Psychiatric Misadventures

	                        Paul R. McHugh

I.

	_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.

II.

	The most conspicuous misdirection of psychiatric practice--
the precipitate dismissal of patients with severe, chronic mental
disorders such as schizophrenia from psychiatric hospitals--
certainly required a vastly oversimplified view of mental illness.
These actions were defended as efforts to bring "freedom" to these
people, sounding a typical 1960s theme, as though it were not their
illnesses but society that deprived them of freedom in the first
place.
	There were several collaborators in this sad enterprise--
prominent among them the state governments looking for release from
the traditional but heavy fiscal burden of housing the mentally
ill. Crucial to the process were the fashionable opinions of the
time about society's institutions and, specifically, the
oversimplified opinions about schizophrenia and other mental
illnesses generated by the so-called "anti-psychiatrists": Thomas
Szasz, R. D. Laing, Erving Goffman, Michael Foucault, and the rest.
These men provided an acid commentary on psychiatric thought and
practice, which in turn eroded confidence in the spirit of
psychiatric concern for the mentally ill that had previously
generated, and regularly regenerated, advocacy on the part of
mainstream psychiatry for their welfare. This traditional concern
had lasted for more than 120 years in America, or ever since the
1840s crusades led by Dorothea Dix to provide professional services
and humane conditions for the mentally ill.
	The "anti-psychiatry" school depicted mental institutions as
medically useless, self-serving institutions run for the
management, and quite unnecessary for patients. These commentators
scorned social attitudes about the mentally ill and the
contemporary psychiatric practice, but not one of them described
the impairments of mind in patients with schizophrenia,
manic-depressive illness, or with mental retardation or senility.
Data about these impairments were what Dix and an enlightened
public came to emphasize when founding psychiatrically supervised,
state-supported hospitals. These hospitals rescued the mentally ill
from destitution, jails, and the mean streets of cities.
	Description of the mental problems of psychiatric patients was
not the style of the popular 1960s commentators. They were more
interested in painting a picture of their own devising that would
provoke first suspicion and then disdain for contemporary
psychiatric practices and did so, not by producing new standards
or reforming specific practices, but by ridiculing and caricaturing
efforts of the institutions and people at hand just as fashion
directed. The power of their scorn was surprising and had amazing
results, leading many to believe that it was the institutions that
provoked the patients' illnesses rather than the illnesses that
called out for shelter and treatment.
	Here, from Szasz's book, Schizophrenia: The Sacred Symbol of
Psychiatry, is a typical comment:
	"The sense in which I mean that Psychiatry creates
schizophrenia is readily illustrated by the analogy between
institutional psychiatry and involuntary servitude. If there is no
slavery there can be no slaves.... Similarly if there is no
psychiatry there can be no schizophrenics. In other words, the
identity of an individual as a schizophrenic depends on the
existence of the social system of [institutional] psychiatry."
	The only reply to such commentary is to know the patients for
what they are-in schizophrenia, people disabled by delusions,
hallucinations, and disruptions of thinking capacities-and to
reject an approach that would trivialize their impairments and deny
them their frequent need for hospital care.
	On one occasion in the early 1970s, when I was working at
Cornell University Medical Center in New York, a friend and senior
member of the biochemistry faculty called me about a medical
student who was balking over a term paper because his career plan
was to become a champion of the "psychiatrically oppressed."
Biochemistry term papers seemed "irrelevant." Could I offer him a
project with psychiatric patients that might be developed into a
term paper satisfying the requirements of her department? "He's a
neat guy," she said, "but he is stubborn about this and full of
views about contemporary psychiatry." "Send him over," I said, but
I awaited his arrival with some apprehension. I needn't have feared
the encounter because, in contrast to many other students of those
times, he was not looking for a fight. "It's just that I know what
I want to do--understand the people who are isolated by the label
schizophrenia--and help them achieve what they want in life. I've
written enough irrelevant papers in my life," he said. He had
graduated summa cum laude from Princeton, with a concentration i
philosophy, so he certainly had placed a large number of words o
paper.
	"Have you ever seen anyone with schizophrenia?" I asked.
	"Not in the flesh," he said, "but I think I know what you do
with them."
	"Well," I replied, "I will be glad to have you see one, and
let you tell me how to appreciate his choice of an eccentric way
of life that he could be released to express it."
   I had plenty of patients under my care at the time and chose
one who was the same age as the student but who had a severe
disruption in his thought processes. Even to talk with him was a
distressing experience because few of his thoughts were connected,
and all of them were vaguely tied to delusional beliefs about the
world, his family, and our society. He wasn't aggressive or in any
way threatening. He was just bewilderingly incoherent. I left the
student with the patient, promising to return in half an hour to
learn what he thought.
	On my return, I found the student subdued. I started, in a
slightly teasing way, to ask where he suggested I might send the
patient to start his new life-but was quickly cut off by the
student who, finding his voice, said, "That was nothing like what
I expected and nothing like what I've read about. Obviously you
can't send this poor fellow out of the hospital. Please tell me how
you're treating him."
	With this evidence confirming my colleague's judgment of the
student's basic good nature in what, after all, had been a
heartfelt if inexperienced opinion, we went on to talk about the
impairments and disabilities of patients with serious mental
illnesses, their partial responses to combinations of medication
and psychological management, and, finally, to the meretricious
ideas about their treatment that had been promulgated by
contemporary fashion and the anti-psychiatry critics without making
an effort to examine patients.
	The student wrote his biochemistry paper on emerging concepts
of the neurochemistry of mental disorders. He buckled down in
medical school, and he came, after graduation, to join me as a
resident psychiatrist and eventually proved to be one of the best
doctors I ever taught. We had overcome something together--all out
of going to see a patient, recognizing his burdens, and avoiding
assumptions about what fashion said we should find.
	A saving grace for any medical theory or practice--the thing
that spares it perpetual thraldom to the gusty winds of fashion--
is the patients. They are real, they are around, and a knowledge
of their distressing symptoms guards against oversimplification.

