The Brain Must Have Something To Do With It - An Interview with Dr. Paul R. McHugh

Dr. Paul R. McHugh is a University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine and served as the psychiatrist-in-chief and the Henry Phipps professor and director at the Johns Hopkins Hospital from 1975 to 2001. After earning his undergraduate degree from Harvard in 1952 and his medical degree from Harvard Medical School in 1956, Dr. McHugh pursued a medical internship at the Peter Bent Brigham Hospital and completed his residency training at the Massachusetts General Hospital in 1960. He then served as a clinical assistant in psychiatry at the Maudsley Hospital in London for a year, after which he returned to the U.S. to study neuroendocrinology at the Walter Reed Army Institute of Research. In 1964, Dr. McHugh joined Cornell University Medical College, where he remained until 1973, before becoming Chairman of the Department of Psychiatry at the University of Oregon Health Sciences Center. Over the course of his career, Dr. McHugh has worked to reshape psychiatry and psychiatric clinical practice by emphasizing the importance of scientific reasoning in understanding mental illness, fighting strongly against the psychoanalytic approach to psychiatry. He is the author of several books, including The Perspectives of Psychiatry and Try to Remember. He has also served on many advisory boards, including the U.S. President's Council on Bioethics. 

It was a pleasure and an honor to interview Dr. McHugh, and our conversation covered his background, his perspectives on psychiatry, psychoanalysis, medicine, and science, and his advice to young students. Psychiatry has existed as a formal medical discipline for around two centuries, although its roots date back to ancient civilizations, where mental illness was typically attributed to the supernatural. Around 400 BCE, the Greek physician Hippocrates, known as the father of medicine today, explained mental illness using his humoral theory of illness, which stated that mental illness was caused by imbalances in bodily fluids. Humoralism remained one of the primary ways of treating mental illness for nearly 2,500 years, until the late-19th century, when men like Josef Breuer and Sigmund Freud proposed psychological explanations for mental illnesses rather than attributing them purely to physiology. Freud is considered the founder of psychoanalysis, and psychoanalytic treatment is based on the idea that mental illness stems from wishes and desires that originate in the unconscious of a person. Hearing about Dr. McHugh's stance against psychoanalytic theory and its place in psychiatry was refreshing and inspiring. Dr. McHugh emphasizes the importance of strong fundamentals and rigorous education, even for those who don't wish to pursue the sciences. His story and approach yield invaluable lessons: don't be satisfied with tradition, challenge yourself, and challenge your field! 

What follows is a selection from our interview, beginning with Dr. McHugh's background and path to medicine and psychiatry. 

Vivek: What piqued your interest in medicine, and why did you eventually choose to pursue psychiatry?

