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- The following is a conversation
with Andrew Scull, a historian of

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psychiatry and mental health.
He has authored many books that I

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highly recommend including
Madness in Civilization:

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A Cultural History of Insanity
from the Bible to Freud, from

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the Madhouse to Modern
Medicine and Desperate Remedies:

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Psychiatry's Turbulent
Quest to Cure Mental Illness.

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Andrew Scull has spent decades
studying how societies have understood

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madness, how psychiatry rose
to authority, and how often

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that authority was used with false
confidence and catastrophic

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consequences. In this conversation
we'll trace the long arc from the

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asylum era to eugenics,
from lobotomy and insulin coma

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therapy to electroconvulsive
therapy, psychoanalysis,

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antipsychotics,
antidepressants and the modern crisis

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of mental health.
It is in part a story about the

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terrifying history of bad
ideas in medicine but it is

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also about the fascinating
mystery of the human mind and

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about the difficult
journey to understand it.

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This is a Lex Fridman podcast. To support
it please check out our sponsors in the

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description where you can also
find links to contact me, ask

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questions, give feedback and so on.
And now dear friends here's Andrew Scull.

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Is it fair to characterize your view
on psychiatry and mental illness

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as that there's a crisis in modern
psychiatry? We have made some progress-

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- Yes -... over the past century but
mostly we still are not good at treating

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mental illness either via the drugs or
talk therapy meaning psychopharmacology or

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psychotherapy or as you put
it the brain or the mind route.

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So let's start at the end of our story.
Let's start at where we

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stand before we go into the rich history
that you so eloquently write about.

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- So psychiatry is a
profession that tries to

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deal with an enormously
complicated thing. The

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human mind, the human emotions, the human
ability to attempt to understand the world

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and in particular obviously
it focuses on people where

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our common sense approach
to the world seems to break down.

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People whose emotional
life is filled with turmoil,

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people whose ability
to relate to others is badly

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damaged, people who see things
in the world that the rest of

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us simply think aren't there.
They're illusions,

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they're hallucinations, they're
delusions and this is a subject that has

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occupied some very clever
minds over the years

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and there's no question that in the course
of at least the last three quarters of a

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century there has been some limited

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progress in dealing with the problems that
mental illness creates. Some of that is

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confined to the milder
forms of mental distress;

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the more serious forms of psychosis and

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breakdown of emotional control
those are areas where I think

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again there's been some progress
but it's easy to overstate how much

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of that there's been. As we'll see
probably later in our conversation today

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the advent of modern
psychopharmacology which

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occurred in the early nineteen
fifties was a serendipitous

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event. It wasn't planned for.
It happened almost by accident

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and it did mark in some
ways an advance over some

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of the things that psychiatry
had engaged in before that

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and no question for some people that
revolution and a parallel revolution

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in the psychotherapeutic realm have

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created some advance
for patients and we should not

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minimize that.
What we have available to us

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are symptomatic treatments
not cures. We don't have

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a psychiatric penicillin
for any of the conditions we're

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gonna be talking about. That doesn't
mean we can't do some things that

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help but the help is quite limited
and it's important to understand

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both the ways in which
we have progressed and the

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limits of that progress and also
to understand that when we treat something

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sometimes we create new
problems what we call

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iatrogenic problems, things caused
by the interventions that we use.

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That's true of some
psychotherapeutic interventions and

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most certainly true of the drugs we
use to treat mental illness these days.

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So for example in treating PTSD
we often get patients to confront

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the episode -- the trauma which
provoked their distress and that is

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often a very, very fraught
process and for many

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patients it actually makes things worse.
For some patients it makes them better.

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So that's a situation
where you could see problems

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With both antipsychotics
and antidepressants, the two

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main classes of psychotropic drugs
that we use, um, they're at best partially

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effective and they don't work for a

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significant fraction of patients
who are given them and one of the big

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problems psychiatry faces is that

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psychiatrists don't know in advance
who's going to respond well

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to the drugs, who's
going to respond badly,

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for which group of patients
in the middle the side effects and

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the main effects, if that's what we
want to call them, the therapeutic effect

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are finely balanced and making
those judgment calls about what to do

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are very, very difficult.
Now in terms of the

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crisis psychiatry faces
at the moment as I see it there are

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a number of strands that point to this.
Psychiatry's diagnostic system,

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that is still used -- I mean,
the fundamental basis of,

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of psychiatric diagnosis today was really
first formulated in 1980 with the third

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edition of The Diagnostic and Statistical
Manual of a profession -- - DSM-III

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-... DSM-III and then there's been
DSM-III-R, DSM-IV, DSM-IV-TR, and now DSM

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5. Finally not with a
Roman numeral but with

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with an Arabic numeral.
So they thought with DSM

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5 when they needed to modify
it it would be like a piece of

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software. You have Windows 10,
Windows 11, and

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so on right? Now that diagnostic system

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came into being because
psychiatrists had a very hard time

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agreeing with one another about what
was wrong with somebody, and that

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became embarrassingly clear
in -- first in the professional

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literature which outsiders
didn't read and then via a

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very famous study that's
a scientific fraud by David

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Rosenhan called On Being
Sane in Insane Places where he

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claimed to have sent in pseudo
patients to the hospital

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and they all were diagnosed as schizo.
All but one of them diagnosed as

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schizophrenic the other as somebody
with bipolar disorder and they

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were fake patients.
So almost in a panic after

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that study appeared in Science and because

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there was an abundant
professional literature from the

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1960s showing the same thing that
diagnosis was a very erratic process.

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The DSM-III task force led by Robert
Spitzer who was then at Columbia

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was explicitly set up to try
to create a sort of tick the

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boxes approach to deciding which box a

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patient belonged in. Were you
schizophrenic? Were you this type of

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schizophrenic or that type
of schizophrenic? Were you

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manic depressive or bipolar?
Did you have various forms of depression?

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And to construct those boxes what they
relied upon was a list of symptoms and if

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you had more than a certain
number If you had more than

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six of ten Six or ten or more
symptoms of a certain sort

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you could be diagnosed with major
depression for example. So that

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system came into being.
It was partially embedded

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because it appealed to drug
companies who were developing

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drugs to treat these various disorders.

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It appealed to insurance companies 'cause
it gave them a stable base to look at.

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It appealed to, as diagnosis always does
to patients and their families who are

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scrambling to deal with these enormous
upsets in the mental life of either

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themselves or a family member.

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So provided some sense
of certainty around diagnosis.

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But that was always based simply
on symptoms in the way an eighteenth

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century doctor might
diagnose dropsy or diagnose,

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Some other kind of disor---
Fever for example well

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fever and other diseases they
talked about in the eighteenth

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century are really a constellation
of very different things under one label.

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And I think that's what
is turning out to be true of the

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DSM labels. But that approach

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was really all that psychiatry
could come up with if it

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wanted to make sure whether you
were in Walla Walla or New York or

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San Francisco or Atlanta you
reached the same conclusion faced

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by the same patient. That you
had a reliable diagnostic system.

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That didn't mean necessarily it
was a valid diagnostic system if you

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understand the distinction
between validity and

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reliability. Reliability
means you and I faced with the

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same sets of facts reach
the same conclusion but

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that conclusion may or may not reflect the

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underlying reality of things right?
So you had this

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diagnostic system and it
went through various

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iterations each time it went
through an iteration the number

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of possible psychiatric disorders you
could get grew and grew and grew and it

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became difficult to believe
in some of those categories shall

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we say. That they were
really illnesses rather

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th-than some sorta social construct.
But beyond that um,

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psychiatrists wanted to be more
like other medical doctors to root

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their diagnoses in an
understanding of the underlying

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pathology of the disorder.
What was it that caused

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people to become schizophrenic?
The sense was

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if we could grasp that we'd have
a better handle on how to attack it How

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To treat it. And when uh, DSM-5 was mooted
the fifth edition in the early 2000s

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NIMH then under the leadership
of Steven Hyman who's at

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Harvard now and succeeded by Thomas Insel

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who ruled NIMH for about
thirteen years. The

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two of them had pushed
psychiatry and psychiatric

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research in a very particular direction.

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On the one hand, towards understanding
the genetics of mental illness,

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and on the other, to looking at what
the new discipline of neuroscience could

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contribute to understanding things.
Both of them were heavily invested

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in the idea that mental
illness was brain disease.

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And if it was brain disease,
then the question was what was making the

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mechanism here go awry? What was

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causing people's emotions
or their cognitive skills or

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their sense of the world
to become so disordered?

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And they invested a lot of money
in that approach. When Insel stepped

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down, he gave an interview
actually to somebody at MIT

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and he's repeated it since in a book
he wrote about his experiences

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where he said, "Well, you know,
as I look back on my 13 years,

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I funded an enormous
amount of scientific...

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really cool scientific research.

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I funded geneticists and I
funded neuroscientists and

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we-- they did a lot of really
interesting science."

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And after spending 20 billion
dollars, the lot of the

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mentally ill has improved
not one bit right?"

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Which was a pretty devastating
statement, I thought.

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- And NIMH is National
Institute of Mental Health.

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- National Institute of Mental Health,
yes. I shouldn't resort to jargon.

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But the National Institute of Mental
Health had been founded in the late

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1940s with the goal of improving,
doing basic research training people in

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the field advancing the care of the
mentally ill and producing obviously

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cures and advances. Uh,
and its mission has varied widely

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over the years since but starting in the

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in the-- in the 1990s—the
period when the first George Bush

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declared the decade of the brain—uh, NIMH

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increasingly focused on the idea
that mental illness was purely a

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brain disease and there's something
to that and there's also some

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mistake in thinking about it that way.

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- This is, by the way, as we
will talk about this distinction

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between seeing mental health,
the maladies of the human mind,

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as a problem of the brain,
like neurobiology, neuroscience, versus

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the problem of the mind, which is more in
the cognitive, psychotherapy, these more,

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less amenable to scientific rigor.
So I think what's

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appealing about studying the brain
and neurobiology, neurosciences, there's

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data. Yes. It's more rigorous.
You can do science.

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- It’s the kind of thing that really
appealed to medical school deans because

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once NIH and the drug companies
too were funding basic research on

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neurobiology and basic research
on genetics, the money flooded in. Um, and

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psychiatry, which had been something
of an orphan, became much more popular,

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- and we should say that this is
something you write a lot about.

