US psychiatrist's battle to challenge culture that embraced promotion of multiple personality disorder.
By RUTHIE BLUM LEIBOWITZPaul McHugh 88 248(photo credit: Esteban Alterman)
'A woman once came to me, complaining of depression and suggesting she might need medication," recounts Paul McHugh, here on a personal visit last month - his first to the Holy Land and Jewish state he has always admired. "So, I started taking her history, and asked her whether anything in her life had changed recently. She said that her husband had died suddenly two and a half months earlier. I asked her why she thought she needed medication. Her answer was that her friends had told her she should be over her grief by now. 'You have lousy friends,' I replied."
The point, says McHugh - former psychiatrist-in-chief of the Johns Hopkins Hospital in Baltimore, Maryland, (and currently University Distinguished Service professor of psychiatry at Johns Hopkins School of Medicine, professor of mental health at the Johns Hopkins Bloomberg School of Public Health and a member of the President's Council on Bioethics) - is that maladies may and often do differ from one another, even when their symptoms are similar. In other words, he explains, the grief this woman was experiencing was not necessarily a clinical manifestation of illness requiring a chemical anti-depressant, but rather a natural, "impairing" response to a difficult experience - one which she needed help getting through.
This may sound self-evident. Everyone knows by now, for instance, that a sore throat can be caused by a bacterium or a virus - and that treatment for it, therefore, is not uniform.
Where malaise of the mind is concerned, however, the picture is less clear and - according to McHugh's chilling accounts - is growing murkier by the minute, thanks to the politics of his profession, and the fertile societal ground which enables it to flourish.
McHugh's teachings, writings and breakthroughs have had a far-reaching impact (The Perspectives of Psychiatry, which he coauthored with Phillip R. Slavney, is considered one of the most influential texts in the field). He has spent the bulk of his decades-long career focused on separating fad-based suppositions from fact-based science. In the process, he has come up against much criticism and controversy. Being a practicing Catholic on the less fashionable side of the assisted suicide and other such debates will do that - especially when championing personal responsibility over victimhood.
BUT NO battle came close, in scope or span, to that which McHugh found himself fighting, and eventually winning, against the "discovery" of multiple personality disorder (MPD) and its "cure": recovered memory for the purpose of "integration."
The disturbing details of this internecine war between camps within the psychiatric community are spelled out in Try to Remember: Psychiatry's Clash over Meaning, Memory, and Mind (Dana Press), McHugh's latest book, which is being released next week. Stories of families across the United States ripped apart by accusations of incestuous pedophilia - based on nothing other than certain psychiatrists' dubious assumptions about patients' mental states and dangerous methods of treatment - hit home how suggestible an entire society can be when its cultural climate is ripe. Thousands of women in treatment for one form of malaise or another began to be persuaded by their therapists to "remember" acts committed against them when they were children, and encouraged to bring forth their alternate personalities.
McHugh refers to the psychiatrists whose methods he questioned as "mannerist Freudians."
Their movement, he asserts, was one of "social change based on a myth."
And though recovered memory was something McHugh proved successful at countering, through years of research and endless court appearances, he is still confronting other aspects of the same agenda that he believes are running rampant. A prime example, he says, surrounds post-traumatic stress disorder:
"The promotion of PTSD among our soldiers now is similar to the memory recovery movement. The idea is that any problem that emerges must be caused by the trauma of military duty. It is now being massively diagnosed, and I think there is a political reason for it. It denies valor, and the validity of their enterprise," he rules, adding, "We used to call them heroes and give them medals. Now we call them victims and give them diseases."
Lest the complexity of his argument be misunderstood, McHugh clarifies: "It's not that I deny the possibility of psychological problems arising among soldiers, but such problems could include homesickness and uncertainty of the future - normal reactions to having been in the military - and treating them accordingly usually leads to their end."
It is this kind of commonsense attitude that comes across again and again during our hour-long interview at the King David Hotel in Jerusalem. What is most striking about it (not to mention the jolly way in which he conveys it) is that it is accompanied by his incessant stressing of the science behind the brain.
His purpose: to restore psychiatry to its rightful place in our minds - and in the laboratory.
How does memory actually work? Those of us who grew up in a certain generation were taught about the phenomenon of repression - of our mind's ability, and often desire, to block out unpleasant experiences. In your book, you indicate that, in fact, it is the unpleasant experiences we are unable to forget, no matter how much we wish we could. One example you point to is Holocaust survivors.
