody who has something “normal” people don’t. Similarly, the Dimensional Perspective makes sense of a troubled person as “abnormal” only in a statistical and arbitrary sense by showing their vulnerability or at-risk status for emotional unrest depends upon their psychological deviation from the mean along the normal Bell-shaped distribution curves of human intelligence or temperament. One is identified as a psychiatric patient because of who one is.
The Behavioral Perspective encompasses people who are patients because they persist in enslaving activities that bring physical, psychological, and social disasters in their wake. They are identified as patients because they are doing something ordinary people don’t. Those whom psychiatrists recognize as people responding to a set of circumstances—such as the grief stricken, the demoralized, the traumatized, and the like—and whose plight psychiatrists grasp within the Life Story Perspective are patients primarily in the sense that they are people seeking professional (ie, diagnostic, prognostic, or therapeutic) help because of the persistence or severity of their “normal” suffering, and those features usually depend not on them but on the intensity and significance of their loss or injury. They are patients because of what they’ve encountered. We think all these matters are of an objective fact-based nature and relate coherently to the complex issue of “normality.”