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There are all these factors to

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consider. So there's cultural elements,
political, public policy elements. Then at

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a certain point, drug companies,
insurance companies come in, of course.

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all human beings around somebody who's

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suffering with a mental health issue,
so family factors, that's connected,

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cultural stuff.

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- it's a very complicated area
and oversimplification is a real problem I

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think.

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Uh, and I think even that dichotomy
you just drew between, um, the

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brain and the social or psychological,
some mix of those things,

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I think in some ways
that's a category mistake,

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that's a mistaken way of looking at the

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world, because the brain you have
today, you're not born with. Human

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brains are remarkably plastic things.
They develop in response to the

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environment. Social, psychological
are embedded in our brains.

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Rigid separation, saying one
or the other—no. Abundant evidence from

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epidemiology that social factors play
an important role in the development

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of illness. - Nevertheless, history of
psychotherapy, for example, subfields...

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human mind is complicated,
all these factors. To say anything

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helpful, you have to simplify.
Freud famously simplified a lot towards

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a particular view of the human

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mind. That simplification, actually,
we'll talk about if it's correct

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in a deeper sense, was productive.

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- Yes. In fact, whenever you're trying
to deal with a very complicated set

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of issues,

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you have to simplify.
You have to make heuristic

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00:17:16,740 --> 00:17:20,280
decisions about what you're going
to neglect and what you're gonna

228
00:17:20,400 --> 00:17:23,867
emphasize. But what
I'm trying to say, well,

229
00:17:23,950 --> 00:17:27,500
you asked me about
the crisis in psychiatry,

230
00:17:28,420 --> 00:17:33,650
and the simplest way for me
to encapsulate the issue and the

231
00:17:33,740 --> 00:17:40,260
problem as I see it that's arisen—one
of the problems—is a quote by Leon

232
00:17:40,360 --> 00:17:46,180
Eisenberg, who had a very long
career at Harvard, and Eisenberg

233
00:17:46,960 --> 00:17:50,020
said towards the end of his career,
he said, "When I entered

234
00:17:50,120 --> 00:17:56,980
psychiatry, it was brainless psychiatry,
leaving it mindless psychiatry." Yeah,

235
00:17:57,360 --> 00:18:03,480
sums up the way the field
to a large degree has moved.

236
00:18:04,140 --> 00:18:09,563
In the process, insights are
lost, though in other ways,

237
00:18:09,647 --> 00:18:12,400
things are being gained. Um,

238
00:18:13,480 --> 00:18:17,860
Freudians tended to neglect
the biological, to suggest the brain

239
00:18:18,680 --> 00:18:22,477
as a biological organism
was not something we needed to

240
00:18:22,560 --> 00:18:26,457
worry about. We worried at the level of a

241
00:18:26,540 --> 00:18:32,770
psychological model of how
our minds work. And all too often,

242
00:18:34,120 --> 00:18:38,040
not exclusively because some
of the psychiatrists I'm friends with

243
00:18:38,800 --> 00:18:45,540
are very sophisticated men and women
and do grasp that you can't move in these

244
00:18:47,060 --> 00:18:50,540
bipolar directions. You've got
to meet somewhere in the middle.

245
00:18:51,220 --> 00:18:57,840
But that sort of got lost,
I think, in all the enthusiasm for

246
00:18:58,700 --> 00:19:02,617
neuroscience. I mean,
when antipsychotic drugs were discovered

247
00:19:02,700 --> 00:19:08,580
in the early 1950s, we had no clue
of how they worked. And one of the things

248
00:19:09,640 --> 00:19:13,480
that they helped us spawn
as people began to say, "Well,

249
00:19:13,580 --> 00:19:15,780
why did these drugs work?
What did they do?"

250
00:19:17,080 --> 00:19:20,437
Was to begin to understand
that the brain wasn't just a set of

251
00:19:20,520 --> 00:19:24,137
electrical signals, as had been
thought in the first half of the 20th

252
00:19:24,220 --> 00:19:28,097
century and before.
But rather there was this very

253
00:19:28,180 --> 00:19:32,077
interesting chemical soup
running around in our brains with

254
00:19:32,160 --> 00:19:35,780
neurotransmitters that help
the brain work the way it did

255
00:19:35,940 --> 00:19:39,020
and perhaps explained why it went awry.

256
00:19:40,080 --> 00:19:43,897
So it was one of the many factors
that gave rise to neuroscience. The

257
00:19:43,980 --> 00:19:47,877
first neuroscience conventions were
in the 1970s, and they attracted a

258
00:19:47,960 --> 00:19:51,337
few hundred people.
Now it's tens of thousands of

259
00:19:51,420 --> 00:19:55,317
neuroscientists.
It's a huge enterprise. So

260
00:19:55,400 --> 00:19:59,260
diagnosis has come under threat.
The categories that

261
00:19:59,380 --> 00:20:02,997
we have all become familiar with,
that we're told are real

262
00:20:03,080 --> 00:20:07,540
diseases like bipolar disorder,
schizophrenia, major depression,

263
00:20:08,940 --> 00:20:12,597
are beginning to falter,
and we're beginning to

264
00:20:12,680 --> 00:20:16,277
worry about whether
those diagnoses are real

265
00:20:16,360 --> 00:20:19,940
ways of thinking about the world
and may in fact mislead us.

266
00:20:20,120 --> 00:20:23,417
Because if we think there's
something called schizophrenia or the

267
00:20:23,500 --> 00:20:27,277
schizophrenias, as the inventor
of that term put it, if we think

268
00:20:27,360 --> 00:20:31,177
there's something like that
and we try to research where it

269
00:20:31,260 --> 00:20:37,577
comes from, but that's not really
what's going on, obviously we're probably

270
00:20:37,660 --> 00:20:41,417
gonna not make the progress we
could be making if we had a better

271
00:20:41,500 --> 00:20:43,737
diagnostic system. And that's what

272
00:20:43,820 --> 00:20:47,657
DSM-V thought it was gonna
be able to do and discovered

273
00:20:47,740 --> 00:20:51,420
it couldn't. So it stayed basically
with the symptomatic approach.

274
00:20:51,620 --> 00:20:53,467
- If we can just really brief -

275
00:20:53,550 --> 00:20:57,317
I would love to talk a little bit more
about the DSM, but just to give a history

276
00:20:57,400 --> 00:21:04,400
here, looking it up on Perplexity,
DSM One in 1952 was a 32 page pamphlet-

277
00:21:04,970 --> 00:21:09,720
with 106 diagnoses heavily
influenced by psychodynamic concepts-

278
00:21:10,240 --> 00:21:14,080
and etiology using broad, often
vague categories like reactions.

279
00:21:14,490 --> 00:21:21,417
DSM Two in 1968 expanded to 185
diagnoses still psychodynamically

280
00:21:21,500 --> 00:21:25,397
flavored and reliability poor,
but added more attention

281
00:21:25,480 --> 00:21:29,277
to childhood disorders and later
removed homosexuality as a disorder in

282
00:21:29,360 --> 00:21:33,217
1974 printing.
Then to the revolution, as you

283
00:21:33,300 --> 00:21:37,000
mentioned, the DSM Three
in 1980 introduced explicit

284
00:21:37,100 --> 00:21:43,960
symptom-based diagnostic criteria, a multi
axial assessment system, and an officially

285
00:21:44,220 --> 00:21:49,817
atheoretical stance about causes aiming to
improve reliability and research utility.

286
00:21:49,900 --> 00:21:53,477
And then DSM Three R
in 1987 revised criterion

287
00:21:53,560 --> 00:22:00,560
expanded to around two 97 diagnoses.
DSM Four in '94 and DSM Four TR in

288
00:22:01,460 --> 00:22:05,910
2000 focused on literature
driven empirical revisions,-

289
00:22:06,400 --> 00:22:10,257
added and deleted some disorders
increased coordination with

290
00:22:10,340 --> 00:22:17,317
ICD 10 and goes on. And then
finally in 2013 DSM Five came

291
00:22:17,400 --> 00:22:20,320
out which eliminated the multiaxial system

292
00:22:21,100 --> 00:22:24,777
integrated most information
into a single nonaxial

293
00:22:24,860 --> 00:22:28,790
diagnostic list than separate
notations for psychological and medical

294
00:22:28,900 --> 00:22:32,717
factors. It reorganized chapters e.g.

295
00:22:32,800 --> 00:22:36,660
Neurodevelopmental,
obsessive-compulsive related, trauma and

296
00:22:36,820 --> 00:22:40,760
stress related disorders introduce
new and refined entities and so

297
00:22:40,860 --> 00:22:47,740
on. But big picture trajectory
conceptually the DSM moved from cause

298
00:22:47,824 --> 00:22:48,937
focused and

299
00:22:49,020 --> 00:22:55,060
psychoanalytical to symptom-based,
theoretical, and reliability driven

300
00:22:56,380 --> 00:23:00,260
over time. There has been growth
in the number of granularity of categories

301
00:23:00,420 --> 00:23:04,057
closer alignment with ICD
ongoing controversy

302
00:23:04,140 --> 00:23:07,437
over medicalization, validity,
and the balance between

303
00:23:07,520 --> 00:23:11,337
categorical and dimensional
approaches. Yes. It

304
00:23:11,420 --> 00:23:15,220
feels like that description
doesn't necessarily fully get to the

305
00:23:15,320 --> 00:23:21,860
core of why the DSM five doesn't
quite get the full scope of the problem

306
00:23:22,140 --> 00:23:26,197
- You invest a ton of money. You invest-

307
00:23:26,280 --> 00:23:30,180
...$20 billion-- More than $20
billion in a particular approach.

308
00:23:30,920 --> 00:23:34,500
And at the time you're constructing
this, you say, "Finally,

309
00:23:34,940 --> 00:23:38,377
because of all the work that's
being done in genetics, we now have

310
00:23:38,460 --> 00:23:40,320
decoded the human genome.

311
00:23:40,560 --> 00:23:47,560
We have PCR so we can chop it up and we
can look at bits of it. We have a lot more

312
00:23:48,100 --> 00:23:52,680
understanding of the role
of neurotransmission in the brain.