It's complicated. Freud was the first to bring to light the idea of repression - that you might hide something objectionable from your consciousness. Initially, he thought this "objectionable something" might be some kind of trauma. Later, he came to believe that what you are hiding from yourself is not an actual, historical event or experience, but rather feelings toward your parents that you believe to be inappropriate and shameful. Incestuous feelings for the parent of the opposite sex. It is this emotional state he said you would repress - not that you would forget who you are, or who abused you. It would then enter your unconscious, the "world" from which he believed that all mental life ultimately derived.
Now, what happened with the "mannerist Freudians," as I call them, was that they - who accepted the idea of repression - decided that a person could repress an actual historical event, not merely a feeling, but rather something he could not live with - the betrayal by a parent or somebody else.
And you disagree with both notions of repression?
I'm not sure that they have any place in our understanding of memory. Repression was a plausible concept, because we do know that we forget things. But it's never been demonstrated in the laboratory that it is particularly awkward events or feelings that we would be able to forget. In fact, the more awkward the feelings are - the more distressing or embarrassing the events were - the more likely we are to remember them. Now, if you impose onto a memory an event that didn't happen, or impose false details of event that did happen - both of which have been demonstrated as possible to do - then you will have all the kinds of problems that a bad memory produces, whether the event happened or not.
Speaking of which, is memory ever really reliable?
Memory is a form of testimony, and its reliability tends to be greater the closer one is to an event, and weaker as time passes. But no memory has to be absolutely true or absolutely false - which is why you look for corroboration. I cannot immediately say that the recovery of a memory is necessarily wrong. I believe that people can forget things. Memory is a fallible human faculty. So, when someone says he remembers something, I don't say it's false; I say it's something that requires some additional confirming evidence. We know now that there are many things, even in eyewitness testimony, that can get distorted. Often, you have the gist, but can be mistaken about certain details.
Was this phenomenon of multiple personality disorders sprouting up all over the place an American one, or did it occur in other countries?
It was an American fad, spurred by the [1973] publication of Sybil [by Flora Rheta Schreiber, about a woman with 16 personalities]. But, as often happens with American fads, it turned up in other places as well. It was promoted and encouraged by people who found in it a way of awakening the concepts of Freud, at a time when American psychiatry was moving away from the idea that all mental disorders are due to unconscious conflict. We were moving away from that for a number of reasons, primarily because it turned out not to be very useful in the care and treatment of the mentally ill to see all their illnesses as having a similar source. The alternative was to look at mental disorders, like medical ones, as having different sources.
But then, along came a new unconscious driving force that psychiatrists could unveil, and in the process display their capacity to "rescue" patients from their victimhood. This was a return to Freud, but with a much more contemporary ring: ultimately powerless women victimized by men, needing champions to speak for them. This fit in wonderfully with adversarial feminism. It said to women, "You really do have an adversary - trusted male figures you grew up with, such as fathers, brothers, uncles, etc. - and many of you don't even know it." And it had a ring of plausibility to it, because some fathers, brothers and uncles do abuse their female relatives.
But the fact that people do abuse other people doesn't mean that anyone in a depression was a victim of abuse. And if you're going to accuse somebody of being an incestuous pedophile, you'd better have something other than your perception that the symptoms your patient is exhibiting are pure evidence of that abuse. You have to have something better than that, which these psychiatrists didn't have. Yet, thousands of families were affected by this. It was not trivial. And its champions were of the opinion that there were many more incestuous pedophiles out there than anyone believed. This made some people conclude that if sexual abuse didn't happen to them, they were unique, rather than the other way around.
This whole notion made it possible for the psychiatrists and therapists once again to be the revealers of secrets, rather than helpers for understanding the various ways in which mental life can go awry. It was back to Freud, but without Freud's grace, without Freud's depth, without Freud's understanding of human nature. Indeed, the great thing about Freud is this understanding, and he was very persuasive, in part because he was so subtle. These people, on the other hand, are anything but subtle. Their thinking about mental life is crude, rough and simplistic. That's why I call them "mannerist Freudians" - like the manneristic artists who tried to copy Michelangelo and Da Vinci, and produced works of a crude, far less subtle, kind.
If Freud had been alive during your battles against this movement, whose side do you think he would have been on?
I'm sure he would have been on our side, in spite of the fact that he would not have agreed with me on what I think about some of his dynamics. By the way, the orthodox Freudian analysts in America were very much on my side in this controversy. They thought the whole multiple personality disorder thing was a cruel abuse of Freud's concepts of repression and denial. In fact, they had all kinds of reasons for not liking the mannerists. Not only didn't they agree with the theme itself - that mental disorders are generated by incestuous abuse in childhood - but they also didn't agree with the idea that what was revealed in the consultation room should be revealed outside.
