By Jim Duffy
Psychiatrist Paul McHugh has attracted controversy over three decades, but when he sets his sights on a trendy diagnosis, his aim almost always proves true.
n 1992, Paul McHugh looked back on his 17 years as Henry Phipps Professor of Psychiatry and director of the Department of Psychiatry and decided it was time to go. He’d taken a floundering department and put it back on the national map. He’d co-written an acclaimed psychiatry text, conducted important research on the workings of satiety and sent scores of talented young psychiatrists out to key posts at medical centers throughout the nation.
Now, with retirement looming, the then-61-year-old McHugh felt anxious. While he loved it at Hopkins, he wondered what was left for him to accomplish. And he worried that the administration had decided to rest on his department’s laurels for the foreseeable future. “I came to the conclusion that maybe they were waiting for my successor,” he recalls, “that maybe they were going to hold onto resources and not reinvest in psychiatry until the next person came in.”
So McHugh reluctantly broke the news that he was about to accept a position as director and CEO of Friends Hospital in Philadelphia. And suddenly the reserved Johns Hopkins School of Medicine sprang into gear and launched a full-court press to convince the outspoken Bostonian, whose name had become synonymous with the demystification of psychiatry, that it couldn’t do without him.
“They basically said, ‘Hell, we don’t want your successor—we want you,’” McHugh recalls. “In retrospect, it was my misconception.”
Today, it’s hard to fathom that McHugh came so close to leaving. Over the last couple of months, a flurry of festivities and events has marked the passage of the genial psychiatrist’s 30th anniversary in the field, starting with the long-awaited publication of a second edition of The Perspectives of Psychiatry, the landmark text he wrote with his department colleague Phillip R. Slavney. Then, on Nov. 12, a standing-room-only crowd gathered in Hurd Hall for the dedication of the Paul R. McHugh Chair in Psychiatry, endowed with $1.76 million in contributions from admiring colleagues, friends and former patients and dedicated to research in the “motivated behaviors” of sex, eating and addictions.
“He took a department that had been a shambles and made it number one in the world,” touted neuroscientist Solomon Snyder, M.D., during the celebration of the anniversary. Accepting the accolades with characteristic good humor, McHugh conceded with an elfin grin that there was a certain sweetness in “hearing the endless drumbeat of one’s name again and again.”
Advice That Shaped a Career
When McHugh arrived at Hopkins in 1975 to take charge of the department, he remembers asking a colleague for an insider’s tour of the outpatient facility. As the pair walked through the unit, McHugh’s guide recounted horror stories about a dysfunctional workplace plagued by morale problems and philosophical differences. “This place is a disaster,” she told her new director, “and it can’t be fixed.”
An accomplished storyteller, McHugh relays the incident with relish, his Irish eyes twinkling and his laughter resounding through his office on Meyer 4. And while his anecdote may sound a note of self-congratulation—showing just how far his department had to come in order to reclaim national status—that’s not really his point. To McHugh, the problems he grappled with to put Hopkins psychiatry back on course exemplify the point he’s spent three decades drumming home: It’s easy to lose your way in psychiatry, to settle for something less than the best of science and medicine.
McHugh’s career has always been about keeping his profession on course. Criticized by some as a contrarian and cherished by others as a voice of reason, he has a penchant for dismissing trends like recovered memory (in which adults suddenly recall through therapy suppressed early experiences of sexual abuse) and multiple personality disorder as “psychiatric misadventures.”
He followed a rather unusual route into psychiatry. Reared and educated in the Boston area—he speaks with an accent so thick it recalls the verbal excesses of Clarence the angel in “It’s a Wonderful Life”—McHugh earned a medical degree from Harvard and embarked on an internship at Peter Bent Brigham Hospital. In the fall of 1956, he met with Brigham’s Department of Medicine chairman, George Thorn, M.D., and told him of his interest in psychiatry. Thorn’s reaction was less than enthusiastic: “Gee, I’ve had a number of interns go into psychiatry, but I’ve been very disappointed in what they’ve achieved,” he told McHugh. “I wonder, sometimes, if perhaps it’s because they haven’t studied the brain.”
Today, that might seem a logical suggestion, but at the time it bordered on the revolutionary, especially in psychotherapy-happy Boston. “I don’t know how he came up with that,” McHugh marvels. “I mean, this was before anyone had really even heard about neuroscience.”
McHugh heeded the advice, completing a residency in neurology and neuropathology at Massachusetts General before continuing his psychiatry education at the University of London’s Institute of Psychiatry and Walter Reed’s Division of Neuropsychiatry. Along the way, he decided to pursue a career outside New England: “Boston would have been the death of me because of its total commitment to psychoanalysis,” he says. “I realized by then that Dr. Thorn was right. His advice, in a way, really shaped my entire career.”
After stints at Cornell, where he founded the Bourne Behavioral Research Laboratory, and the Oregon Health Sciences Center, where he chaired the Psychiatry Department, McHugh accepted the call to come to Baltimore and reinvent Hopkins psychiatry. As his first tour of the outpatient services showed, that task proved quite a challenge.