III.

	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.

IV.

	Medical errors of oversimplification and misplaced emphasis
usually play themselves out for all to see. But the pure inventions
bring out a darker, hateful potential when psychiatric thought goes
awry. The invention of entities of mind and then their elaborate
description, usually fuelled by the energy from some social
attitude they amplify, is a recurring event in the history of
psychiatry.
	Most psychiatric histories choose to describe such invention
by detailing its most vivid example--witches. The experience in
Salem, Massachusetts, of three hundred years ago is prototypical.
Briefly, in 1692, several young women and girls who had for some
weeks been secretly listening to tales of spells, voodoo, and
illicit cultic practices from a Barbados slave suddenly displayed
a set of mystifying mental and behavioural changes. They developed
trance-like states, falling on the ground and flailing away, and
screaming at night and at prayer, seemingly in great distress and
in need of help. The local physician, who witnessed this, was as
bewildered as anyone else and eventually made a diagnosis of
"bewitchment." "The evil hand is on them," he said and turned them
over to the local officials for care.
	The clergy and magistrates, regarding the young people as
victims and pampering them by showing much attention to their
symptoms, assumed that local agents of Satan were at work and,
using as grounds the answers to leading questions, indicted several
citizens. The accepted proof of guilt was bizarre. The young women
spoke of visions of the accused, of sensing their presence at night
by pains and torments and of ghostly visitations to their homes,
all occurring while the accused were known to be elsewhere. The
victims even screeched out in court that they felt pinches and
pains provoked by the accused, even while they were sitting quietly
across the room. Judges believed this "spectral" evidence because
it conformed to contemporary thought about the capacities of
witches; they dismissed all denials of the accused and promptly
executed them.
	The whole exercise should have been discredited when, after
the executions, there was no change in the distraught behaviour of
the young women. Instead more and more citizens were indicted. A
prosecution depending on "spectral evidence" was at last seen as
capricious--as irrefutable as it was undemonstrable. The trials
ceased, and eventually several of the young women admitted that
their beliefs had been "delusions" and their accusations false.
	The modern diagnosis for these young women is, of course,
hysteria not bewitchment. Psychiatrists use the term hysteria to
identify behavioural displays in which physical or mental disorders
are imitated. The reasons for the behaviour vary with the person
displaying the disorder but are derived from that person's more or
less unconscious effort to appear more significant to others and
to be more entitled to their interest and support. The status of
the putatively bewitched in Salem of 1692 brought both attentive
concern and license to indict to young women previously scarcely
noticed by the community. The forms of hysterical behavior--whether
they be physical activities, such as falling and shaking, or mental
phenomena, such as pains, visions, or memories--are shaped by
unintended suggestions from others and sustained by the attention
of onlookers--especially such onlookers as doctors who are socially
empowered to assign, by affixing a diagnosis, the status of
"patient" to a person. Whenever these diagnosticians mistake
hysteria for what it is attempting to imitate-misidentifying it
either as a physical illness or inventing some psychological
explanation such as bewitchment--then the behavioural display will
continue, expand, and, in certain settings, spread to others. The
usual result is trouble for everyone.
	During the last seven or eight years, another example of
misidentified hysterical behaviour has surfaced and again has been
bolstered by an invented view of its cause that fits a cultural
fashion. This condition is "multiple personality disorder" (MPD,
as it has come to be abbreviated). The majority of the patients who
eventually receive this diagnosis come to therapists with standard
psychiatric complaints, such as depression or difficulty in
relationships. Some therapists see much more in these symptoms and
suggest to the patient and to others that they represent the subtle
actions of several alternative personalities, or "alters,"
co-existing in the patient's mental life. These suggestions