313
00:23:54,260 --> 00:23:59,320
Surely we're going to be able
to recast our diagnostic system

314
00:24:00,200 --> 00:24:04,140
based on underlying
pathology so that we won't be

315
00:24:04,560 --> 00:24:08,137
worrying about symptoms anymore.
We'll be looking at the actual

316
00:24:08,220 --> 00:24:11,570
underlying pathological
changes that have taken place.

317
00:24:12,480 --> 00:24:16,300
But in the event, it turned out
they couldn't do that. By about

318
00:24:16,480 --> 00:24:20,357
2008, they had thrown up their
hands and said, "No, we're going

319
00:24:20,440 --> 00:24:23,460
to have to continue to refine,

320
00:24:24,800 --> 00:24:30,660
rely upon the same basic approach
that we developed in 1980." And

321
00:24:31,700 --> 00:24:37,340
when that document came out, and there'd
been a lot of criticism, some of it from

322
00:24:38,240 --> 00:24:45,240
Robert Spitzer, who had been largely in
control of DSM-III and DSM-III-R, and then

323
00:24:45,940 --> 00:24:49,480
his successor Allen Frances,
who'd run DSM-IV,

324
00:24:50,520 --> 00:24:54,297
they both were fiercely critical
about what was going on and said it was

325
00:24:54,380 --> 00:24:58,130
being done in the dark and it was done
in secrecy and it wasn't scientific.

326
00:24:58,920 --> 00:25:00,690
And when it was about to come out,

327
00:25:01,720 --> 00:25:04,900
Thomas Insel and Steven Hyman,
the two then existing and the

328
00:25:05,140 --> 00:25:08,797
preceding director of the National
Institute of Mental Health, denounced the

329
00:25:08,880 --> 00:25:11,920
document as unscientific and useless.

330
00:25:12,700 --> 00:25:16,497
So if you're talking about a crisis,
that's a crisis for the field. If its

331
00:25:16,580 --> 00:25:21,460
diagnostic system is being dissed
by leading figures like that,

332
00:25:22,580 --> 00:25:28,707
What else was a problem?
The difficulties with the drug existing

333
00:25:28,790 --> 00:25:33,500
therapies, particularly,
had become more and more manifest.

334
00:25:33,980 --> 00:25:40,980
To make matters worse, partly because
Big Pharma had sometimes behaved,

335
00:25:42,960 --> 00:25:49,797
shall we say, rather unethically sometimes
with these drugs, it had hidden things

336
00:25:49,880 --> 00:25:55,803
that undercut their claims.
It had manufactured studies.

337
00:25:55,886 --> 00:25:58,460
It had manipulated data.

338
00:25:59,080 --> 00:26:02,780
And it got caught out, and it
paid billions of dollars in damages

339
00:26:02,880 --> 00:26:06,140
for some of the tricks it had got up to.

340
00:26:06,500 --> 00:26:10,197
Not just in psychiatry—I
mean Vioxx, for example, the

341
00:26:10,280 --> 00:26:13,820
painkiller, was another huge
scandal, and it was a $5 billion

342
00:26:13,960 --> 00:26:17,817
settlement. But the drug companies had

343
00:26:17,900 --> 00:26:21,737
suffered some reputational damage.
Beyond that, they didn't

344
00:26:21,820 --> 00:26:25,477
have any real clues. Unfortunately,
neuroscience hadn't thrown up new

345
00:26:25,560 --> 00:26:28,900
targets for different
forms of drug development

346
00:26:29,720 --> 00:26:33,477
And they decided they could make more
money with spending their money on

347
00:26:33,560 --> 00:26:36,490
research on other diseases,
not mental illness

348
00:26:37,740 --> 00:26:41,297
A crisis was you were stuck
with a set of drugs that Steve Hyman

349
00:26:41,380 --> 00:26:44,900
says, "Aren't really any
advance on the ones by

350
00:26:45,020 --> 00:26:48,520
accident we found in the fifties.
Mm-hmm. And

351
00:26:48,960 --> 00:26:52,397
there isn't new research
unless it's small startups going

352
00:26:52,480 --> 00:26:57,140
on to develop new ones,
so you have an increasing sense

353
00:26:57,960 --> 00:27:04,960
Your diagnostic process is falling apart,
your drug treatments' limitations are

354
00:27:06,250 --> 00:27:07,037
becoming

355
00:27:07,120 --> 00:27:14,057
more manifest and, um, as well for people

356
00:27:14,140 --> 00:27:18,520
with serious mental illness.
Public policy has screwed things up badly.

357
00:27:19,380 --> 00:27:25,977
So if you, a person with serious
mental illness, you will

358
00:27:26,060 --> 00:27:31,720
die on average fifteen to twenty-five
years before the rest of us. That

359
00:27:32,660 --> 00:27:36,317
gap has been growing rather than
diminishing. So, that's not a good

360
00:27:36,400 --> 00:27:38,897
thing. It's not something I want to

361
00:27:38,980 --> 00:27:42,830
lay entirely at the door of psychiatry.
So don't get me wrong, I think a

362
00:27:43,000 --> 00:27:49,146
lot of this is public policy that
has really abandoned treatment for

363
00:27:49,229 --> 00:27:54,437
the seriously mentally ill. And you
see it on the streets of our cities. You

364
00:27:54,520 --> 00:27:57,100
see the sidewalk psychotics.
You see people who are

365
00:27:57,220 --> 00:28:04,077
cycling between brief periods of inpatient
care, uh, the gutter, or the flop

366
00:28:04,160 --> 00:28:07,700
house and the jail. You so the three

367
00:28:07,900 --> 00:28:11,857
largest centers of inpatient
psychiatric care, if you can call it

368
00:28:11,940 --> 00:28:15,577
that in the United States
today are the Los Angeles

369
00:28:15,660 --> 00:28:20,017
County Jail, Cook County Jail
in Chicago, and Rikers Island in New

370
00:28:20,100 --> 00:28:24,731
York, that's shockingly, because
by their very nature, of course,

371
00:28:24,814 --> 00:28:29,580
prisons aren't equipped to deal
with serious mental illness

372
00:28:29,760 --> 00:28:32,840
- Some dark ways to return
to the asylum era.

373
00:28:32,940 --> 00:28:37,776
- Yeah, well, you know, the asylums
had acquired a very bad reputation,

374
00:28:37,859 --> 00:28:42,677
and I've written about some of the
reasons why that happened, but when

375
00:28:42,760 --> 00:28:48,281
asylums were founded, it was a period of
enormous optimism that we were going to be

376
00:28:48,365 --> 00:28:49,577
able to cure these

377
00:28:49,660 --> 00:28:54,260
people that we would rescue them
from attics and from jail cells,

378
00:28:54,343 --> 00:28:58,780
and through providing a therapeutic
environment, coaxing them to

379
00:28:58,940 --> 00:29:04,273
work, creating a system where
they learn to control themselves,

380
00:29:04,357 --> 00:29:10,148
not necessarily to drive their demons out,
but to keep them under some sort of wraps.

381
00:29:10,231 --> 00:29:14,177
The expectation was when the asylums
came along is that they'd not

382
00:29:14,260 --> 00:29:18,077
only rescue people from horrendous
conditions in the prisons and

383
00:29:18,160 --> 00:29:22,017
the jails, but they'd
actively cure them and

384
00:29:22,100 --> 00:29:28,437
the earliest alienists, as they
called themselves then, thought that

385
00:29:28,520 --> 00:29:33,393
they could cure 60, 70, 80 percent,
maybe even more of patients,

386
00:29:33,477 --> 00:29:35,737
as long as they came in early.

387
00:29:35,820 --> 00:29:39,357
And really, asylums were
built out of that sense.

388
00:29:39,440 --> 00:29:42,192
of optimism, that sense that we, you know,

389
00:29:42,275 --> 00:29:45,380
that so much was environmental
and so much was

390
00:29:46,420 --> 00:29:51,784
Not exacerbating the condition by treating
people like animals or treating them,

391
00:29:51,867 --> 00:29:57,498
you know. Beating them and in other
ways horrifically maltreating them,

392
00:29:57,582 --> 00:30:00,297
that would create, um, a sense of

393
00:30:00,380 --> 00:30:06,020
Cure and really that underlay
the construction of the asylums and

394
00:30:06,120 --> 00:30:12,884
Now having abandoned the asylums, which
we did starting a little bit in the 1950s

395
00:30:12,968 --> 00:30:16,180
but really the late 1960s onwards, uh.

396
00:30:16,280 --> 00:30:20,381
That was because there was going to be
something miraculous called community

397
00:30:20,464 --> 00:30:25,257
care, but Community care is a shell game
without a pee. It's like one o' those.

398
00:30:25,340 --> 00:30:31,369
confidence tricks. There were no
substitute community facilities

399
00:30:31,452 --> 00:30:34,920
for dealing with the really
serious mentally ill.

400
00:30:35,420 --> 00:30:38,687
- So now we're in this truly,
in, in this crisis-

401
00:30:38,770 --> 00:30:42,430
... in this essentially
dark ages. And in part

402
00:30:42,960 --> 00:30:47,227
I think our conversation, our journey
through the history of psychiatry-

403
00:30:47,310 --> 00:30:50,957
... is an exploration of some

404
00:30:51,040 --> 00:30:54,997
gigantic mistakes but also
an exploration of where lay some

405
00:30:55,080 --> 00:30:58,917
hope for the future. So we'll
talk quite a bit about this. I

406
00:30:59,000 --> 00:31:02,460
was wondering if you can also just lay out

407
00:31:02,580 --> 00:31:06,177
what are the big categories of mental
illness that we're referring to. You've

408
00:31:06,260 --> 00:31:10,957
already hinted at them,
but like levels of seriousness-

409
00:31:11,040 --> 00:31:13,097
... and the categories of illness-

410
00:31:13,180 --> 00:31:15,760
... like with psychosis
and depression and so on.

411
00:31:16,220 --> 00:31:23,220
- So going back to the early 20th century
was when the German psychiatrist Emil

412
00:31:23,980 --> 00:31:28,260
Kraepelin working with thousands
of records in German asylums

413
00:31:29,060 --> 00:31:32,597
inductively developed
a distinction between two very

414
00:31:32,680 --> 00:31:35,220
broad categories of mental illness.

