PSYCHIATRY IS A RUDIMENTARY MEDICAL ART – Paul McHugh
October 21, 2012
PSYCHIATRY IS A RUDIMENTARY MEDICAL ART. It lacks easy access to proof of its proposals even as it deals with disorders of the most complex features of human life–mind and behaviour. Yet, probably because of the earlier examples of Freud and Jung, a belief persists that psychiatrists are entitled to special privileges-that they know the secret of human nature–and thus can venture beyond their clinic-based competencies to instruct on non-medical matters: interpreting literature, counselling the electorate, prescribing for the millennium.
At The Johns Hopkins University, my better days are spent teaching psychiatry to residents and medical students. As I attempt to make clear to them what psychiatrists actually do know and how they know it, I am often aware that I am drawing them back from trendy thought, redirecting them from Salvationist aspirations toward the traditional concerns of psychiatry, which is about the differentiation, understanding, and treatment of the mentally ill.
Part of my justification for curbing my students’ expansive impulses is that they have enough to learn, and several things to unlearn, about patients. Such sciences as epidemiology, genetics, and neuropharmacology, which support and surround psychiatry today, are bringing new power to our practice just as science did for internal medicine and surgery earlier in this century. Only those physicians with critical capacities–who see the conceptual structure of this discipline and can distinguish valid from invalid opinions–will be competent to make use of these new scientific concepts and technologies in productive ways. I want my students to number among those who will transform psychiatry in the future.
But my other justification for corralling their enthusiasms is the sense that the intermingling of psychiatry with contemporary culture is excessive and injures both parties. During the thirty years of my professional experience, I have witnessed the power of cultural fashion to lead psychiatric thought and practice off in false, eve disastrous, directions. I have become familiar with how these fashions and their consequences caused psychiatry to lose its moorings. Roughly every ten years, from the mid-1960s on, psychiatric practice has condoned some bizarre misdirection, proving how all too often the discipline has been the captive of the culture.
Each misdirection was the consequence of one of three common medical mistakes–oversimplification, misplaced emphasis, or pure invention. Psychiatry may be more vulnerable to such errors than other clinical endeavours, given its lack of checks and correctives, such as the autopsies and laboratory tests that protect other medical specialties. But for each error, cultural fashion provided the inclination and the impetus. When caught up by the social suppositions of their time, psychiatrists can do much harm.
The claim that schizophrenic patients are in any sense living a alternative “life style” that our institutions were inhibiting was of course fatuous. It is now obvious to every citizen of our cities that these patients have impaired capacities to comprehend the world and that they need protection and serious active treatment. Without such help, they drift back to precisely the place Dorothea Dix found them 150 years ago.
From the faddish idea of institutions as essentially oppressive emerged a nuance that became more dominant as the 1970s progressed. This was that social custom was itself oppressive. In fact, according to this view, all standards by which behaviours are judged are simply matters of opinion–and emotional opinions at that, likely to be enforced but never justified. In the 1970s, this antinomian idea fuelled several psychiatric misdirections.
A challenge to standards can affect at least the discourse in a psychiatric clinic, if not the practice. These challenges are expressed in such slogans as “Do your own thing,” “Whose life is it anyway?” “Be sure to get your own,” or Joseph Campbell’s “Follow your bliss.” All of these slogans are familiar to psychiatrists trying to redirect confused, depressed, and often self-belittling patients. Such is their pervasiveness in the culture that they may even divert psychiatrists into misplaced emphases in their understanding of patients.
This interrelationship of cultural antinomianism and a psychiatric misplaced emphasis is seen at its grimmest in the practice known as sex-reassignment surgery. I happen to know about this because Johns Hopkins was one of the places in the United States where this practice was given its start. It was part of my intention, when I arrived in Baltimore in 1975, to help end it.
Not uncommonly, a person comes to the clinic and says something like, “As long as I can remember, I’ve thought I was in the wrong body. True, I’ve married and had a couple of kids, and I’ve had a number of homosexual encounters, but always, in the back and now more often in the front of my mind, there’s this idea that actually I’m more a woman than a man.”
When we ask what he has done about this, the man often says, “I’ve tried dressing like a woman and feel quite comfortable. I’ve eve made myself up and gone out in public. I can get away with it because it’s all so natural to me. I’m here because all this male equipment is disgusting to me. I want medical help to change my body: hormone treatments, silicone implants, surgical amputation of my genitalia, and the construction of a vagina. Will you do it?” The patient claims it is a torture for him to live as a man, especially now that he has read in the newspapers about the possibility of switching surgically to womanhood. Upon examination it is not difficult to identify other mental and personality difficulties in him, but he is primarily disquieted because of his intrusive thoughts that his sex is not a settled issue in his life.