encourage many patients to see their problems in a fresh and, to
them, remarkably interesting way. Suddenly they are transformed
into odd people with repeated shifts of demeanour and deportment
that they display on command.
	Sexual politics in the 1980s and 1990s, particularly those
connected with sexual oppression and victimization, galvanizes
these inventions. Forgotten sexual mistreatment in childhood is
the most frequently proffered explanation of MPD. Just as an
epidemic of bewitchment served to prove the arrival of Satan in
Salem, so in our day an epidemic of MPD is used to confirm that a
vast number of adults were sexually abused by guardians during
their childhood. Now I don't for a moment deny that children are
sometimes victims of sexual abuse, or that a behavioural problem
originating from such abuse can be a hidden feature in any life.
Such realities are not at issue. What I am concerned with here is
what has been imagined from these realities and inventively applied
to others.
	Adults with MPD, so the theory goes, were assaulted as young
children by a trusted and beloved person--usually a father, but
grandfathers, uncles, brothers, or others, often abetted by women
in their power, are also possibilities. This sexual assault, the
theory holds, is blocked from memory (repressed and dissociated)
because it was so shocking. This dissociating blockade itself--
again according to the theory--destroys the integration of mind and
evokes multiple personalities as separate, disconnected,
sequestered, "alternative" collections of thought, memory, and
feeling. These resultant distinct "personalities" produce a variety
of what might seem standard psychiatric symptoms--depression,
weight problems, panic states, demoralization, and so forth--that
only careful review will reveal to be expressions of MPD that is
the outcome of sexual abuse.
	These patients have not come to treatment reporting a sexual
assault in childhood. Only after therapy has promoted MPD behaviour
is the possibility that they were sexually abused as children
suggested to them. From recollections of the mists of childhood,
a vague sense of vulnerability may slowly emerge, facilitated and
encouraged by the treating group. This sense of vulnerability is
thought a harbinger of clearer memories of victimization that,
although buried, have been active for decades producing the
different "personalities." The long supposedly forgotten abuse is
finally "remembered" after months of "uncovering" therapy, during
which long conversations by the therapist with "alter"
personalities take place. Any other actual proof of the assault is
thought unnecessary. Spectral evidence-developed through
suggestions and just as irrefutable as that at Salem-once again is
sanctioned.
	Like bewitchment from Satan's local agents, the idea of MPD
and its cause has caught on among large numbers of psychiatrists
and psychotherapists. Its partisans see the patients as victims,
cosset them in groups, encourage more expressions of "alters" (up
to as many as eighty or ninety), and are ferocious toward any
defenders of those they believe are perpetrators of the abuse. Just
as the divines of Massachusetts were convinced that they were
fighting Satan by recognizing bewitchment, so the contemporary
divines--these are therapists--are confident that they are fighting
perpetrators of a common expression of sexual oppression, child
abuse, by recognizing MPD.
	The incidence of MPD has of late indeed taken on epidemic
proportions, particularly in certain treatment centers. Whereas its
diagnosis was reported less than two hundred times from a variety
of supposed causes in the last century, it has been applied to more
than 20,000 people in the last decade and largely attributed to
sexual abuse.
	I have been involved in direct and indirect ways with five
such cases in the past year alone. In every one, the very same
story has been played out in a stereotyped script-like way. In each
a young woman with a rather straightforward set of psychiatric
symptoms--depression and demoralization--sought help and her case
was stretched into a diagnosis of MPD. Eventually, in each example,
an accusation of prior sexual abuse was levelled by her against her
father. The accusation developed after months of therapy, first as
vague feelings of a dream-like kind--childhood reminiscences of
danger and darkness eventually crystallizing, sometimes "in a
flash," into a recollection of father forcing sex upon the patient
as a child. No other evidence of these events was presented but the
memory, and plenty of refuting testimony, coming from former