415
00:31:36,200 --> 00:31:39,080
One he called dementia
praecox or early dementia,

416
00:31:40,020 --> 00:31:43,980
and the other he called manic depressive
illness which was a more remitting

417
00:31:44,080 --> 00:31:47,450
illness that sometimes went away entirely,

418
00:31:47,940 --> 00:31:54,111
other times went back and forth whereas
dementia praecox was a one way ticket

419
00:31:54,194 --> 00:31:55,027
down.

420
00:31:55,980 --> 00:32:01,440
Now that label was transformed
by a Swiss psychiatrist Bleuler

421
00:32:02,580 --> 00:32:06,380
into the term we use today
schizophrenia although

422
00:32:06,820 --> 00:32:10,697
Bleuler talked about
the schizophrenias because he thought

423
00:32:10,780 --> 00:32:15,970
under that broad label there were
a diverse group of things running around.

424
00:32:16,900 --> 00:32:20,337
And I think that was an important
insight that tends to get lost

425
00:32:20,420 --> 00:32:24,277
sometimes.
This was jamming together people

426
00:32:24,360 --> 00:32:28,217
with very serious psychosis,
that is people who'd lost touch

427
00:32:28,300 --> 00:32:31,180
with we liked-- what we
like to think of as reality,

428
00:32:32,180 --> 00:32:36,900
whose emotional and cognitive
lives were in total turmoil,

429
00:32:37,760 --> 00:32:41,660
Who were -- who lost
the ability to connect

430
00:32:41,760 --> 00:32:44,920
with other human beings.
So their social skills

431
00:32:45,140 --> 00:32:48,797
atrophied, their-- Well,
this is something contemporary

432
00:32:48,880 --> 00:32:52,550
psychiatrists would refer to as
the positive and negative symptoms

433
00:32:52,633 --> 00:32:57,540
of schizophrenia. - But underlying
the definition of schizophrenia here is a

434
00:32:57,660 --> 00:33:01,460
detachment from reality. So you're
hearing voices-... you're seeing visions.

435
00:33:01,640 --> 00:33:05,497
- You're thinking people are
plotting against you. You think the

436
00:33:05,580 --> 00:33:08,097
television is talking directly to you.

437
00:33:08,180 --> 00:33:11,817
- And because of that it has
these consequences of how you're

438
00:33:11,900 --> 00:33:14,841
connected to the rest of the world
and what your emotional life is like,

439
00:33:14,924 --> 00:33:15,837
all that kind of stuff.

440
00:33:15,920 --> 00:33:19,320
- Yes. Your emotional life flattens out.
Your language capacity

441
00:33:19,720 --> 00:33:23,380
deteriorates. Your ability
to relate to other people

442
00:33:24,000 --> 00:33:27,767
either vanishes or becomes
caught up in the web of

443
00:33:27,850 --> 00:33:31,320
delusions where you think
people around you are plotting

444
00:33:31,440 --> 00:33:33,697
against you or doing
terrible things to you.

445
00:33:33,780 --> 00:33:37,237
- And is that a different world than
the world of bipolar and the world of

446
00:33:37,320 --> 00:33:42,157
depression? - Yes. The Greeks recognized
and the Romans, ancient Greece and

447
00:33:42,240 --> 00:33:46,540
ancient Rome recognized different
forms of insanity as they called it.

448
00:33:47,460 --> 00:33:48,960
So melancholia

449
00:33:49,900 --> 00:33:53,677
would have been the term the Greeks
and the Romans would have used and it

450
00:33:53,760 --> 00:34:00,760
survived and was very much around.
And I think that is a form of

451
00:34:01,520 --> 00:34:07,840
depression. What's happened now is major
depression has become a catchall category.

452
00:34:07,960 --> 00:34:14,700
So it embraces both what we might think
of as milder forms of emotional distress

453
00:34:15,780 --> 00:34:19,740
along with what melancholia
referred to which was really

454
00:34:20,800 --> 00:34:24,497
a kind of depression that had
psychotic features. This loss of

455
00:34:24,580 --> 00:34:28,180
contact as it were with everyday reality.

456
00:34:28,460 --> 00:34:31,190
- Something you would talk about
maybe like a clinical depression.

457
00:34:31,273 --> 00:34:31,997
And by the way, we

458
00:34:32,080 --> 00:34:36,977
should mention that this field
in the 21st century is like a minefield.

459
00:34:37,060 --> 00:34:43,074
- Yes, very much so. So here's a very
strange bit of historical record.

460
00:34:43,157 --> 00:34:47,757
The other distinction and the
distinction we're grappling with so we

461
00:34:47,840 --> 00:34:51,657
have people who are-- whose
depression is of such a scale they're

462
00:34:51,740 --> 00:34:55,417
threatening to do away with themselves.
They've retreated

463
00:34:55,500 --> 00:34:59,140
into complete almost immobility. They're

464
00:34:59,280 --> 00:35:02,840
overwhelmed by senses
of sadness and loss and

465
00:35:02,940 --> 00:35:06,897
they're-- If they're religious then
they're damned to hell and all those

466
00:35:06,980 --> 00:35:10,560
kinds of things. So we have this psychosis

467
00:35:11,180 --> 00:35:14,657
that we've been talking about.
We have something also that the

468
00:35:14,740 --> 00:35:18,677
ancients recognize: dementia;
the loss really the loss

469
00:35:18,760 --> 00:35:24,090
of our mind as it were.
But then we also have

470
00:35:24,920 --> 00:35:31,257
other kinds of disturbance
of our mental faculties that generally

471
00:35:31,340 --> 00:35:35,057
we think of as more minor but I
don't want to make light of them

472
00:35:35,140 --> 00:35:38,847
because often people suffer
from these things genuinely

473
00:35:38,930 --> 00:35:42,797
suffer pretty badly.
But those things-- we in

474
00:35:42,880 --> 00:35:46,500
the 20th and 21st centuries
tend to talk about as neuroses

475
00:35:47,100 --> 00:35:53,617
neurotic diseases, psychotic diseases.
In the 19th century neurosis was a

476
00:35:53,700 --> 00:35:57,600
term that meant things
rooted in the brain as you can

477
00:35:57,700 --> 00:36:01,660
see from the root of the word
and psychosis was stuff that

478
00:36:02,220 --> 00:36:03,770
came from the mind, the psyche.

479
00:36:04,540 --> 00:36:08,300
And yet sometime in the late 19th
century those things crossed over

480
00:36:09,080 --> 00:36:16,080
and so when we talk in the present we
do tend to distinguish between the core,

481
00:36:17,400 --> 00:36:20,627
really the most severe
forms of mental disorder,

482
00:36:20,710 --> 00:36:24,517
...which would include things
like Alzheimer's disease

483
00:36:24,600 --> 00:36:28,140
and other forms of dementia, would include

484
00:36:28,480 --> 00:36:32,357
very serious depression,
would include bipolar

485
00:36:32,440 --> 00:36:36,500
disorder where people oscillate
either have extreme mania so they're

486
00:36:37,300 --> 00:36:41,120
they're not getting any sleep.
They're talking at an extraordinary rate

487
00:36:41,260 --> 00:36:44,697
Their behavior is very hard
to tolerate, and they're exhausting

488
00:36:44,780 --> 00:36:48,697
themselves, and they may even die
from exhaustion if it's not controlled.

489
00:36:48,780 --> 00:36:52,297
And very often that
alternates with periods of

490
00:36:52,380 --> 00:36:59,350
depression. So that was a category
that was captured initially as,

491
00:36:59,860 --> 00:37:03,477
Manic depressive illness
and later on evolved into

492
00:37:03,560 --> 00:37:07,497
bipolar disorder and then
separating out depression

493
00:37:07,580 --> 00:37:11,317
and major depression separately.
But then there are a whole bunch of

494
00:37:11,400 --> 00:37:15,060
other things like, for example, phobias.

495
00:37:15,560 --> 00:37:19,220
People can't go outside because
they find it too frightening.

496
00:37:19,990 --> 00:37:23,780
Milder phobias: "I can't get in an
airplane because it's gonna crash,"

497
00:37:24,510 --> 00:37:28,280
"I can't go to school because it's
overwhelming for me." So school phobia

498
00:37:28,420 --> 00:37:35,040
emerges as a diagnosis. A disorder
that at first attracted Freud, hysteria.

499
00:37:35,520 --> 00:37:38,217
- And now we should say you
wrote a book on hysteria.

500
00:37:38,300 --> 00:37:38,907
- Oh, I did indeed, yes.

501
00:37:38,990 --> 00:37:42,577
- You mentioned... I mean,
hysteria, every classification we're

502
00:37:42,660 --> 00:37:46,397
talking about has been
used and abused by every

503
00:37:46,480 --> 00:37:49,007
layer of society including
institutions- - Yes

504
00:37:49,090 --> 00:37:55,700
-...including just culturally the word
hysteria applied to different races

505
00:37:55,800 --> 00:37:59,047
disproportionately, to different,
um- - Genders particularly, yes, yes

506
00:37:59,130 --> 00:38:00,337
-...genders disproportionate-

507
00:38:00,420 --> 00:38:04,237
So we're in this crisis of trying
to figure out what to do with this super

508
00:38:04,320 --> 00:38:09,660
complicated human mind- - Yes -...and
everybody is dogmatically creating

509
00:38:09,780 --> 00:38:15,417
narratives that hold, take hold,
and in so doing can lead to some abuses-

510
00:38:15,500 --> 00:38:17,777
- Yes, they do. Yes,
they do -...as you document.

511
00:38:17,860 --> 00:38:21,560
- If you look back at the asylum
era born in this period of intense

512
00:38:21,740 --> 00:38:25,577
optimism, and then the claims
to be able to cure these vast

513
00:38:25,660 --> 00:38:27,600
numbers of patients were overblown.

514
00:38:28,660 --> 00:38:32,517
Uh, I do believe the early asylums
actually did good work and that some

515
00:38:32,600 --> 00:38:38,040
patients did very well and recovered as a
result of their stays. But what happened,

516
00:38:39,060 --> 00:38:42,560
they weren't discharging 80%
of their patients. They were discharging

517
00:38:42,760 --> 00:38:48,680
35 or 40% of their patients, and what
that meant is every year left behind

518
00:38:49,540 --> 00:38:53,497
were a batch of chronic patients, and then
the next year you repeated it. And over

519
00:38:53,580 --> 00:38:57,337
time, what that means is the ratio of new

520
00:38:57,420 --> 00:39:01,090
patients to chronic patients
gets worse and worse.