'It's Just Like Medicine
“When he came in, things were a shambles in psychiatry,” recalls Sol Snyder. While staffed with some brilliant doctors, the faculty was divided so staunchly into theoretical camps that operating cohesive research and educational programs proved impossible. When it came to patient care, doctors tended to greet each new case as another in a succession of one-of-a-kind anomalies.
“That’s the kind of thing that happens in psychiatry,” McHugh complains. “They were bouncing around and seeing every case as being unique and a new challenge. I wanted to show them that, no, there are things that are common to cases, and then there are things that are individual to cases. It’s just like in medicine: Everybody that has a heart attack has some of the same things going on, but of course at the same time they come from different backgrounds and have different bodies.”
As an administrator, McHugh took his department back to the basics, getting out on the patient units to talk to residents and staff about standard diagnostic procedures and treatment decisions, and focusing clinical and research efforts on specialties—including addictions and eating disorders (McHugh himself has done important work on the biological mechanisms behind satiety)—suited to his philosophies and his faculty’s strengths. Then, in 1983, he and Slavney outlined the Hopkins approach in The Perspectives of Psychiatry, a work that seeks to systematically apply the best work of behaviorists, psychotherapists, social scientists and other specialists long viewed as at odds with each other.
A master of the pointed one-liner, McHugh over the years introduced a series of them into the departmental repertoire. First and foremost was: “What do we know and how do we know it?” It’s a question designed to keep psychiatrists away from flights of theoretical fancy and teach residents to keep their feet on solid scientific ground. “Teaching psychiatry is often like practicing psychotherapy,” McHugh says. “You have to drive ideas out of people’s heads first, before you go on to fill them with others.”
More than 300 resident physicians and fellows have been educated under McHugh’s guidance, including the current psychiatry directors at Harvard, Tufts, Iowa and Penn State. His teaching approach has been known to bruise some egos, especially among residents challenged to public debate by the esteemed and exceptionally witty director, but more often than not McHugh earns their loyalty by delivering extraordinary levels of encouragement. Robert G. Robinson, now the head of psychiatry at the University of Iowa, recalls the day in 1979 when McHugh learned that Robinson had won his first grant. “Paul called me in his office and was so happy and enthusiastic that he was jumping up and down,” Robinson says.
He gives the same insightful support to faculty. Professor Peter Rabins recalls complaining to McHugh one day about the voluminous requests he was fielding for a paper he’d written on memory loss in the elderly. McHugh responded not with sympathy, but with congratulations: “There’s a real need for this information, then, don’t you think? Why don’t you write a book?” The result of that offhand suggestion, The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer’s Disease, Related Dementing Illnesses, and Memory Loss in Later Life, has sold a million copies.
“He is the greatest American teacher of psychiatry in the 20th century, with the possible exception of Adolf Meyer,” says Marshal Folstein, a former student who is now chairman of psychiatry at Tufts/New England Medical Center. “His ideas are always 10 to 15 years ahead of the field in this country, and so his students are always at the forefront of research and practice.”
I love a Good Argument
In the years since his decision to stay put at Hopkins, McHugh has refocused his energies. He’s moved out of the lab to devote more time to updating The Perspectives of Psychiatry and setting out to spread the tenets of Hopkins psychiatry into the public domain. He’s delivered a series of razor-sharp essays and important speeches on controversial issues like assisted suicide, recovered memory and sex-change surgery. “I love a good argument, especially when it’s in my discipline,” McHugh says with a laugh, “and it’s been a great way to try to see to it that everybody in America knows Johns Hopkins psychiatry.”
In the midst of the outpouring of admiration in November, the idea that McHugh had come very near to leaving Hopkins and Baltimore six years ago seemed ludicrous. A two-day international conference about links between research and psychiatric practice that culminated the weekend held in McHugh’s honor was awash with everyone from literary celebrities to pillars of psychiatry. Essayist Joseph Epstein, former editor of The American Scholar (which frequently features McHugh’s essays), stopped by, praising the honoree as a “manic impressive” for his feverish enthusiasm. And writer and neuroscience buff Tom Wolfe, a longtime friend whom McHugh treated for depression suffered in the wake of bypass surgery, traveled from New York City to be there. Wolfe, in fact, dedicated his most recent novel, A Man in Full, to McHugh, “whose brilliance, comradeship and unfailing kindness saved the day.”
Wolfe was seated at McHugh’s side when Dean/CEO Ed Miller took the podium to make the surprise announcement that McHugh had been named a distinguished University professor in honor of “a career that will permanently mark psychiatry as a science well into the 21st century.”
What McHugh cherished most about the big weekend, he says, was looking out at the conference audience and seeing so many former students. “That’s what was so thrilling to me—the sense of reunion,” he says. “You know, I always thought that if I could get in the right position, get all these young people around me, that I’d be able to block and tackle for them as well as anybody could.”