Try to Remember: Psychiatry's Clash over Meaning, Memory and Mind

Diagnostic labels are a cause of fierce debate in this enjoyable set of 'stories', says David Pilgrim

January 1, 2009

This book contains three overlapping stories. The first is a fascinating account of Paul McHugh's battle within psychiatry about the legitimacy of dissociative identity disorder (DID), which is still mainly known as multiple personality disorder outside the US. This diagnosis is popular among its recipients, whereas few line up gleefully for the label of, say, schizophrenia.

While the latter is rarely a great career move, DID may offer the prospect of exculpation for criminal acts or, even more excitingly, film scripts and best-selling books. It is also diagnosed overwhelmingly in the US, suggesting that it can be read, at one level, as a peculiar culturally communicated form of psychological exotica. McHugh rages against the wrong-headedness of his colleagues about DID and weaves into this his second story. This examines his contempt for psychoanalysis and his demand for its replacement with a rationalistic form of therapy - for now the ubiquitous cognitive-behavioural therapy - as the harbinger of scientific progress.

McHugh contends that Freudians habitually insist that patients are victims of childhood abuse and their repressed experiences require therapeutic excavation. Instead, according to McHugh, these false claims are co-constructed collusively by needy patients and needy therapists. This scenario is more than possible, but we have to be careful on a case-by-case basis about making strong stereotypical claims about either patients or therapists. Parents abusing their children, sexually and otherwise, will seek to escape responsibility. McHugh is right to point out, though, that child abuse is a crime (a forensic matter for us all to unravel) rather than a medical condition - hence the problem with paediatricians "diagnosing" sexual abuse.

A further pertinent caution, as Jeffrey Masson found when researching The Assault on Truth: Freud's Suppression of the Seduction Theory, is that Sigmund Freud deserted his original claim about the high prevalence of incest survivors on his couch and replaced it with the idea of extensive patient fantasy. He thereby betrayed and deserted true victims rather than setting up false accusers (McHugh's contrary emphasis). Thus it is more valid to focus on the discursive legacy of "dissociation" as a mental state, derived from the variegated versions of many clinicians in the wake of Pierre Janet and Freud, rather than singling out the latter as blameworthy.

The third story is McHugh's own revision of psychiatric diagnosis. Although critical of the rationale of many current categories, he retains a nomothetic approach - the labelling of embodied individual expressions of putative objective disease entities. He does not favour contingent formulations of madness and misery, which might come in many shapes and sizes. Such an idiographic approach would rob psychiatry of one of its dwindling unique selling points - diagnosis.

Emil Kraepelin, conveniently for both medicine and eugenics, considered that mental disorders were naturally occurring categories, implicating neurological damage and with genetically fixed deteriorating courses. McHugh invents his own alternative version of this tradition of medical naturalism.

However, the advantage of this particular version of butterflies-pinned-to-a-board psychiatry is elusive. McHugh, like the tradition he seeks to modify, still commits the fundamental epistemic error of confusing reality with his preferred view of reality. Moreover, he does not explain how patients are helped by having their unique existential predicaments and responsibilities reduced to a label, any label.

This is a good read, but the professional motives of the author and his preferred constructs can both be interrogated critically. McHugh sets out with brio to debunk and demystify, but he has constructed his own desired stories. Readers will no doubt make up their own minds about what to believe.

Try to Remember: Psychiatry's Clash over Meaning, Memory and Mind

By Paul R. McHugh

Dana Press, distributed by Chicago University Press

300pp, £13.50

Published 26 November 2008

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