nursemaids and the mother, was available but dismissed.
	On one occasion, the identity of the molester--forgotten for
years and now first vaguely and then more surely remembered under
the persuasive power of therapy--changed, but the change was as
telling about the nature of evidence as was the emergence of the
original charge. A woman called her mother to claim that she had
come to realize that when she was young she was severely and
repeatedly sexually molested by her uncle, the mother's brother.
The mother questioned the daughter carefully about the dates and
times of these incidents and then set about determining whether
they were in fact possible. She soon discovered that her brother
was on military service in Korea at the time of the alleged abuse.
With this information, the mother went to her daughter with the
hope of showing her that her therapist was misleading her in
destructive ways. When she heard this new information, the daughter
seemed momentarily taken aback, but then said, "I see, Mother. Yes.
Well, let me think. If your dates are right, I suppose it must have
been Dad." And with that, she began to claim that she had been a
victim of her father's abusive attentions, and nothing could
dissuade her.
	The accused men whom I studied, denying the charges and amazed
at their source, submitted to detailed reviews of their sexual
lives and polygraphic testing to try to prove their innocence and
thereby erase doubts about themselves. Professional requests by me
to the daughters' therapists for better evidence of the abuse were
dismissed as derived from the pleadings of the guilty and scorned
as beneath contempt, given that the diagnosis of MPD and the
testimony of the patients patently confirmed the assumptions.
	In Salem, the conviction depended on how judges thought
witches behaved. In our day, the conviction depends on how some
therapists think a child's memory of trauma works. In fact, severe
traumas are not blocked out by children but remembered all too
well. They are amplified in consciousness, remaining like grief to
be reborn and reemphasized on anniversaries and in settings that
can simulate the environments where they occurred. Good evidence
for this is found in the memories of children from concentration
camps. More recently, the children of Chowchilla, California, who
were kidnapped in their school bus and buried in sand for many
hours, remembered every detail of their traumatic experience and
needed psychiatric assistance, not to bring out forgotten material
that was repressed, but to help them move away from a constant
ruminative preoccupation with the experience .
	Many psychiatrists upon first hearing of these diagnostic
formulations (MPD being the result of repressed memories of sexual
abuse in childhood) have fallen back upon what they think is a
evenhanded way of approaching it. "The mind is very mysterious in
its ways," they say. "Anything is possible in a family." In fact,
this credulous stance toward evidence and the failure to consider
the alternative of hysterical behaviours and memories are what
continue to support this crude psychiatric analysis.
	The helpful clinical approach to the patient with putative
MPD, as with any instance of hysterical display, is to direct
attention away from the behaviour--one simply never talks to an
"alter." Within a few days of a consistent therapeutic emphasis
away from the MPD behaviour, it fades and generally useful
psychotherapy on the presenting true problems begins. Real sexual
traumas can be dealt with, if they are present, as can the
ambivalent and confused feelings that many adults have about their
parents.
	Similarly, the proper approach to end epidemics of MPD and the
assumptions of a vast prevalence of sexual abuse in ordinary
families is for psychiatrists to be aware of the potential,
whenever we are dealing with hysteria, to mistake it for something
else. When it is so mistaken, this can lead to monstrous concepts
defended by coincidence, the induction of memories, and a display
of "spectral" evidence--all to justify a belief that the community
is under siege. This belief, of course, is what releases the power
of the witches' court and the Lynch mob.
	As a corrective, psychiatrists need only review with a patient
how the MPD behaviour was diagnosed and how the putative memories
of sexual abuse were suggested. These practices will eventually be
discredited, and this epidemic will end in the same way that the
witch trials ended in Salem. But time is passing, many families are
being hurt, and confidence in the competence and impartiality of
psychiatry is eroding.

