The Mind Has Mountains: Reflections on Society and Psychiatry

Paul McHugh has strong opinions on many subjects. The MindHas Mountains (the title is from Gerald Manley Hopkins) collects 23 of his essays and talks over the past two decades. McHugh is a counterpuncher, at his best exposing the foolishness of misguided colleagues whose ideas he disputes or, worse, who seem to think that their psychiatric expertise can be generalized to expertise about almost anything else. In his own words he tries “to challenge or amend some egregious thought or practice in psychiatry” (p. xi). He says that his teaching is like his practice: “You must knock bad ideas out of heads before you can start putting good ones in” (p. 1). The approach has advantages and disadvantages. It makes for engaging rhetoric and lively writing, especially when you agree with him, but when you don’t, his tendency to ignore opposing arguments and make not quite accurate assertions can irritate. However he is always interesting, provocative, and a wonderful stimulant to one’s own thinking.

McHugh is the Henry Phipps Professor of Psychiatry Emeritus at Johns Hopkins, and a member of the Presidential Council on Bioethics (he discusses stem cell research and the use of drugs for the enhancement of performance rather than the treatment of disorders) and the National Review Board of the U.S. Conference of Catholic Bishops (their concern with the sexual abuse of children by clergy is not discussed in these essays). There is a typographical error in the text that captures McHugh’s style. In describing how the human capacity for self-expression allows psychiatrists to enter the mental life of their patients, he says that they “emphatically penetrate” their patients’ thoughts. I think he means “empathically,” but emphatic is real McHugh. With anyone else I would wonder whether it might be a Freudian slip; with McHugh I wonder whether it foreshadows an essay on how psychiatrists ought to confront their patients more directly!

There is an old maxim that tough cases make bad laws. McHugh often focuses on tough cases—the Kevorkian episode and Terry Schiavo when discussing physician’s roles in caring for dying patients, or accounts of sexual experiments aboard alien spacecraft when discussing repressed memories. It is easy to ridicule such extremes, but while such ridicule may clarify the boundaries of reasonable discussion, it does not solve all of the tough problems. For example, in discussing physician-assisted suicide (which he opposes) he recognizes that “Most suicidally depressed patients are not rational individuals” (p. 75), but then ignores the more difficult problem of the others, those who are rational (and, for that matter, may not be depressed).

There are only a few clinical vignettes in the book. One illustrates McHugh’s approach, and how others (including myself) might differ. The patient is a young woman, depressed after several failed romances, in each of which an intimate relationship ends with the man telling her he is “not ready.” She fears that there is something about her to blame. McHugh tells her that she is “natural,” her boyfriends are not, and that she has been cooperating with a flawed cultural system. I understand where McHugh is coming from, but I don’t think that it is psychiatry. I would wonder whether the patient’s pattern of recurrent painful relationships reflected a personality trait, the type that some call masochistic or self-defeating, and that sympathy, advice, or discussions of cultural trends might be less helpful than psychotherapy aimed at dealing with her personality.

McHugh has a keen understanding of the importance of a life-story perspective in psychiatry, and even advocates recognition of relational disorders in the DSM. However he seems particularly unfriendly to psychoanalysis. He joins Frederic Crews in blaming the false memory debacle on psychoanalysis, and praises Crews’ deeply flawed book that links the two as “an outstanding contribution” (pp. 129–133). He goes so far as to claim that psychoanalysts have “probably retarded the growth of the culture at large” (p. 117)—a fairly strong statement with no apparent evidence or argument to support it.

All this illustrates that McHugh can be provocative, and that I, like most readers, can be provoked. However there is no one I would rather debate. He discusses the fundamental questions of psychiatry (mind and brain, disease and life course), crucial questions of medicine and bioethics, and pressing social issues, bringing new perspectives to all. If you like to think about matters related to psychiatry, this book will make you think once more about those you had thought long settled.