Adventures in Academic Psychiatry
By Paul R. McHugh
When he arrived as the new department director 26 years ago, house staff told him, "Your way is not the Hopkins way. Leave us alone." The last thing he planned to do was leave them alone.
One morning in late August 1975, I arrived at the Phipps Clinic as the newly appointed director of the Department of Psychiatry and Behavioral Sciences. By the end of that first day I knew I had a job. The department was in chaos, nobody seemed to know why, and many presumed that I couldn’t help. The administrator and secretaries were pleased to see me as were a few faculty who had carried directorial duties while awaiting my arrival. But most of the clinicians faculty and resident psychiatristslooked at me with that condescending facial expression special to psychiatrists that asks, "Are you thinking of teaching me?" Because I was also a neurologist, they supposed that I would think "neurobiologically" not "psychologically" about patients as they did.
The first floor of the Phipps Building was cluttered with posted memorabilia about its first director, Adolf Meyer, whose concepts had shaped American psychiatry in his time early in the 20th century. But for all his iconic presence in photos, diagrams, old lecture notes and sculptures, Meyer’s ideas were unknown to the students at the Phipps now 35 years after his retirement. The worship of his ashes and ignorance of his contributions demonstrated again the short step from "Who’s Who" to "Who’s He." I eventually cleared this stuff awaysending it to the Hopkins historical archivesand tried to remind people of Meyer’s thought in my teaching. A few of his former students, notably Wendell Muncie, Leo Kanner and Jerome Frank, seemed pleased by both actions.
In those first weeks in 1975 I visited everyone to hear their views and experiences. I also began clinical rounds primarily to see the way people at Phipps talked to one another, how they responded to clinical questions, how they thought. My aim was to see what needed doing promptly and where resistance might come. Some of what I saw was what might be expected in an organization that had had little leadership for a generation. But there was more.
All organizations without leadership go awry over time, but psychiatry departments do so in a special way. They fragment into competing therapeutic cults usually around forceful guides, each of whom claims to know some special secret about the treatment of psychiatric patients. Psychoanalysts, milieu therapists, encounter groupies, behaviorists and psychopharmacologists all had champions at Phipps. Each of them made contributions to patient care and teaching, but each tended to dismiss the others as misguided. All the talk in the clinic was about "therapy," and everyone (doctors, students, nurses, even aides) was doing "therapy" with the patientssimultaneously and often in conflict.
Case conferences brought the problem to light. A patient would be presented by a resident or student. But the clinical information provided was carefully selected by a guide to support the kind of therapy the patient was receiving. The discussions that followed would be heated as one voice refuted another, usually with little more backing beyond some personal anecdote or some misplaced reference to a beclouding scientific concept. The Heisenberg Uncertainty Principle was a favorite. These disorganized conversations taught little to students beyond how nimble many of our faculty were in argument.
These conferences mirrored the wards and outpatient services. Each patient was treated according to the conceptions of the therapist to whom he or she had been by chance assigned. No uniform practice, uniform evaluation or uniform conceptual scheme could be found at Hopkins. And yet the situation seemed ordained. One therapist said to me about the outpatient service, "This is the most disorganized place I’ve ever seen, but nobody can ever do anything about it."
At heart, everyone wanted to do his "own thing." A small contingent of senior residents visited me early in my first months to protest my frequent presence on wards, at clinical meetings and the like. They especially didn’t like my suggestions, whether right or wrong. "Your way is not the Hopkins way," they said. At Hopkins, I was told, residents were left to learn from experience and came to the faculty only when they had a question they thought a faculty member might be able to answer. "Leave us alone," they said "We’ll be OK."
The last thing I planned to do was leave them alone because, although they were gifted, hardworking people, they lacked a coherent, broad-ranging conception of the nature and practices of this discipline. I tried to persuade them that my ideas about psychiatry would strengthen them, transform their busy but disjointed efforts into a progressive program of study, eventually allowing them to become better judges of theory and practice, and, if they were so inclined, add to the current body of knowledge with their own research. But being human, most of the first group of residents did not believe me. When I didn’t follow their suggestions, several left Hopkins to train elsewhere.
I, though, knew something they didn’t. Chaos and lack of direction were not unique to Johns Hopkins and they couldn’t avoid my questions by going elsewhere. Incoherence was universal in American academic psychiatry in 1975. The inadequacy of the explanatory and therapeutic concepts of Freudian psychoanalysisthe theory that dominated American psychiatry for a generationhad become obvious by the mid-1970s, but no lucid system of thought had advanced to replace it.
Thus the job before me was more challenging than just putting the daily affairs of the Phipps Clinic on an even keelthe services, the medical student curriculum, the schedules, etc. The task was to present and argue for basic changes in thinking at Hopkins that would permit us to meet our national as well as our local Phipps-based responsibilities.
If we were to keep our promises to resident physicians who came to us expecting to flourish professionally, and if we were to step up and lead American academic psychiatry out of the swamp into which it had become mired, our ways of thought and practice had to change. Never had I felt such an acute sense of responsibility for the consequences of my ideas on the social and professional lives of others.
Once I appreciated the task, the path was clear. First I had to put in place some basic clinical and administrative components missing from the Phipps Clinic when I arrived. We had no social work division to bring us information about the social networks from which our patients emerged and into which they must return. We had no clinical psychology division ready to provide us with measurement of our patients’ psychological capacities and potentials. We had no nursing program suitable for the challenges of the future. When I proposed that the Phipps take in and care for patients with cancer depression, Alzheimer’s and Huntington’s disease, and eventually AIDS, a nurse said to me, "Caring for such patients is not why I went into psychiatric nursing. I want to do psychotherapy, and the medically ill are just not suitable."