521
00:39:02,100 --> 00:39:05,717
And more and more the image
of the asylum is defined by the

522
00:39:05,800 --> 00:39:09,397
chronic patient who hasn't
recovered and maybe spends years or

523
00:39:09,480 --> 00:39:16,480
decades there and only leaves in a pine
box. So the image of the asylum declined

524
00:39:18,340 --> 00:39:21,800
drastically. As they became
more and more overcrowded,

525
00:39:21,900 --> 00:39:25,737
conditions in them deteriorated.
Patients were often

526
00:39:25,820 --> 00:39:29,717
abused. Psychiatrists didn't know
what to do with them, and they

527
00:39:29,800 --> 00:39:35,540
faced a problem in the late 19th century.
You'd promised 70% or 80% cures,

528
00:39:36,380 --> 00:39:40,097
but we're not seeing that. In fact,
when we calculate cures and the numbers of

529
00:39:40,180 --> 00:39:44,037
people in the asylum,
it's more like 10% or 12%. That's

530
00:39:44,120 --> 00:39:48,017
the way you could play with statistics
'cause that's all the old patients

531
00:39:48,100 --> 00:39:55,100
mixed with the new. But still, it looks
very bad. How do you explain this doctor?

532
00:39:56,220 --> 00:40:00,057
You've promised us one thing, and you
delivered something quite different. The

533
00:40:00,140 --> 00:40:04,057
answer came in a way
of blaming the victim, in a way

534
00:40:04,140 --> 00:40:06,980
of saying, "Well, you know,
what we didn't understand

535
00:40:07,780 --> 00:40:11,480
was that mental illness
is a fundamentally biological

536
00:40:11,580 --> 00:40:15,277
condition. These people are evolutionary

537
00:40:15,360 --> 00:40:18,877
throwbacks." Evolution
was generally thought of as a

538
00:40:18,960 --> 00:40:22,897
progressive onwards and upwards,
but these people had fallen back

539
00:40:22,980 --> 00:40:26,537
into a lesser form of

540
00:40:26,620 --> 00:40:31,286
existence. They'd lost their essential
humanity because their brains were

541
00:40:31,369 --> 00:40:32,203
defective.

542
00:40:32,820 --> 00:40:38,140
So what emerged then was the idea
of degeneration, the idea that

543
00:40:39,000 --> 00:40:42,477
these patients were degenerates.
They were people with an inferior

544
00:40:42,560 --> 00:40:46,357
biology. You couldn't release them because
they breed like rabbits. They didn't

545
00:40:46,440 --> 00:40:50,680
have any self-control because
of their diminished humanity.

546
00:40:50,980 --> 00:40:52,500
- This is the narrative.

547
00:40:52,900 --> 00:40:56,777
- This is the narrative.
And so what it did was provide a

548
00:40:56,860 --> 00:41:00,717
justification for locking up people
in asylums that wasn't therapeutic

549
00:41:00,800 --> 00:41:02,877
at all. It was just
keeping them out of the way.

550
00:41:02,960 --> 00:41:06,147
- And then it led to the justification
of sterilization- - Exactly.

551
00:41:06,230 --> 00:41:07,127
-...based on the same argument.

552
00:41:07,210 --> 00:41:10,707
- So maybe we can release them
if we make sure they can't breed.

553
00:41:10,790 --> 00:41:12,457
- This is the beginning of the darkness.

554
00:41:12,540 --> 00:41:16,397
- It is the beginning of the darkness.
My own state was

555
00:41:16,480 --> 00:41:20,197
one of the pioneers
in this process, and it

556
00:41:20,280 --> 00:41:24,020
continued to sterilize mental
patients up until about 1960.

557
00:41:24,620 --> 00:41:31,620
- By the 1960s, over 60,000 sterilizations
have been performed in the US with

558
00:41:32,380 --> 00:41:36,477
California performing
a disproportionately high number.

559
00:41:36,560 --> 00:41:39,757
- That's correct. But even more serious

560
00:41:39,840 --> 00:41:43,790
consequences could flow
from these set of issues.

561
00:41:44,420 --> 00:41:51,205
When you start talking, one British
psychiatrist said that if his patients

562
00:41:51,289 --> 00:41:55,520
that were coming into
the asylum had been puppies,

563
00:41:57,040 --> 00:42:00,937
we'd have tied them up in a sack because
they were some horrible mongrel, not

564
00:42:01,020 --> 00:42:03,749
a purebred dog, tied them up
in a sack with some lead weights,

565
00:42:03,833 --> 00:42:05,877
and thrown them in a
pond and drowned them.

566
00:42:05,960 --> 00:42:06,793
- Man.

567
00:42:06,920 --> 00:42:10,440
- That kind of language
is very, very dangerous.

568
00:42:11,160 --> 00:42:14,517
And what happened,
California's law surrounding

569
00:42:14,600 --> 00:42:18,417
sterilization was advocated
for in the West. By that I

570
00:42:18,500 --> 00:42:22,550
mean North America
and Britain and much of Europe.

571
00:42:23,420 --> 00:42:27,337
There were enough checks and balances
in a democratic system that even

572
00:42:27,420 --> 00:42:30,760
though there were enthusiasts,
the eugenicists who said,

573
00:42:31,210 --> 00:42:34,360
"Best get rid of these people,
put them to death,"

574
00:42:35,100 --> 00:42:40,450
that never really, that never
really acquired mass support.

575
00:42:41,290 --> 00:42:44,750
But what happened in Germany
once Nazi-- the Nazis came to

576
00:42:44,850 --> 00:42:48,630
power is they seized on these
notions and that the idea

577
00:42:48,730 --> 00:42:52,460
that the mentally ill were,
as they put it, useless eaters,

578
00:42:52,550 --> 00:42:56,467
people consuming resources but never
gonna get better, just a burden on

579
00:42:56,550 --> 00:43:00,387
the state. Their lives weren't worth
living because after all, they had this

580
00:43:00,470 --> 00:43:03,687
serious mental illness. So first you

581
00:43:03,770 --> 00:43:07,487
sterilize, and then you go,
"But we're still supporting all these

582
00:43:07,570 --> 00:43:11,330
people." And so Hitler starts
something called the T4 program

583
00:43:11,430 --> 00:43:17,150
after the street name of the house where
this was concocted, Tiergartenstraße 4.

584
00:43:18,330 --> 00:43:24,670
And the mentally ill were the first
people to suffer from the Final Solution.

585
00:43:25,470 --> 00:43:29,327
It was in the mass killing of the mentally
ill, which may have been as many as a

586
00:43:29,410 --> 00:43:34,270
quarter million people,
that the technology of the gas chamber

587
00:43:34,354 --> 00:43:39,567
was developed,
and the technology of disguising the

588
00:43:39,650 --> 00:43:46,500
gas chamber as showers was developed.
And so patients were taken away

589
00:43:47,530 --> 00:43:51,327
to a number of psychiatric
centers and systematically

590
00:43:51,410 --> 00:43:55,187
put to death, and they had
the crematoriums and the black

591
00:43:55,270 --> 00:43:59,027
smoke, and local people talked about
the buses that were bringing them in as

592
00:43:59,110 --> 00:44:02,450
killing crates. So they were
aware of what was going on.

593
00:44:02,570 --> 00:44:05,707
- Were they influenced by the narratives
that were born in the United States?

594
00:44:05,790 --> 00:44:07,707
- Yes, absolutely.
They- - About this kind of-

595
00:44:07,790 --> 00:44:10,987
- About that sort of thing,
and lacking the check, the checks and

596
00:44:11,070 --> 00:44:15,650
balances that at least until
recently this country had, um,

597
00:44:16,510 --> 00:44:18,850
it was relatively easy for Hitler

598
00:44:19,690 --> 00:44:23,507
to do that. And particularly
with the war looming, the idea

599
00:44:23,590 --> 00:44:27,387
that we're gonna support all
these useless people, let's kill

600
00:44:27,470 --> 00:44:33,770
them. And German psychiatry for the most
part collaborated with that process.

601
00:44:34,210 --> 00:44:38,930
- I wonder how many people throughout that
whole journey in the psychiatry profession

602
00:44:39,870 --> 00:44:43,850
sort of were brave enough
to speak up like, "Hey, maybe the

603
00:44:43,950 --> 00:44:46,677
sack of puppies kinda
language-" - Oh, yes. Oh, yes.

604
00:44:46,760 --> 00:44:47,710
-... is a problem?"

605
00:44:48,310 --> 00:44:52,730
- That's the really nasty direction
that that language could lead to.

606
00:44:53,690 --> 00:44:57,110
And it was symptomatic of the kind of

607
00:44:57,610 --> 00:45:01,227
stigma that tends to attach
itself to mental illness and this

608
00:45:01,310 --> 00:45:05,140
sense of hopelessness.
So but if you're a healing profession,

609
00:45:05,630 --> 00:45:09,090
if, if you enter psychiatry thinking,

610
00:45:09,610 --> 00:45:13,560
"I'm gonna do this to help people, to cure
people, to make their lives better,"

611
00:45:15,290 --> 00:45:19,940
to just become a glorified boarding
housekeeper keeping them under lock

612
00:45:20,023 --> 00:45:20,857
and key

613
00:45:21,090 --> 00:45:24,750
or in the alternative to collaborate
in this, in the sorts of

614
00:45:25,130 --> 00:45:28,247
awfulness that the Nazis
perpetrated, that's

615
00:45:28,330 --> 00:45:32,127
something from which decent human beings

616
00:45:32,210 --> 00:45:37,590
tend to recoil and decent
psychiatrists tended to recoil. And so

617
00:45:38,650 --> 00:45:41,847
still thinking as they
did by the end of the 19th

618
00:45:41,930 --> 00:45:47,850
century that mental illness
was predominantly a biological problem,

619
00:45:49,630 --> 00:45:53,487
some of them began to say, "Well,
maybe biology as well as being the

620
00:45:53,570 --> 00:45:57,550
problem could provide the solution.
Maybe we should look for

621
00:45:57,730 --> 00:46:02,567
ways to intervene in the biological
systems of these people and make them

622
00:46:02,651 --> 00:46:03,484
better."

