Dr. Camsari: Dr. McHugh, would you please share with me, how did you come up with the approach of the Perspectives of Psychiatry throughout your professional development as a psychiatrist?
Dr. McHugh: I had wonderful training from the best people in neurology and psychiatry in the world, I think, I had neurology training at MGH from Professor Dr. Raymond Adams, and I had psychiatry training at Institute of Psychiatry in London from Professor Dr. Aubrey Lewis. Both of these people had a sense that psychiatry had to develop a coherent and comprehensive structure that relating, but ultimately to find a way to understand the nature of the disorders, I think that is what they were trying to work towards and it seemed to me the problem between neurology and psychiatry is neurologists had a clear idea of what their disorders were in nature, they were after all in some ways injuries to brain and they could take the form of any pathology, whereas the psychiatrists were uncertain, we used words like “endogenous” and “exogenous” conditions and things of that sort, these were unsatisfactory concepts to people like Dr Aubrey Lewis, he thought you cannot tell these from the presentations of depressed patients, so that is how I came to be thinking about what was fundamental to psychiatry mainly, what is the nature of mental illness and that is what I came up.
Dr. Camsari: When you started to write the Perspectives Book, were you at Hopkins or was that before?
Dr. McHugh: No, I and Dr Phillip Slavney started working on the Perspectives when we were at University of Oregon actually. We decided that we would write a book but we were not exactly certain about what kind of a book that we would write to present our point of views, we at first decided to write a small textbook that we would write a little about our method but one day he and I agreed on what we should be doing , we would be talking about how in a methodological way emphasis on method of assessment we might be able to differentiate the families of mental disorders and thus come to say what we believe mental illness is.
Dr. Camsari: Dr McHugh, I know that you were a chairman at Hopkins for 26 years, between 1975 and 2001. Did this revolutionary idea of Perspectives play a role in your being appointed as a chairman in Psychiatry at Hopkins in 1970’s?
Dr. McHugh: No, not really, but it [being at Hopkins] gave a me a better forum and more support fundamentally for the enterprise of brainstorming, after all, I had very good students and very good colleagues and I could share with them and get back from them and also of course working with Dr. Timothy Moran in laboratory studying a basic behavior, food intake, I was extending my understanding of behavior and its controls.
Dr. Camsari: Did you face any resistance while implementing this idea which was new?
Dr. McHugh: I was experiencing resistance in 1970’s from the psychoanalytic community. Most of the issues of resistance were more resistance to my teaching in general to medical students than specifically to the perspectives, even though I was making the point to the psychoanalysts that after all, the way to understand their work was to appreciate that life story of the patient was important to understand the mental disorders.
Dr. Camsari: So your work actually also included psychodynamic knowledge?
Dr. McHugh: It was intended to encompass what they had accomplished. The things what they had accomplished, I believe, could be encompassed within this. They, on the other hand felt that it was replaced through out the perspectives. In fact one said, “when I read the first page it gets my dukes up”
Dr. Camsari: Have you seen over the years that this idea was spread out of Hopkins as well?
Dr. McHugh: The idea first went out with Dr. Robert Robinson at University of Iowa, Dr. Marshall Folstein at Tufts Medical School. The real problem for us, if we talk about the acceptance of the Perspectives Model, it appeared at the time exactly when DSM III appeared, and they were out of the gates together and DSM was the hare and we were the tortoise. And now we are kind of catching up. The DSM approach to ignoring all aspects of generation or cause, only looking at symptoms is beginning to reach its 30th year. And now people are wondering and we think, look, it would not be odd now to bring our thoughts up for psychiatrists that are acquainted with DSM III or IV, and they would not find it hard now to begin to think with the perspectives, particularly if we could persuade the APA that instead of axis organization they have that maybe they could have the idea, axis I included only the conditions you could think of were likely to be brain diseases, axis II could continue as it is, personality and all indeed the dimensional perspective, axis III could be now put aside and replaced with the behavior perspective, and axis IV could again be the life story and it would not be all that much of a change, we could keep axis V as GAF and then maybe people would begin to see that instead of everything being axis I with modifications out of the other axes, that some of our patients are axis II, III,IV, now identifying them with the dimensional, behavioral and lifestory perspective and I think that what is going to probably happen.
Dr. Camsari: Dr McHugh, I know that you have been in touch with DSM committees, do you think they are convinced with this idea?
Dr. McHugh: No, I do not believe at this moment they are convinced. They are hare and we are the tortoise. They have to complete and finish their run, even discipline itself will see the ultimate need to replace the symptom descriptive mode of classification and takes on a generative and causal mode. All fields go through a descriptive phase and that is only critiscism you can offer them is that they stay in the descriptive phase longer than they should. And we are thinking that now psychiatry has come to the end or should have come to the end of its descriptive phase alone and right now thinking in terms of generative likelihood that schizophrenia is a different kind of disorder than PTSD which is also a different kind of disorder than alcoholism or addiction which is also a different kind of disorder than histrionic personality and we psychiatrists are taking care of all those kinds of patients and would like not only to understand why the therapy needs to be different for each one of those conditions but also research domains and research directions will be different and then we would have a heuristic classification and not the field guide which is only useful for reliability of diagnosis.
Dr. Camsari: Dr McHugh, thanks to the Hopkins approach to psychiatry, during my psychiatry training at Hopkins, I started to again feel like that I am a doctor who is practicing a field of medicine. So is that kind of a feedback that you always get from your trainees?
Dr. McHugh: I hope that all of my trainees feel that way. It is our intention to point that we are medical people. We want to be sure that medical people see the domain of psychological life is a domain unplummeted by biology and has a biological domain itself though has its own rules and ways of going awry. You and I have talked about this before, we need to persuade them mental life is an emergent property of the brain, like any other emergent property, in science, it has its own features of action and features of disorder, you know, if people did not see that point, they would think that in the physical domain, study of hydrodynamics is the study of hydrogen and oxygen rather than fluidity of water itself which emerges from those two elements.
**This interview was conducted with the full consent and cooperation of the interviewee on July 28, 2012 at the Johns Hopkins Hospital, Baltimore, Maryland. Additionally, the interviewee has given explicit permission for the publication of this interview.