Dr. McHugh: Yes, well, when I was growing up, I came to admire my family doctor. We're talking about the 1930s. Although there wasn't as much they could do back then, they always turned to us and did the best they could to help. I thought that was wonderful, and I decided I would try to make a career in medicine myself, to walk in his footsteps, as it were. But then, when I got into medical school and began to see the academic side, rather than simply the practice side, it entranced me intellectually. It was an applied science, and an applied science for human benefit. That was very compelling to me. We're now talking about the 1950s, and I was at Harvard Medical School. At that time, many of the brightest students in my class were getting interested in psychoanalysis and the Freudian idea that all of mental life, and all mental disorders, could be explained through understanding a person’s life story, especially their repressed concerns. That seemed like a very interesting, almost salvationist idea, and I was attracted to it, particularly because so many gifted people were going into it. But when I got to my medical internship at the Peter Bent Brigham Hospital and told the department director I planned to go into psychiatry and psychoanalysis, he said that would be a big mistake. He believed psychoanalysis was steering psychiatry away from medicine, particularly because, as he pointed out, they didn’t know anything about the brain. He said, “The brain must have something to do with it.” He advised me not to follow the standard course directly into psychiatry, but instead to take time to study the brain. This was before the whole idea of neuroscience even emerged. We're talking about the fall of 1956. I thought, “Well, he’s the Hersey Professor of Medicine—who am I, a young kid from Lawrence, Mass?” So I followed his advice. Apparently, I was one of the few who did. With his help, I was accepted into the neurology program at Massachusetts General Hospital. As soon as I began, I realized psychiatry was heading in the wrong direction with psychoanalysis. They weren’t seeing the patient for who they were or what they were suffering from; they were overlaying their own interpretations. Thanks to my neurological experience, I became more committed to an empirical, observational approach—truly looking at the patient. By the end of that program, when it came time to further my psychiatric education, it was recommended that I go to Britain, where psychoanalysis wasn’t so dominant. I went to the Maudsley Hospital Institute of Psychiatry in London, which focused on empirical psychiatry. That was a revelation. I was married to an Englishwoman, so it was a lovely opportunity for her to return home, too. I stayed about a year and a half, and my eyes were opened again by what they showed me, what psychiatric conditions really looked like, what people were suffering from. After that, I felt I had to spend time in a research lab. If medicine is applied science, then you ought to understand the science itself. So I applied to the neuropsychiatry program at Walter Reed and was accepted. There, I studied neuroendocrinology with some of the most distinguished neuroscientists and neuroanatomists in America, including Walle Nauta. It was the kind of work that, had I been at a university, would’ve earned me a PhD. I never got the degree, but I essentially completed a thesis during my three years there. I was supposed to return to Harvard, but I looked around and saw that psychoanalysts still dominated, and the institution was so status-conscious. I’d been in Boston a long time. I wanted to go out into the world. I accepted a position in Psychiatry and Neurology at New York Hospital–Cornell Medical Center. That turned out to be a very good decision. I met wonderful people, mostly neurologists like Don Reis, Jerry Posner, and others. I began teaching what I’d learned to medical students. Initially, I wasn’t welcomed; there was still a psychoanalytic fringe. But I started a tutorial group, and before long, a small band of students became interested. I built a community. Eventually, Cornell offered me the directorship of one of their outlying hospitals, previously discredited and considered a backwater. I thought, "Perfect– I can restore its reputation and also build my own as a teacher and investigator." So I went to the Westchester Division in White Plains, New York. People thought it was a backwater, but we revived it: excellent research, excellent faculty, new energy. We reopened the hospital, brought in eager young faculty, and built momentum. For a while, it looked like I might be named chair of psychiatry across the system, but again, the psychoanalysts opposed me. They thought I rejected their vision of human nature, and they were right. They gave the job to a psychoanalyst, and I moved on. I was offered a department chair in Oregon, which was lovely. I stayed a couple of years. Then Johns Hopkins came calling. Unlike Cornell, they wanted someone who wasn’t a psychoanalyst. When the psychoanalysts who opposed me at Cornell tried to stop my appointment at Hopkins—ten or eleven of them showed up—the people at Hopkins basically said, “Maybe that’s exactly why we should take him.” And they did. I came to Hopkins in 1975. It felt like going to heaven. Hopkins Medicine was brilliant, collegial, and innovative. They expected you to challenge the field, not just uphold tradition. And that’s how I got here.

Vivek: It seems like studying neurology was really central to how you developed your views on psychiatry. So, what would you say was so different about your approach compared to the dominant psychoanalytic model at the time?

Dr. McHugh: Yes, well, psychoanalysis had this notion that rather than asking what might make sense of mental disorders, they asked what would be startling if true. It wasn’t about empirical evidence. They believed repressed, unconscious conflicts were at the root of all problems, and that analysis would gradually uncover and persuade the patient of that. I found that deeply unsatisfying. That idea assumes all mental disorders are of the same nature. But thanks to neurology, I knew some patients had brain diseases, others were dealing with grief or trauma. They weren't all the same. I began to push back, first at Cornell, then Oregon, and finally at Hopkins. I argued that psychoanalysts had to prove their claims. But they didn’t think they needed to; they thought they had truth. That’s not medicine. So, I started talking about methods– how different approaches were required to make sense of different disorders. Story-based methods might help with grief or PTSD, but not with schizophrenia or bipolar disorder. With my students, we began developing a methodological framework, and that eventually became our book, The Perspectives of Psychiatry. Neurology had shown me that by studying how patients present, you can get insight into the likely cause of their issues. Then, through scientific tools—pathology, psychology, endocrinology—you can prove those causes. And if you know the cause, you can think about treatment and prevention, which is what medicine is about. If you just say, like the psychoanalysts did, that it’s all unconscious conflicts, you’re not going to get very far. At Hopkins, our approach allowed the development of actual research programs. We weren’t saying, “We already understand everything.” We were saying, “Here’s a hypothesis. Let’s go test it.” And Hopkins supported that, because they’re committed to science. When people complained about my lack of psychoanalytic leanings, the deans and trustees just laughed. “They had their day,” they said. “Now we’re going to give him his.” 