623
00:46:04,030 --> 00:46:08,647
The same logic that applies
I would say in the present-

624
00:46:08,730 --> 00:46:10,567
... for, for many working in the field.

625
00:46:10,650 --> 00:46:14,027
- But in a cruder form.
- But in a very different form, exactly.

626
00:46:14,110 --> 00:46:17,967
- Yeah. If, if we can just speak
about the Nazis a bit more, you

627
00:46:18,050 --> 00:46:21,787
highlight that America financially
supported the German psychiatric

628
00:46:21,870 --> 00:46:25,747
researchers with deep Nazi
ties like Ernst Rudin who was

629
00:46:25,830 --> 00:46:29,610
the key architect of Hitler's mass
sterilization and extermination

630
00:46:29,710 --> 00:46:33,627
laws. So it seems like the Nazis borrowed

631
00:46:33,710 --> 00:46:37,007
the American narratives of the
psychiatrist that these are lesser

632
00:46:37,090 --> 00:46:42,330
biological beings and then this financial
support and the ties continued.

633
00:46:42,450 --> 00:46:46,227
- Yeah. So one of the organizations that

634
00:46:46,310 --> 00:46:50,854
recognized that mental illness
was an acute social problem,

635
00:46:50,938 --> 00:46:52,820
very costly to the state

636
00:46:54,750 --> 00:46:59,530
inflicting all kinds of suffering
on people was The Rockefeller Foundation.

637
00:47:00,510 --> 00:47:03,987
What we don't realize today is that the

638
00:47:04,070 --> 00:47:07,950
involvement of the federal
government in medical research

639
00:47:08,090 --> 00:47:11,817
and indeed scientific
research is a World War II

640
00:47:11,900 --> 00:47:15,787
and post-war development partly
the Cold War and Sputnik and

641
00:47:15,870 --> 00:47:21,000
all of that. But that's when big
science and big medicine got funded-

642
00:47:21,130 --> 00:47:24,250
... in extravagant ways. Before the war,

643
00:47:25,170 --> 00:47:29,007
science was an orphan. It didn't get
money from the government much and

644
00:47:29,090 --> 00:47:36,090
medicine even more so. So to the extent
medical training was reformed,

645
00:47:36,995 --> 00:47:42,630
that was the product of investment by The
Rockefeller Foundation enormously wealthy

646
00:47:42,830 --> 00:47:47,420
by the standards of the time.
And come about 1930,

647
00:47:48,790 --> 00:47:52,607
The Rockefeller Foundation
decided it needed

648
00:47:52,690 --> 00:47:59,250
to concentrate its resources and pick
priorities for the money it was investing.

649
00:48:00,410 --> 00:48:03,790
And it may seem a rather
strange thing within the

650
00:48:04,090 --> 00:48:07,590
whole range of medical
areas that it could choose,

651
00:48:08,230 --> 00:48:12,107
it chose psychiatry as the one
that it was going to invest in. And

652
00:48:12,190 --> 00:48:15,210
I think it did so in part for

653
00:48:16,590 --> 00:48:20,670
precisely because scientific research
in psychiatry was so backward,

654
00:48:22,310 --> 00:48:26,647
partly because it was such
a pressing public problem.

655
00:48:26,730 --> 00:48:30,527
And partly, and this was less
public but nonetheless I

656
00:48:30,610 --> 00:48:34,447
think played an important role,
several of the trustees of The

657
00:48:34,530 --> 00:48:38,187
Rockefeller Foundation had
direct experience of mental

658
00:48:38,270 --> 00:48:41,167
illness in their families.
Wives who'd been

659
00:48:41,250 --> 00:48:44,947
institutionalized as schizophrenic.
In one case, a

660
00:48:45,030 --> 00:48:47,950
wife who murdered
the children and killed herself

661
00:48:48,710 --> 00:48:52,110
leaving her husband
as a major actor in The

662
00:48:52,310 --> 00:48:55,867
Rockefeller Foundation
bereft and of course inclined

663
00:48:55,950 --> 00:49:01,920
then to support research in this area. And
Rockefeller spread its money very widely,

664
00:49:02,760 --> 00:49:06,477
Precisely 'cause it didn't
know where to spend most of

665
00:49:06,560 --> 00:49:10,080
its money. So it did some support of

666
00:49:10,300 --> 00:49:14,060
Psychotherapeutics.
It supported a number of the then

667
00:49:14,160 --> 00:49:17,600
extant therapeutic experiments going on,

668
00:49:18,360 --> 00:49:22,257
and it supported work in genetics.
And one of the geneticists it

669
00:49:22,340 --> 00:49:26,137
supported, Ernst Rüdin in Germany,
who was the leading

670
00:49:26,220 --> 00:49:29,510
German researcher in genetics
and mental disorder.

671
00:49:30,320 --> 00:49:34,120
And Rüdin, because he's absorbed
the lessons from California

672
00:49:34,400 --> 00:49:38,240
about sterilization, became a very
enthusiastic proponent of that,

673
00:49:38,980 --> 00:49:42,230
and then a supporter
of murdering mental patients.

674
00:49:42,700 --> 00:49:46,239
- And we should say, I mean, we'll
probably talk about the complicated nature

675
00:49:46,322 --> 00:49:50,347
of science- ...that it sometimes can
be captured by certain ideologies and-

676
00:49:50,430 --> 00:49:54,150
...in so doing do a lot
of damage to humanity. But

677
00:49:54,360 --> 00:49:58,137
ultimately, the beacon of hope
for the future of humanity lays in the

678
00:49:58,220 --> 00:50:02,150
scientific method, as flawed as it is.
So everything we're talking about,

679
00:50:02,600 --> 00:50:07,500
we get to see how you F up-

680
00:50:09,740 --> 00:50:14,397
In a major dark disturbing ways
throughout the 20th century-

681
00:50:14,480 --> 00:50:17,797
...on the-- in the psychiatric
profession. But that

682
00:50:17,880 --> 00:50:21,497
should be instructive lessons
of how we proceed forward to do

683
00:50:21,580 --> 00:50:23,100
better and better and better.

684
00:50:24,120 --> 00:50:30,928
- We can discuss a series of therapeutic
experiments on people who were shut up

685
00:50:31,011 --> 00:50:35,217
in a double sense. They were locked away,
and their voices were not heeded

686
00:50:35,300 --> 00:50:39,117
because it was the product
of their madness. And so what we see in

687
00:50:39,200 --> 00:50:42,697
the first five decades really of the 20th

688
00:50:42,780 --> 00:50:46,717
century is people with
a variety of motivations

689
00:50:46,800 --> 00:50:50,100
including the desire to improve
the lot of the mentally ill

690
00:50:50,580 --> 00:50:54,800
engaging in uncontrolled experiments
that had terrible results.

691
00:50:55,680 --> 00:50:59,540
And the science behind it
was shaky but nonetheless

692
00:50:59,800 --> 00:51:03,260
it existed. It wasn't just
plucked out of the sky.

693
00:51:04,350 --> 00:51:08,257
And yes, it eventually those things
break down. I mean, the clearest case

694
00:51:08,340 --> 00:51:12,157
of that because it's the most
extreme of these at least in the

695
00:51:12,240 --> 00:51:15,780
public imagination is lobotomy. The

696
00:51:15,880 --> 00:51:19,800
idea that you are going to solve
psychotic breakdowns in people

697
00:51:20,600 --> 00:51:23,940
by excising part of their brain

698
00:51:24,660 --> 00:51:28,380
initially by drilling holes
in the skull and injecting alcohol

699
00:51:28,480 --> 00:51:32,097
or using what looks like a butter
knife to break connections

700
00:51:32,180 --> 00:51:36,057
between the brain.
And then later when that process

701
00:51:36,140 --> 00:51:40,010
seems to be too slow,
the Henry Ford of lobotomy--

702
00:51:40,320 --> 00:51:44,157
his daughter said Walter Freeman aspired
to be the Henry Ford of lobotomy, the

703
00:51:44,240 --> 00:51:47,650
one who could mechanize
the production of it and get it done

704
00:51:47,800 --> 00:51:51,377
fast. He invented the ice
pick lobotomy where you

705
00:51:51,460 --> 00:51:54,850
used an ice pick in the orbit of the eye

706
00:51:55,660 --> 00:51:59,540
having rendered somebody unconscious
after two or three electric shocks

707
00:52:00,460 --> 00:52:04,320
and you banged it through
the bone and wiggled it about and

708
00:52:04,440 --> 00:52:08,460
severed -- I mean,
it's just hard to even describe.

709
00:52:08,720 --> 00:52:12,340
- So this is from the 1930s to the 1970s?

710
00:52:12,680 --> 00:52:16,600
- Yes. Freeman starts his work in 1936

711
00:52:16,780 --> 00:52:20,757
borrowing from the work
of the preceding year of Portuguese

712
00:52:20,840 --> 00:52:24,777
neurologist named Egas Moniz.
And Moniz wins the Nobel

713
00:52:24,860 --> 00:52:28,240
Prize in medicine in 1949 for lobotomy.

714
00:52:28,780 --> 00:52:32,717
So it's important to see that.
That was 14 years

715
00:52:32,800 --> 00:52:36,717
of experience and yet
that won a Nobel Prize. I'm

716
00:52:36,800 --> 00:52:38,750
sure that's one they'd like to retract.

717
00:52:38,870 --> 00:52:42,520
- So he popularized Walter
Freeman, the ice pick.

718
00:52:42,770 --> 00:52:46,197
- And his particular specialty
after the war became this ice pick

719
00:52:46,280 --> 00:52:50,177
lobotomy because there were
over half million patients in

720
00:52:50,260 --> 00:52:54,237
America's mental hospitals.
Freeman was convinced this operation was

721
00:52:54,320 --> 00:53:00,490
a cure all. And so he traveled
around in a camper truck

722
00:53:01,300 --> 00:53:04,357
which he called the Lobotomobile
and he would descend in the

723
00:53:04,440 --> 00:53:09,965
summer on state hospitals and he would
teach them how to do this ice pick

724
00:53:10,049 --> 00:53:14,440
lobotomy. - This is by the
way an image of the tool.

