To the Editor:
Kay S. Hymowitz provides everything an author might wish for in her review of my book, The Mind Has Mountains—a thorough reading, a conscientious effort to distill the central ideas, and a set of critical reflections on their implications [Books in Review, July-August]. For her efforts and the kind sentiments she expresses, I am deeply grateful. I write now because her piece seems to encourage a conversation about the medical basis of psychiatric authority.
Kay Hymowitz notes that the discipline of psychiatry has had a powerful influence on social and cultural thought. She ascribes this power—correctly, I think—not to the discipline’s capacities for evaluation and treatment (which compare unfavorably with most medical and surgical disciplines) but to its readiness to offer opinions about human nature at a time when we lack “a rich alternative for describing inner life.”
But, she asks, when psychiatrists counsel unhappy people, do they not extend themselves beyond the authority of medicine? Do not therapists such as myself, in striving to help these “sufferers,” depend on a “personal vision”—one that is laden with “unspoken assumptions” and that, for all its possible “wisdom,” represents a subtle form of proselytizing for a certain point of view?
It is impossible to dismiss this argument categorically. Psychotherapy is an effort to help people by talking with them, and no one would be foolish enough to claim that his own conversation is free of bias and preconceptions. But psychotherapists are aware of this problem, and have striven to make contemporary psychotherapy more objective and trustworthy.
A particular source of concern in this regard may be the status of psychology, the fundamental science upon which psychiatry relies. Psychology considers matters of human thought, emotion, and behavior—the data of which seem to be less objective than those of, say, structural neurophysiology or functional neurochemistry. Still, psychiatrists can and do use these data in an objective fashion, especially in their diagnoses and prognoses.
Contemporary cognitive-behavioral therapy (CBT), for instance, draws its premises and practices from the evidence of psychology. CBT rests on the view that certain assumptions and expectations held by patients—derived in various ways from their life experiences—provoke their demoralized state. These antecedent thoughts have powerful effects on feelings and behavior. They need to be challenged and replaced if the patients are to find more confident and coherent ways of managing their lives. Certainly in such areas as educational psychology and social psychology this observation has proved itself and is accepted as a part of the scientific study of human beings.
Practically, CBT psychotherapists help most by winning their patients’ assent to the idea that their assumptions and attitudes are self-defeating. This is not always easy, but once patients acknowledge their own role in their life story, they can proceed to reorder their mode of thinking. In this process, therapists do not so much tailor solutions as act as midwives, prompting patients to think on their own.
What sometimes raises questions about the scientific legitimacy of therapy is the readiness of some psychiatrists to bring out unfashionable themes that have psychological salience in their patients’ lives. Guile is especially suspected when the emphasis in treatment moves toward support of what can be dubbed “middle-class” values. A neat example is the case of the young woman with the several unhappy romances whom I discuss in the book. Of my suggestion that yearning for marriage was a sign of sanity rather than mental disorder and needed to be supported, Kay Hymowitz writes, “This is, assuredly, wisdom; but is it medicine?”
Here, a historical reflection may be instructive. From the inception of psychotherapy a century ago in the Viennese consulting rooms of Sigmund Freud, doctors often suggested to their patients that their behavioral problems derived from the sexual restrictions of the culture. Much human unhappiness, they claimed, represented “discontent,” in one way or another, with the constraints of “civilization.”
Whether this was the correct way to understand these unhappy people—and it is hard to judge at this distance—times have changed. What may once have been an excessively constraining culture is today a wildly permissive one. If Freudian psychotherapists could claim a scientific foundation for their idea that sexual restraint could lead to neurotic distress, then surely science can support the idea that contemporary sexual permissiveness may produce its own misery by defeating the psychologically identifiable “bonding” function of sexuality.
Psychology teaches that sex is nature’s means of transforming strangers into relatives and of building and sustaining new families. Why wouldn’t one expect the frustration of this natural function to exact a psychological price, at least from some people? That such an idea would also match a wise or commonsensical one merely emphasizes what may turn out to be one of the enduring lessons of CBT—namely, that many forms of “commonplace unhappiness” have rather commonplace explanations.
Paul McHugh
Johns Hopkins University
Baltimore, Maryland
Kay S. Hymowitz writes:
Paul McHugh takes issue with my skepticism about the medical ambitions of psychotherapy, arguing that after the long dark night of Freudian romanticism, practitioners have become “more objective and trustworthy.” He may well be correct about this. It seems entirely possible that Cognitive Behavioral Therapy (CBT), an approach that has gained favor in recent years and that he admires, is bringing more discipline to the profession. A casual observer of CBT like myself can see that its aims are more clearly defined and its script more precise than those of psychoanalysis. It seems unlikely that therapists guided by CBT will make us endure the likes of Repressed Memory Syndrome or Multiple Personality Disorder.
Still, CBT is a long way from being rigorous science. Dr. McHugh states that the therapy “rests on the view that certain assumptions and expectations held by patients . . . provoke their demoralized state.” This means that the psychotherapist must judge which of his patients’ assumptions and expectations need to be “challenged and replaced.” But surely negative assumptions have an entirely different status from that of cancerous cells or failing organs.
Let us consider a particularly delicate example: that of a terminally ill patient who is contemplating suicide. Dr. McHugh argues in his book that suicide is never merited; he would surely see the patient’s thoughts as in need of “reordering.” Another practitioner might see the suicidal thought not as dysfunctional but as rationally stoic. I truly doubt that science can resolve a dispute so packed with philosophical, religious, and cultural assumptions.
Or consider the example of the unhappy young woman Dr. McHugh mentions in his letter. He argues, in effect, that her expectation that she should have sex with her boyfriends is in need of treatment. Though I fully agree with Dr. McHugh that we live in a permissive culture that “may produce its own misery,” I do not believe that this rises to the level of scientific fact. I suspect it is not even a belief broadly shared by his own professional colleagues. He states that psychology teaches us “that sex is nature’s means of transforming strangers into relatives.” Why, then, have psychologists not announced this finding either to other scientists or to a general public that would surely benefit from its implications?
Moreover, at least at this point in its career, CBT is not immune to the sort of missionary overreach that Dr. McHugh criticizes in psychoanalysis. CBT researchers are now claiming that their therapy can help not just with depression and other mental disorders but also with chronic-fatigue syndrome, chronic lower-back pain, insomnia, neuropathy, high blood pressure, and even low sperm concentration. They also cite some success with Attention Deficit and Post Traumatic Stress disorders, two maladies whose existence Dr. McHugh casts doubt on in his book. Here we find ourselves in all-too-familiar psychiatric territory: a therapy that claims a scientific cure for illnesses that may or may not exist, but that have great cultural salience.
As I understand it, CBT has a theory about the mechanics of unhappiness—people have negative thoughts, which lead them to have sad or angry feelings, which lead them to behave in dysfunctional ways. It delineates a procedure that appears to reduce, though not eliminate, the subjectivity of practitioners treating mental suffering. But CBT has no theory of the mind; it offers no hypotheses about the origin of negative thoughts, no notion about why some thoughts are unconscious and others are not, or about why certain thoughts lead some people to have one set of feelings or behaviors and some to have others. In other words, CBT is in its infancy. Whether it can grow up to be a genuine science is an open question.