Hopkins, even in its early years, with people like William Osler and others, had already shown that medicine could be understood through scientific principles. Hopkins led the way. But psychiatry as a field, even today, is still at war with itself over what really counts, over what the best approach is. It had its psychoanalysts, its behaviorists, its various kinds of empiricists. And to this day, they haven’t agreed on a unifying system. That’s what my Perspectives approach tries to offer: a framework for understanding. And, sure, people argue with me about it, but I think we’ll win out in the end. Psychiatry needs more than just a way to label people and give them symptomatic treatments. If someone has depression, you give them an antidepressant. If they’re psychotic, you give them an antipsychotic. That kind of plug-and-play, one-for-one model, Osler used to call it "penny-in-the-slot therapeutics," is not what medicine ought to be. We’ve been trying to talk about how to understand disorders from the ground up. That way, we can think about what kinds of treatments are appropriate, some medical or physical, others psychological or educational, guided by principles.

Dr. McHugh's critique of psychoanalysis is foundational to his approach to psychiatry as a whole. He doesn't just disagree with psychoanalytic theory but states that the field, without scientific evidence, approaches something more akin to philosophy and storytelling than real science. Dr. McHugh's book, The Perspectives of Psychiatry, proposes a model that emphasizes that different kinds of disorders require different types of treatments. He believes psychiatry is pluralistic, that is, no single theory of mental illness is sufficient. Thus, he outlines four "perspectives" to approach psychiatric conditions: the disease perspective, which focuses on how biological or neurological injuries cause disorders; the dimensional perspective, which refers to extremes or variations of psychological traits; the behavioral perspective, which describes habitual, maladaptive behaviors that are learned over time; and the life story perspective, which refers to mental/emotional distress stemming from a person's life experiences or trauma. These four descriptions aren't boxes meant to be checked off, but rather a framework intended to help psychiatrists determine how to think about a problem. I think this is one of the key takeaways from our conversations: medicine, and psychiatry specifically, should not be a theory-first field; clinical practice should be guided by what one sees in the patient. Therefore, Dr. McHugh argues that the different psychiatric conditions require different kinds of thinking and cannot be effectively approached with a single theory like psychoanalysis. 

Vivek: Would you say psychiatry still has a long way to go?

Dr. McHugh: Yes. Psychiatry hasn’t come of age yet. Now, when does a medical field come of age? Not when it cures everything, that’s impossible, but when it understands the likely causes of the disorders it treats, and uses that understanding to design research to test, prove, or disprove its ideas. That’s how you get to prevention and treatment. That’s how medicine works.

But when a field is still just naming things and treating symptoms without deeper insight, well, that’s not where medicine is anymore. Surgery and pediatrics are already past that. Psychiatry is still stuck at the “field guide” level.

Now, field guides are a place where biology starts, but it moves on from there. That’s a longer story, though.

Vivek: Obviously, becoming a doctor, especially one as well-regarded as yourself, takes serious dedication. Could you tell us about how you learn and absorb information?

Dr. McHugh: Sure. I think the most important thing is that I had a very good education— a broad one. If you’re going into an applied science like medicine, you need to have spent time in basic science, too. I think a few years in a laboratory, doing real experiments, is an essential experience. It teaches you how we come to know what we know.

Some knowledge we gain through the heart, through emotion, and principle. For example, the idea that all people are created equal, I didn’t get that from science. I got that from my upbringing, my education, and from the values I was taught. That’s heart knowledge. But for things that depend on facts and mechanisms, you need scientific training.