V.

	Major psychiatric misdirections often share this intimidating
mixture of a medical mistake lashed to a trendy idea. Any challenge
to such a misdirection must confront simultaneously the
professional authority of the proponents and the political power
of fashionable convictions. Such challenges are not for the
fainthearted or inexperienced. They seldom quickly succeed because
they are often misrepresented as ignorant or, in the cant word of
our day, uncaring. Each of the three misdirections I have dealt
with in this essay ran for a full decade, despite vigorous
criticism. Eventually the mischief became obvious to nearly
everyone and fashion moved on to attach itself to something else.
	In ten years much damage can be done and much effort over a
longer period of time is required to repair it. Thus with the
mentally-ill homeless, only a new crusade and social commitment
will bring them adequate help again. Age accentuates the sad
caricature of the sexual reassigned and saps their bravado. Some,
pathetically, ask about re-reassignment. Groups of parents falsely
accused of sexual mistreatment by their grown children are
gathering together to fight back in ways that will produce dramatic
but distressing spectacles. How good it would have been if in the
first place all these misguided programs had been avoided or at
least their spa abbreviated.
	Psychiatry, it needs always to be remembered, is a medical
discipline--capable of glorious medical triumphs and hideous
medical mistakes. We psychiatrists don't know the secret of human
nature. We cannot build a New Jerusalem. But we can teach the
lessons of our past. We can describe how our explanations for
mental disorders are devised and develop--where they are strong and
where they are vulnerable to misuse. We can clarify the
presumptions about what we know and how we know it. We can strive
within the traditional responsibilities of our profession to build
a sound relationship with people who consult us--placing them on
more equal terms with us and encouraging them to approach us as
they would any other medical specialists, by asking questions and
expecting answers, based on science, about our assumptions,
practices, and plans. With effort and good sense, we can construct
a clinical discipline that, while delivering less to fashion, will
bring more to patients and their families.

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PAUL R. McHUGH is Henry Phipps Professor and Director of the
Department of Psychiatry and Behavioural Sciences at the Johns
Hopkins University School of Medicine. He is the author (with
Phillip R. Slavney) of _The Perspectives of Psychiatry and
Psychiatric Polarities._ This article is from The _American
Scholar,_ Autumn 1992.

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