Experts say that “gender identity,” a sense of one’s own maleness or femaleness, is complicated. They believe that it will emerge through the step-like features of most complex developmental processes in which nature and nurture combine. They venture that, although their research on those born with genital and hormonal abnormalities may not apply to a person with normal bodily structures, something must have gone wrong in this patient’s early and formative life to cause him to feel as he does. Why not help him look more like what he says he feels? Our surgeons can do it. What the hell!
The skills of our plastic surgeons, particularly on the genito-urinary system, are impressive. They were obtained, however, not to treat the gender identity problem, but to repair congenital defects, injuries, and the effects of destructive diseases such as cancer in this region of the body.
That you can get something done doesn’t always mean that you should do it. In sex reassignment cases, there are so many problems right at the start. The patient’s claim that this has been a lifelong problem is seldom checked with others who have known him since childhood. It seems so intrusive and untrusting to discuss the problem with others, even though they might provide a better gage of the seriousness of the problem, how it emerged, its fluctuations of intensity over time, and its connection with other experiences. When you discuss what the patient means by “feeling like a woman,” you often get a sex stereotype in return–something that woman physicians note immediately is a male caricature of women’s attitudes and interests. One of our patients, for example, said that, as a woman, he would be more “invested with being than with doing.”
It is not obvious how this patient’s feeling that he is a woman trapped in a man’s body differs from the feeling of a patient with anorexia nervosa that she is obese despite her emaciated, cachectic state. We don’t do liposuction on anorexics. Why amputate the genitals of these poor men? Surely, the fault is in the mind not the member.
Yet, if you justify augmenting breasts for women who feel underendowed, why not do it and more for the man who wants to be a woman? A plastic surgeon at Johns Hopkins provided the voice of reality for me on this matter based on his practice and his natural awe at the mystery of the body. One day while we were talking about it, he said to me: “Imagine what it’s like to get up at dawn and think about spending the day slashing with a knife at perfectly well-formed organs, because you psychiatrists do not understand what is the problem here but hope surgery may do the poor wretch some good.”
The zeal for this sex-change surgery–perhaps, with the exception of frontal lobotomy, the most radical therapy ever encouraged by twentieth century psychiatrists–did not derive from critical reasoning or thoughtful assessments. These were so faulty that no one holds them up anymore as standards for launching any therapeutic exercise, let alone one so irretrievable as a sex-change operation. The energy came from the fashions of the seventies that invaded the clinic–if you can do it and he wants it, why not do it? It was all tied up with the spirit of doing your thing, following your bliss, an aesthetic that sees diversity as everything and can accept any idea, including that of permanent sex change, as interesting and that views resistance to such ideas as uptight if not oppressive. Moral matters should have some salience here. These include the waste of human resources; the confusions imposed on society where these men/women insist on acceptance, even in athletic competition, with women; the encouragement of the “illusion of technique,” which assumes that the body is like a suit of clothes to be hemmed and stitched to style; and, finally, the ghastliness of the mutilated anatomy.
But lay these strong moral objections aside and consider only that this surgical practice has distracted effort from genuine investigations attempting to find out just what has gone wrong for these people–what has, by their testimony, given them years of torment and psychological distress and prompted them to accept these grim and disfiguring surgical procedures.
We need to know how to prevent such sadness, indeed horror. We have to learn how to manage this condition as a mental disorder when we fail to prevent it. If it depends on child rearing, then let’s hear about its inner dynamics so that parents can be taught to guide their children properly. If it is an aspect of confusion tied to homosexuality, we need to understand its nature and exactly how to manage it as a manifestation of serious mental disorder among homosexual individuals. But instead of attempting to learn enough to accomplish these worthy goals, psychiatrists collaborated in a exercise of folly with distressed people during a time when “do your own thing” had something akin to the force of a command. As physicians, psychiatrists, when they give in to this, abandon the role of protecting patients from their symptoms and become little more than technicians working on behalf of a cultural force.
Excerpt from “Psychiatric Misadventures” Paul R. McHugh 1992
Read the full text here: http://www.lhup.edu/~dsimanek/mchugh.htm