Just-so therapy.

The Mind Has Mountains

Reflections on Society and Psychiatry

Paul R. McHugh

The Johns Hopkins University Press, $25, 272 pp.

The Mind Has Mountains is a long and uneven feast of a book made up of seventeen essay-length courses. The author, Paul R. McHugh, is former director of psychiatry at the medical school of the Johns Hopkins University. As an appetizer, McHugh offers stories of psychiatric misadventure and therapy gone awry. The main course consists of essays related to the cultures of life and death, particularly as revealed in the cases of Dr. Jack Kevorkian and Terri Schiavo. Dessert includes reflections on the happy demise of Freudianism and other psychiatric mistakes, followed by a digressive but bracing aperitif on terrorism. Laced through these essays is McHugh's mistrust of metaphor; and so, to conclude my own metaphor, I would say that while the fare McHugh offers is sometimes quite good indeed, the real appeal of the meal is its presentation: the author knows how to tell a story.

McHugh portrays contemporary psychiatry as dangerously enamored of metaphor and narrative at the expense of reason and empirical research. The results of this "cultural antinomianism" have hurt patients most of all: schizophrenics are considered to be living an "alternative lifestyle" and are released from the institutions that sought to help them; patients confused about their gender identity are not helped to understand and accept reality but are rather "mutilated" through sex-reassignment surgery. In McHugh's opinion, all of these mistakes have their source in a psychiatric hubris that seeks to bring about a "New Jerusalem" by challenging clinical barriers instead of focusing on less romantic but much more effective medical therapies. For McHugh, the dangers of this grandiosity are epitomized in the case of Dr. Margaret Bean-Bayog and her patient Paul Lozano. After Lozano committed suicide, notes were found that suggested he and Bean-Bayog had been sexually involved. While a sexual relationship was never proved, McHugh points to Bean-Bayog's overall conduct as exemplifying the problems besetting contemporary psychiatry. Bean-Bayog was too confident not only of her own first impressions but also of the psychological "theory" to which she subscribed. This kept her from seeking consultation and criticism and from properly coordinating pharmacotherapy with psychotherapy for her clinically depressed patient.

McHugh presents several such cases of psychiatry gone off-track. In many ways the real villain in these tales is the "interpretative idiom of psychodynamic metaphors" that can quite easily mislead both therapists and their patients. More broadly understood, the villain is narrative itself. Narratives offered by patients about their illnesses are important, but should not be mistaken for explanations. Narratives that psychiatrists embrace about themselves may also distract them from the real needs of their patients. A medical discipline based on empirical research provides the necessary corrective to an excessive concern with personal narrative, a concern that reflects the self-absorption of our age.

McHugh is at his best when he is defending a cautious professional ethic that recognizes the limits of human knowing. His wise and measured conservatism gives him a good vantage point from which to critique the excesses of Dr. Jack Kevorkian, who, in "making dying easy," deprives patients of hope, care, and meaning. McHugh's professional experience, along with his respect for the mystery of life, leads him to see the person at the heart of the Terri Schiavo controversy. And a belief in personal responsibility leads McHugh to criticize the excesses of Freudianism as well as narcissistic narratives of depression such as those offered by Andrew Solomon. For psychological realism, McHugh prefers Shakespeare, who saw human flaws and susceptibilities clearly and also acknowledged the existence of evil. These are the realities that psychiatry must humbly and steadfastly confront.

But McHugh's attitude toward storytelling and narrative turns out to be somewhat conflicted. He mistrusts narrative in clinical settings, but he embraces it for the purposes of his own polemics. In The Mind Has Mountains, people like Bean-Bayog and Kevorkian--or the student who believes schizophrenia to be an "adaptive responsive," or the slovenly Harvard professor overly enamored of Freud--figure as evidence of the confusions McHugh wishes to combat. The problem is that in McHugh's account these people become merely foils for argument; the author's narrative of ideas strips them of their real human complexity.

A more serious problem comes in the final essay, "A Pychiatrist Looks at Terrorism." Mistrustful of those who dither about meaning in a time of peril, McHugh describes terrorists as people in thrall to an "overvalued idea." He argues that any policy to combat terrorism must be toughminded and focused on deterrence, whatever the short-term cost. In the end, he insists, freedom will prevail if given half a chance. Apart from the fact that McHugh does not seem especially competent to offer a cost-benefit analysis of antiterrorism policies, there is a larger problem of interpretation. McHugh seems to accept the master narrative of will and power held dear by neoconservatives and other contemporary Pelagians. With the term "overvalued idea," he impatiently dismisses complex ideologies and histories. By calling an idea "overvalued," he simply sidesteps a real discussion of values and ideas and skips prematurely to a conclusion about practical methods. The various peoples of Iraq and Afghanistan have their own narratives about what's involved in the American effort to bring them freedom, and these are probably more complicated than McHugh supposes. Commentators and policymakers ignore and undervalue such alternative narratives at their own peril--and ours. By the end of this important collection of essays, McHugh seems to have ignored his own counsel about human limitation and professional humility. Scornful of self-indulgent narratives, he, too, has gotten carried away with a good story that is too easy to be true.

Mathew N. Schmalz is associate professor of religious studies at the College of the Holy Cross in Worcester, Massachusetts.