The Mind has Mountains — Reflections on Society and Psychiatry

This book is a collection of essays by Dr P McHugh, the former director of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. In the Preface, Dr McHugh reveals that the contents of the book are prompted by misclaims and opin- ions expressed by psychiatrists and psychologists during the past few decades. The book is essentially a collection of thoughts by Dr McHugh, relating societal issues influential to psychiatry and considered by the author to be miscon- ceptions detrimental to the discipline. As a highly respected academic psychiatrist witnessing the changing era of American psychiatry, Dr McHugh hopes to offer a way of thinking that stimulates the development of psychiatry along a more coherent and productive path.

In Part I, Dr McHugh reviews a series of psychiatric misadventures. This includes the 'antipsychiatry' movement, dismissal of seriously ill patients from hospitals, the history of bewitchment and hysteria, sex correction surgery, and recollection of childhood sexual abuse in multiple person- ality disorder. Throughout the history of psychiatry, major faults have usually comprised a mixture of medical mis- takes and fashion in society. The author stresses that most of these psychiatric misadventures persisted for a long time despite vigorous criticisms. The 'psychotherapy awry' has been a significant period in the history of American psychiatry after the Second World War. The indiscriminate use of psychoanalytic psychotherapy delayed adequate pharmacological treatment for patients, hindered the quest for the scientific proof of the basis of human behaviour, and led to a number of patients with mishandled thera- peutic relationships. The author does not neglect the role of psychotherapy in psychiatry, but emphasises that psycho- therapy plays a role in explaining the nature of mental symptoms, resolves misunderstandings, and encourages more constructive life strategies. However, this treatment modality is only part of a holistic plan, not the sole key to cure.

The success of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has changed the system of psy- chiatric diagnoses. The DSM was initially developed to improve the reliability of diagnosis across different centres. However, it gradually evolved to become a method of clini- cal diagnosis for all kinds of psychiatric disorders, and serves to support the existence of some diagnostic categories. Rather than reaffirming the usefulness of this system, the author offers critical remarks on its limitations. Medical diagnosis needs to be built on understanding of underlying mechanisms, while the DSM is dependent on symptom- atology and lacks reflection of the underlying pathology. For Dr McHugh, DSM-led psychiatry has forgone the chance to search for disease pathology and mechanisms leading to the disturbed mind. From a broader perspective, the current psychiatric diagnostic method includes a spectrum of disorders reflecting behavioural patterns that conflict with societal norms. The validity of this group of behaviours as a psychiatric disorder has been questioned by many and also the author of this book. He has made a clear distinction between serious psychiatric disorders such as schizophrenia and bipolar affective disorders and behavioural abnormal- ities not adaptive to current society. Examples discussed include post-traumatic stress disorder, and avoidant and obsessive-compulsive personality disorder.

In Part II, Dr. McHugh takes on the issue of physician- assisted suicide and euthanasia to reflect the paradoxical challenge to the practice of medicine to save life. He holds the view that this contemporary paradox originated from a convergence of host, agent, and environmental factors. Vul- nerable sick patients living in society are tempted to take their life by advocates of this idea. Using the case of Terri Schiavo, the author questions judicial decisions for suspend- ing life support for patients unable to offer consent for end- of-life decisions. While the author acknowledges the suf- fering of patients with chronic diseases, he takes a clear stand of optimising medical treatment for patients in need, and condemns the advocates of mercy killing or euthanasia. Dr McHugh feels that patients should be relieved of psycho- logical and physical suffering, but not forgo life before its natural end.

Having tackled numerous ethical dilemmas in contem- porary psychiatry, the author puts forward the new struc- ture for explaining mental disorders. The 4 'perspectives' in psychiatry are disease, dimension, behaviour, and life story. He emphasises the need for psychiatrists to integrate ad- vances in neuroscience and environment that modulate behaviours, and that the profession is a branch of medicine and a vital profession with a distinctive structure of know- ledge unique to the management of mental disorders.

The debatable issues raised by Dr McHugh not only rep- resent important turning points in the history of American psychiatry, but also have strong influences in other parts of the world. The rich experience and special position held by the author makes this book a unique reflection of the ups and downs in psychiatric practice in different periods. The boundary of psychiatry as a medical specialty has been challenged throughout history. While the provocative views of the author may not be shared by all, this book is highly readable for those who seek a critical observation of the history of psychiatry.

Linda CW Lam
Department of Psychiatry
The Chinese University of Hong Kong
Hong Kong, China

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