So it was a long course of study, from medical school to learning how to examine and treat patients, to later learning how to apply those skills to mental health. That all came from experience with good teachers. I had excellent teachers and also excellent peers. Honestly, your peers often teach you as much as your mentors.

Today, most academic physicians have MD/PhDs. I don’t have the second degree, but I got the same kind of education. I learned how to think experimentally, how to set up a problem, and test it.

I also had great students and colleagues, and lots of patients. Seeing a wide range of cases is critical. You get better at it over time. You start seeing patterns, making connections, and forming ideas based on real experience.

To me, it’s the free interchange of ideas, the freedom to ask questions and challenge yourself, that leads to meaningful progress. And if you’re lucky, and you use your mind well, you can do a lot of good in the world. And even enjoy it in the process.

So I think following the path of learning doesn’t mean blindly following what everyone else is doing. You have to keep thinking for yourself, especially as you get better and more experienced. That’s where real insight comes from.

Neurology has an advantage over psychiatry in that you can study the brain directly. You can look at autopsies, see the anatomy, and compare it to your ideas. That helps correct mistakes. Psychiatry doesn’t have that, so it demands a different kind of precision, more thinking, more logic, more self-challenge.

Anyway, I’ve been lucky. Lucky in my teachers, lucky in my colleagues, and lucky in my family— they let me pursue what I wanted to do. My poor wife had to move coast to coast with me and make sacrifices for years, until we finally settled into that house over there.

Vivek: That really emphasizes how important broad exposure and diverse perspectives are.

Dr. McHugh: Exactly. That’s why people say, “You need to see a lot of patients,” or “You need to go into the lab.” There’s a reason. You learn by doing in this field. Just like in anything else. The theories come after the cases, not before. Learning by doing. That’s how it happens.

Vivek: It seems like asking questions, good questions, is a big part of your approach. Not just accepting things at face value.

Dr. McHugh: Absolutely. The Socratic method. Living with your residents and students in that spirit of questioning: “Why do you do that? Why are you doing that? I’m not sure it’s right— prove it to me.” Keep proving it. It keeps you honest.

I had a wonderful time with brilliant students, many of whom went on to do even better than me. 

Vivek: Do you have any advice for young students and scientists? What's the kind of mindset they should aspire to?

Dr. McHugh: Right. Well, I don’t know if I have any great answers to that, but I do think it’s important for people to understand what they should get out of each stage along the way.

What should you get out of high school? High school is when you learn how to write. So that writing, expressing your thoughts clearly, is no longer a mystery to you. Someone should have taught you that the English language is something you can use to put your ideas into words. Feelings come easy to kids, but turning those feelings into something that documents the world around you? That should come out of high school.

You should also come out of high school fairly numerate. Maybe you don’t need calculus, but you should be comfortable with algebra, geometry— the basics.

And you should understand the history of your nation and how its institutions are organized. That’s foundational.

College is where you polish those skills and then go deeper. It’s where you major in something, not because majors are magic, but because it puts you in contact with a real discipline and a faculty that’s devoted to it. You start to see how knowledge in that field progresses. You see how people in that field live and think, and contribute to the field.

It doesn’t have to be a science; it could be something humanistic, as long as you see how that field advances.

Your minors, meanwhile, are there to make sure you’re sharpening the tools you got in high school.

Then comes graduate school. That depends on what you want to do. But graduate schools are places where you apply what you’ve learned: medicine, law, business, the sciences. And if you can write, if you’re numerate, if you can think, you can start making real progress. You move from the general to the specific. Medicine is a graduate school. So is law. These are all applied fields, and graduate school is where you start becoming a professional.

So yeah, I think young people need to be told early on, “This is how you’re being turned from a child into an educated adult.” You stop being a pupil and become a student, someone who studies with intention.

What’s the goal of high school? Of college? Of grad school? That clarity helps you see your path. And with those general principles in mind, you can find your specific way forward, whatever that ends up being.

Dr. McHugh's insights extend far beyond psychiatry. His message is consistent: question assumptions. It's important to learn how knowledge is built, how to think critically, and what fundamentals are necessary. I believe that for anyone, whether interested in science and medicine or history and the arts, Dr. McHugh's career serves as an exceptional example: greatness doesn't come from sticking to what's been done.