If you talk to an orthodox Freudian, even today, he will tell you, "Look, our job is to get a person from a troubled place to a place of safety. We take a cruise, and during that cruise, we live in a hermetically sealed room; nothing comes in and nothing goes out. So, if a patient had a fantasy of being abused, and even if that abuse occurred, we would never let news of it leave the room, because that would disrupt the aim of what we are doing, which is to work on the transference relationship."
In other words, they were opposed both to the ideas of the mannerists and to the process. In turn, the mannerists made the orthodox Freudians their enemies as well. They did this by saying that, by abandoning the infant molestation idea - as he did at the turn of the century - and taking up the view of infantile sexuality as being a conflict that generates problems, Freud showed cowardice in the face of objections to his seduction theory.
Before you witnessed the mushrooming of MPD, had you ever encountered a patient with the symptoms of this condition?
A few. Interestingly, they all emerged after the release of the [1957] movie The Three Faces of Eve starring Joanne Woodward. And if you go back and look at that film, you'll see exactly what I was taught about multiple personalities - and what I recognized in the few cases I saw - that these were patients who were interested in drawing the attention of doctors to their particular plight, and multiple personality turned out to be a way of drawing and sustaining that attention.
Indeed, all the cases I saw quickly dissipated when I or my students no longer paid attention to the multiplicity, but kept the focus on the here and now - on what the troubles were that the patients were trying to resolve by this disguise. Usually, they were contemporary difficulties in relation to significant others - sometimes their children, sometimes their parents, but not an abusive kind.
How does this differ from the way mannerist Freudians treated their patients?
Among other things, the mannerists formed groups of people - some of whom remember having been abused, and some of whom had no such memory - and put them all together. What happened was that the people who had actually been abused were looking for help in forgetting and getting beyond it. Whereas the ones who had no such memory and were being encouraged to remember asked those others to tell them more about the details of the abuse, so that maybe it would cause them to remember their own.
How do you treat verified victims of sexual abuse?
It's a succession of things. For example, I've treated men who were abused by Catholic priests when they were boys. The first thing I do is tell them it's terrible what they went through, how sorry I am and that I understand and appreciate how much it cost them in their ability to trust. Often, sexual abuse is not merely a trauma, but it changes the victim's whole view of sexuality. Sex becomes something taken from someone else, rather than something one builds with someone else. So, my job is to begin to talk about how they see intimacy, and to get them to appreciate how aberrant what happened to them was.
In addition, of course, I tell them it's an event that has to be reported. But then together, we start trying to find out whether intimacy is an exploitative thing in their lives, and trying to remember the positive things that have also emerged in their lives. Much depends on the strengths of their families and other things. Often the inquiry is: What is standing in the way of making it possible to move on? And we talk about how holding on to hatreds and resentments is, in the long run, self-defeating. We talk about forgiveness.
You mean, there's a spiritual side to such treatment?
Absolutely - especially since the problem has emerged through sex. Our culture is so screwed up about sex right now that it can't help but see it as something in which one person takes something from another. We have to re-spiritualize sex. I try to remind people that sex is a very complicated part of our lives. It causes a lot of stress, and the reason for that is that is it's nature's way of turning a stranger into a relative. You know, "He doesn't write; he doesn't call..." [he laughs]
Finally, what is the distinction between the field of psychiatry and the politics of psychiatry, as you describe in your book?
The distinction is between those who make an honest attempt at getting at the truth and those who do the opposite. What I found among the mannerist Freudians was how different they were in response to questioning from ordinary psychiatrists I knew and had trained. I'm used to people telling me I'm wrong and demanding that I prove my assertions, and I don't respond by saying, "You must have some hang-up."
When I first encountered the mannerist Freudians, I was struck by their use of their positions and the jargon of science to cloud the issues, rather than clarify them. If you asked them for their data, for example, they demanded to see yours. Then, you'd say, "Wait a minute, you're the one who's making the claim; you're the one who has to provide the data backing it up." Their response always was to say that if you don't accept what they're telling you, there must be something the matter with you.
Then there are psychiatrists who one can clearly see are acting in good faith. They may treat patients differently from the way I would, but they are in a genuine quest to examine conditions, and try to get at the bottom of what differentiates a patient who has that condition, and a patient who does not. n
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