725
00:53:15,300 --> 00:53:17,452
- Yes, those are the tools
he used. Originally,

726
00:53:17,535 --> 00:53:20,240
he used an actual ice pick
and then he developed this-

727
00:53:20,480 --> 00:53:23,197
- This is what he developed.
This is the state-of-the-art technology.

728
00:53:23,280 --> 00:53:25,777
- This is the state of the art
with a hammer or a mallet.

729
00:53:25,860 --> 00:53:32,400
- Oh no! - Yes, I'm sorry.
It's very distressing. I, I don't know-

730
00:53:32,680 --> 00:53:36,057
- You having to write about this by the
way-- - Well, it's really- - Is a lot

731
00:53:36,140 --> 00:53:39,477
-...very, very, very,
very difficult. I came across, for

732
00:53:39,560 --> 00:53:43,237
example, picture of a woman, naked woman

733
00:53:43,320 --> 00:53:46,617
being dragged away by attendants
to be lobotomized and she's

734
00:53:46,700 --> 00:53:53,277
resisting with all her might and to no
avail. You have a picture there of

735
00:53:53,360 --> 00:53:57,680
Walter Freeman lobotomizing
a patient in Washington State.

736
00:53:58,520 --> 00:54:03,363
Freeman was ambidextrous
and when he taught neurology,

737
00:54:03,446 --> 00:54:05,937
he would draw simultaneously

738
00:54:06,020 --> 00:54:09,817
with his left and right hand
and he could do it perfectly.

739
00:54:09,900 --> 00:54:13,737
When he was performing lobotomy, when
his right hand got tired, he switched to

740
00:54:13,820 --> 00:54:19,140
his left hand and he sometimes would
do 20 or 30 lobotomies in an afternoon.

741
00:54:20,080 --> 00:54:23,700
And he boasted, he said,
"You know I could teach any damn

742
00:54:23,800 --> 00:54:27,340
fool to perform a lobotomy in twenty
minutes even a psychiatrist."

743
00:54:27,840 --> 00:54:33,612
Because Freeman was a neurologist and he
had a lot of contempt for psychiatrists.

744
00:54:33,695 --> 00:54:34,529
So

745
00:54:34,740 --> 00:54:40,520
So this was a very ugly episode.
How did it die away? It really took

746
00:54:41,400 --> 00:54:47,737
generational change. Some of these
lobotomists continued to operate into the

747
00:54:47,820 --> 00:54:49,790
sixties even to the early seventies,

748
00:54:50,700 --> 00:54:53,620
but the younger generation
who became acquainted

749
00:54:53,760 --> 00:54:57,457
with the really worst failures of that

750
00:54:57,540 --> 00:55:02,180
regime; the people on the back
wards who were incontinent, who were

751
00:55:03,340 --> 00:55:07,210
basically zombies had
lost all mental power.

752
00:55:07,930 --> 00:55:11,090
They rebelled against
this and by then they had

753
00:55:11,930 --> 00:55:15,640
a different treatment in the
form of antipsychotic drugs-

754
00:55:16,070 --> 00:55:19,320
... which looked much more like
what regular medicine was doing,

755
00:55:20,310 --> 00:55:22,787
And didn't have these
horrible overtones. And of

756
00:55:22,870 --> 00:55:29,870
course in the popular mind I think
the, probably the most famous,

757
00:55:31,670 --> 00:55:37,907
instance of telling the public about
some of these interventions was the

758
00:55:37,990 --> 00:55:41,230
film of Ken Kesey's novel One
Flew Over the Cuckoo's Nest

759
00:55:41,890 --> 00:55:45,027
where you see Jack Nicholson
giving I think the performance of a

760
00:55:45,110 --> 00:55:51,810
lifetime who is given ECT,
electroconvulsive therapy,

761
00:55:52,670 --> 00:55:56,550
at--in a very dramatic rendition
of what that was not, not really

762
00:55:57,770 --> 00:56:01,747
what was going on by, by the 1970s

763
00:56:01,830 --> 00:56:05,687
with ECT but nonetheless certainly
what had been going on back in the

764
00:56:05,770 --> 00:56:10,810
past. And then finally when
ECT doesn't smash him to bits

765
00:56:11,770 --> 00:56:15,607
they lobotomize him and,
and the film ends obviously with him being

766
00:56:15,690 --> 00:56:21,230
smothered to death 'cause Chief can't bear
to see him in, in the state that he's in.

767
00:56:22,210 --> 00:56:25,210
So that fixed in the public mind

768
00:56:26,230 --> 00:56:30,030
some of the images of these things.
It is one of the things that gave

769
00:56:31,210 --> 00:56:35,150
Electroconvulsive therapy such a bad name.

770
00:56:35,470 --> 00:56:38,867
- So we will actually not
to fast forward too quickly,-

771
00:56:38,950 --> 00:56:41,660
-... let's talk about uh, the full journey

772
00:56:42,470 --> 00:56:45,785
of everything we've been talking about.
So we mentioned the asylum era that began

773
00:56:45,868 --> 00:56:50,338
in the mid nineteenth century going
into twentieth and we talked about

774
00:56:50,422 --> 00:56:53,090
the narratives- - And we
talked about sterilization

775
00:56:53,210 --> 00:56:58,610
- Sterilization. And let's look at the
insulin shock therapy of uh, nineteen

776
00:56:58,730 --> 00:57:02,567
thirty three to the nineteen sixties
where you were putting patients

777
00:57:02,650 --> 00:57:06,690
in deep hypoglycemic comas
using large doses of insulin.

778
00:57:07,070 --> 00:57:10,847
- Yeah. So as I mentioned
for psychiatrists who

779
00:57:10,930 --> 00:57:14,687
went into the field and were
ambitious but who also wanted to

780
00:57:14,770 --> 00:57:18,437
think of themselves as therapeutic agents-

781
00:57:18,520 --> 00:57:22,430
....uh, to just sit there
passively and contain the patients

782
00:57:22,530 --> 00:57:28,230
was very unattractive. And so they
looked around for ways in which perhaps

783
00:57:29,210 --> 00:57:31,670
biological interventions could be used

784
00:57:32,470 --> 00:57:37,050
to ameliorate this condition that they
still saw in largely biological terms.

785
00:57:38,290 --> 00:57:45,290
Now in some ways one of the crucial
early ways in which this thinking went

786
00:57:47,370 --> 00:57:51,350
and which affected a large
number of patients was this:

787
00:57:52,030 --> 00:57:55,907
one of the few diagnostic triumphs
of psychiatry in the early nineteenth

788
00:57:55,990 --> 00:57:58,370
century as the profession began to emerge

789
00:57:59,370 --> 00:58:03,267
Was that it began to distinguish
a group of patients who were deemed

790
00:58:03,350 --> 00:58:07,010
to be suffering from something called
general paralysis of the insane.

791
00:58:08,350 --> 00:58:13,880
That encapsulates two things about
what was going on. First of all,

792
00:58:14,750 --> 00:58:18,870
paralysis; the gradual
loss of motor control,

793
00:58:19,690 --> 00:58:24,810
ability to walk, ability
to swallow, ability to, to talk.

794
00:58:26,710 --> 00:58:30,200
So those are primarily what we'd
think of these days as neurological

795
00:58:30,590 --> 00:58:34,310
issues. But those were
accompanied by bizarre

796
00:58:35,170 --> 00:58:38,807
psychiatric symptomatology.
These were people who thought they were

797
00:58:38,890 --> 00:58:44,607
Napoleon or Jesus Christ or the richest
and sexiest man in the world-

798
00:58:44,690 --> 00:58:48,627
...or Mary the mother of God.
They were primarily men

799
00:58:48,710 --> 00:58:50,460
but there were also female victims.

800
00:58:51,750 --> 00:58:55,330
At the turn of the twentieth
century as many as twenty

801
00:58:55,450 --> 00:58:58,810
five percent of the people
being admitted to asylums

802
00:58:59,330 --> 00:59:03,210
were suffering from General Paralysis
of the Insane or GPI for short.

803
00:59:04,830 --> 00:59:08,407
There have been a lot of suspicions
about this being connected somehow to

804
00:59:08,490 --> 00:59:13,310
sex and to moral dissolution and so forth

805
00:59:14,130 --> 00:59:19,607
but what evolved in the early
twentieth century was the

806
00:59:19,690 --> 00:59:25,667
discovery of the actual origins of this

807
00:59:25,750 --> 00:59:29,327
disorder. So I've said psychiatry
has been looking for the

808
00:59:29,410 --> 00:59:32,407
underlying pathology
that lies behind mental

809
00:59:32,490 --> 00:59:36,890
diseases. This was one
that at Rockefeller Institute

810
00:59:37,870 --> 00:59:44,870
they discovered that the organism that
causes syphilis was residing in the brains

811
00:59:45,687 --> 00:59:49,527
of the people who were
suffering from GPI. This was in

812
00:59:49,610 --> 00:59:53,310
fact tertiary stage of syphilis.
Syphilis is a

813
00:59:53,570 --> 00:59:57,337
still a real public health problem.
It was like AIDS in the late nineteenth

814
00:59:57,420 --> 00:59:58,770
century. It was everywhere.

815
00:59:59,850 --> 01:00:03,850
And when you first contract syphilis
in the primary phase you have pain

816
01:00:05,050 --> 01:00:08,330
but then it goes underground
and you think it's gone

817
01:00:09,390 --> 01:00:14,707
and it lurks the way chicken
pox virus lurks and can

818
01:00:14,790 --> 01:00:20,742
surface years later right? It lurks,
it lurks and it's insidiously damaging

819
01:00:20,826 --> 01:00:21,527
sometimes

820
01:00:21,610 --> 01:00:28,610
it attacks the heart and people drop dead
of a heart attack in their forties ohh

821
01:00:30,390 --> 01:00:34,440
he died of a-- You know it's natural heart
attack but in fact it was the syphilis

822
01:00:35,170 --> 01:00:38,720
Or it attacks the central nervous
system the spinal column in the brain

823
01:00:39,130 --> 01:00:42,447
and then you get the paralysis -
Mm-hmm...and then you get also the

824
01:00:42,530 --> 01:00:49,157
psychiatric symptomatology. So when
that was discovered that sort of suggested

825
01:00:49,240 --> 01:00:51,970
that mental illness might
have an infectious origin.