Finally the residency program was not pedagogically progressive. There was no set of goals to be achieved by the student at each step along the way so that advancing educational opportunities could be built upon learned skills. The residents saw whoever was assigned to them and gradually developed a huge load of undifferentiated patients to be followed in psychotherapy.
These components were missing because the department relied on the assumptions of Freudian theory about psychiatric services. This theory holds that the crucial matter in the care of patients is the therapeutic relationship through which psychological problems are revealed and ultimately solved. Learning to build this relationship is the heart of any psychiatric education, and other services such as social work, psychological assessment or medical nursing were thought inessential.
As a moment’s reflection reveals, this concept implies that all psychiatric patients or all patients suitable for a psychiatrist’s attention are fundamentally the same in nature, need the same treatment and differ only in the degree of their distress and extent of their challenge to the therapeutic relationship. Thus at Phipps everyone was a "therapist" every day because talk therapy, and plenty of it, was what psychiatric patients needed.
What I had to do was develop and implement a new framework of thought about psychiatric patients by identifying essential differences among the clinical conditions we manage. Such a framework would transform teaching, practice and research. As the differences among patients were scrutinized, what various patients needed in the form of evaluation, support, treatment and rehabilitation would lead to plans for new services and new practices. As well I could, I promised that as we studied the patients and provided for them, we would become aware of aspects of professional ignorance calling for productive research, encouraging the best of our young psychiatrists to become first-class scientists.
A full discussion of the managerial processes and personal adventures I used to implement this vision is a story in itself. Suffice it to say that ultimately changing the department depended on sustaining a seminar-like atmosphere in the clinic to clarify the nature of each psychiatric patient and to integrate clinical information, treatment programs and research.
Fundamentally this is what I taught: psychiatric patients come in four separate but overlapping forms or natures. Some have brain diseases that explain their symptomspatients with such conditions as Alzheimer’s disease, bipolar disorder and schizophrenia. To explain what they "have," we employ standard investigative approaches to pathogenesis and pathophysiology.
Other psychiatric patients are intermittently distressed because some aspect of their mental constitutionweakness in their cognitive power or instability in their emotional controlrenders them vulnerable to neurotic breakdown when they are challenged by new demands in their day-to-day lifein school perhaps or at work or in their marriage. These patients do not "have" a disease; they are vulnerable to distress under certain circumstances because of who they "are."
A third group of patients is disturbed by a behavior that has become a warped "way of life" for them. These are the alcoholic patients, the addicts, the sexually perverse, the anorexics and others like them. They are psychiatric patients not because of what they "have" or who they "are" but because of what they are "doing" and why they find it compelling.
Finally, there are patients who are in need of psychiatric assistance because of what has happened to themlife experiences that have threatened, interrupted or thwarted their hopes, commitments and aspirations. A loved one has died, say, or they were fired from their job, and the situation provokes easily understood emotional reactions such as grief, homesickness, jealousy, hostility or demoralization. These states are a result of what the patient has "encountered" and the assumptions they make about these encounters.
Each of these four kinds of patients needs a different treatment program. Those with a disease need it to be cured, alleviated and prevented. Constitutional weaknesses need strengthening, and the vulnerable individual who possesses such a weakness needs guidance. Harmful behaviors need to be interrupted, and people with states of mind such as hostility and demoralization need understanding and a redirection of their life plan. No overarching "therapy" fits the needs of all these patients or makes sense of them.
This approach to identifying patients according to the nature of their problems does not deny that talk therapy may help some patients or that psychiatrists should learn about talk therapy as well as other treatment methods. With this approach we do not fight with the champions of each particular treatment. Instead, we try to find and describe the patients to whom each treatment applies. We teach a broader and more critical psychiatry than one directed by a specific therapeutic point of view such as psychoanalysis.
As I had expected, this new, conceptual structure for psychiatry did encourage the vigorous growth of research in our department. As we began identifying psychiatric conditions by their essential natures, a cooperative synergy of interests between clinicians and investigators began emerging. From our ranks scientists in molecular biology, genetics, brain imaging, physiology, analytic and experimental psychology, and epidemiology started to develop and gain international reputations. Lively and informed discussions at our rounds became customary because of our faculty’s and students’ progressive sophistication in dealing with contemporary scientific research.
My aim for more than 25 years was to impart a conceptual structure for psychiatry that would transform the Phipps Service clinically and investigatively. I believed that the local problems that others considered unsolvable were simply the result of conceptual incoherence and that what this psychiatric service needed was a coherent structure for reasoning about its patients. Measurable success with such a model would place the Hopkins Department of Psychiatry once again at the forefront of American psychiatry where it belonged.
It worked out. Practical matters rather than some big theory directed our thoughts and management. Over time, the faculty noticed and rejected the department’s original problems and came up with coherent solutions. We constructed missing administrative components and began expecting and achieving better results. Our patient services improved steadily, staff acquired new skills and better morale, our scientific research expanded, and we educated clinicians and academic leaders for the world.
The results are a matter of record: Today psychiatry at Hopkins brings in $30 million in research funding from the NIHonly the Department of Medicine receives more. Six psychiatry chairmen at medical schools around America were trained in our program, and the new International Textbook of Psychiatry (Oxford Press) identifies that program as the model for the field. But the record should include another item: the names of the people in and out of my own department who helped and supported me in transforming my vision into reality. Rest assured I know I didn’t do it alone.
Paul R. McHugh is Henry Phipps Professor of Psychiatry and psychiatrist-in-chief at The Johns Hopkins Hospital.