826
01:00:52,830 --> 01:00:56,627
Tertiary syphilis GPI went on to win for

827
01:00:56,710 --> 01:01:00,630
somebody who developed a treatment
for it a Nobel Prize one of only

828
01:01:00,770 --> 01:01:04,430
two awarded for psychiatric
innovations. One was a lobotomy

829
01:01:04,930 --> 01:01:08,490
the other was giving people
malaria to cure their syphilis.

830
01:01:08,650 --> 01:01:15,190
- In case people didn't hear
that- Giving people malaria-

831
01:01:15,330 --> 01:01:17,880
.. In order to cure syphilis

832
01:01:18,200 --> 01:01:25,200
- So there was an Austrian doctor,
Wagner Jauregg, who had long thought that

833
01:01:26,200 --> 01:01:29,977
fever could be used to cure
mental illness. And he tried rat

834
01:01:30,060 --> 01:01:33,617
bite fever. He tried giving people
typhoid vaccine that creates a

835
01:01:33,700 --> 01:01:37,480
fever to no avail.
And towards the end of World War I,

836
01:01:38,040 --> 01:01:41,917
the Italians were fighting
in World War I on the side of the

837
01:01:42,000 --> 01:01:44,050
British and the Americans and the French.

838
01:01:44,620 --> 01:01:48,040
They captured an Italian
soldier who had malaria.

839
01:01:48,440 --> 01:01:51,260
Malaria was endemic
in those years in Italy.

840
01:01:51,920 --> 01:01:55,357
And they brought him to him,
and he extracted the malarial blood and

841
01:01:55,440 --> 01:01:59,300
injected it into a series
of patients with GPI, with

842
01:01:59,430 --> 01:02:02,500
general paralysis of the insane,
and claimed it cured them.

843
01:02:03,760 --> 01:02:07,360
We know from later
on when he fessed up that

844
01:02:07,520 --> 01:02:11,277
those claims were wildly
exaggerated, but they were widely

845
01:02:11,360 --> 01:02:14,600
accepted, and malarial treatment

846
01:02:14,720 --> 01:02:19,800
spread to Britain, it spread to Germany,
it spread to the United States.

847
01:02:21,010 --> 01:02:26,327
Sometimes it was vials of malarial
blood, but very often mental

848
01:02:26,410 --> 01:02:29,690
hospitals had actual colonies
of malarial mosquitoes.

849
01:02:30,390 --> 01:02:33,590
So imagine you're a mental patient,
and you're put in a straitjacket,

850
01:02:33,674 --> 01:02:38,317
and you're put in a room, and you can't
move, and mosquitoes are buzzing around,

851
01:02:38,400 --> 01:02:40,907
and they bite you,
and then you develop malaria.

852
01:02:40,990 --> 01:02:42,737
- And he got a Nobel Prize for this?

853
01:02:42,820 --> 01:02:46,357
- Yes, in 1937, he got a Nobel Prize.
'Cause this was a

854
01:02:46,440 --> 01:02:53,440
condition that was invariably fatal.
And the claim was that somehow

855
01:02:53,600 --> 01:02:57,330
the malarial fever worked.
Now, there are two possible

856
01:02:57,420 --> 01:03:01,057
ways. Von Jauregg
thought it stimulated the

857
01:03:01,140 --> 01:03:04,920
immune system to attack whatever
it was, was causing the insanity.

858
01:03:05,310 --> 01:03:08,817
But the other possibility
was the following: When

859
01:03:08,900 --> 01:03:12,420
you have the malarial parasite in a test

860
01:03:12,520 --> 01:03:19,520
tube and you heat the test tube to about
105, 106 degrees, it dies. So the idea

861
01:03:20,220 --> 01:03:23,557
potentially was you were sort of burning
the parasites out of the brain with

862
01:03:23,640 --> 01:03:29,637
this agent. And because people
were pretty unsophisticated about

863
01:03:29,720 --> 01:03:35,370
statistics and because the idea of a
controlled trial had not yet come to pass,

864
01:03:36,320 --> 01:03:42,657
this treatment was used extensively
for a couple of decades. What

865
01:03:42,740 --> 01:03:45,980
caused it to stop, and you talk
about the progress of science,

866
01:03:46,960 --> 01:03:51,290
was the discovery of penicillin,
which was a real magic bullet.

867
01:03:51,580 --> 01:03:55,457
So once you had penicillin,
you weren't gonna continue treating people

868
01:03:55,540 --> 01:03:59,257
with malaria, so it died away.
But it was the first

869
01:03:59,340 --> 01:04:03,177
such treatment, and here's
the other way this feeds into the

870
01:04:03,260 --> 01:04:06,977
narrative of these desperate
remedies that develop in this

871
01:04:07,060 --> 01:04:10,700
period between
the mid-'teens and, say, 1950.

872
01:04:12,220 --> 01:04:17,340
The discovery of the syphilitic origins
of general paralysis of the insane

873
01:04:18,300 --> 01:04:21,720
occurred at a time when
medicine had undergone a

874
01:04:21,920 --> 01:04:25,697
undergone a profound transformation.
In the late 19th

875
01:04:25,780 --> 01:04:30,280
century, the work of Louis Pasteur,
who was a chemist, not an MD,

876
01:04:31,080 --> 01:04:35,850
and the work of Robert Koch
in Germany had uncovered

877
01:04:36,680 --> 01:04:43,680
the origins of a variety of diseases and
suggested that bacteria were the reason

878
01:04:44,796 --> 01:04:50,997
why people sickened. And that led,
of course, to a whole series of public

879
01:04:51,080 --> 01:04:57,097
health triumphs, because initially it
didn't lead to antibiotics. But for a lot

880
01:04:57,180 --> 01:05:04,180
of these diseases, even viral diseases
like rabies, you could develop a vaccine.

881
01:05:05,200 --> 01:05:10,340
And the vaccines were
phenomenally effective. And so

882
01:05:11,200 --> 01:05:16,100
that was one way in which
the new germ theory of disease

883
01:05:16,320 --> 01:05:20,990
transformed medicine and tied it into the
laboratory and into science in a new way.

884
01:05:22,140 --> 01:05:26,040
And the other was the adaptation
of Pasteur's theories

885
01:05:26,230 --> 01:05:33,230
by a British surgeon named Lister,
who previously when pus developed

886
01:05:33,840 --> 01:05:37,230
post-surgery, people had
thought that was a good sign.

887
01:05:38,980 --> 01:05:42,520
Lister said, "No, I don't think so.
This is actually these

888
01:05:42,640 --> 01:05:45,940
nasty germs causing this,
and so we're gonna do

889
01:05:46,080 --> 01:05:49,937
antiseptic surgery."
So he sprayed carbolic acid

890
01:05:50,020 --> 01:05:52,880
on the wounds to try to kill the microbes.

891
01:05:54,060 --> 01:05:57,937
Most of his colleagues thought he
was nuts. Thought he was just-- This

892
01:05:58,020 --> 01:06:01,414
is ridiculous, these microorganisms.
You couldn't even see them, you know?

893
01:06:01,497 --> 01:06:07,327
Well, you could with a... But Lister
prevailed. And eventually we moved from

894
01:06:07,410 --> 01:06:11,297
antiseptic surgery to aseptic surgery,
which is what we have now,

895
01:06:11,380 --> 01:06:15,017
where you try to have a sterilized set of

896
01:06:15,100 --> 01:06:18,990
instruments in a sterilized environment,
so you don't infect things, right?

897
01:06:19,280 --> 01:06:23,617
- By the way, these are definitive
examples of progress in medicine.

898
01:06:23,700 --> 01:06:25,717
- Absolutely. - Penicillin-- - Yes.

899
01:06:25,800 --> 01:06:30,147
-...uh, you know, making sure
there's no germs in during surgery.

900
01:06:30,230 --> 01:06:30,817
- Associated with wounds, yes.

901
01:06:30,900 --> 01:06:34,820
- So these are all just refreshingly
clear examples of progress.

902
01:06:35,240 --> 01:06:39,057
The reason I say it's refreshingly clear
that there's progress, there's not a

903
01:06:39,140 --> 01:06:44,307
refreshingly clear progress in the history
of psychiatry. Maybe, maybe a few hints.

904
01:06:44,390 --> 01:06:46,420
- Some bits, yes. There haven't been

905
01:06:47,460 --> 01:06:50,840
the dramatic breakthroughs that I
think everybody in the field

906
01:06:51,460 --> 01:06:55,177
would hope for.
And there's some debate about

907
01:06:55,260 --> 01:06:59,137
how powerful what we have done is, and I

908
01:06:59,220 --> 01:07:02,997
think it's reasonable to debate
that and to also acknowledge

909
01:07:03,080 --> 01:07:10,080
that there is important progress, limited
as it is. Now you have 25% of the admits

910
01:07:11,160 --> 01:07:14,840
to a mental hospital actually
suffering from an infectious

911
01:07:14,960 --> 01:07:19,740
disease. Medicine in general has now
tied its fortunes to the laboratory.

912
01:07:20,740 --> 01:07:26,640
The idea that disease is caused
by bacteria, we can't yet see viruses.

913
01:07:28,260 --> 01:07:35,260
It is a very powerful one and that notion
that disease is caused by bacterial

914
01:07:35,500 --> 01:07:39,280
infection acquires great momentum but it

915
01:07:39,380 --> 01:07:44,720
hasn't touched psychiatry so medicine
now has interventions that work

916
01:07:46,100 --> 01:07:49,360
And sometimes quite dramatically

917
01:07:50,080 --> 01:07:53,880
um you know the first patient
given diphtheria vaccine--

918
01:07:54,000 --> 01:07:57,587
Diphtheria causes a leather
like membrane to grow over your

919
01:07:57,670 --> 01:08:01,377
throat and you die choking
to death And if you have a

920
01:08:01,460 --> 01:08:07,060
child and you watch that child die
like that You will never be over it

921
01:08:08,200 --> 01:08:11,360
So when you had something
that warded that off

922
01:08:13,180 --> 01:08:16,957
That improved medicine's
image dramatically and

923
01:08:17,040 --> 01:08:20,990
improved its financial prospects
dramatically particularly

924
01:08:21,200 --> 01:08:27,840
as medical training became reformed
and more involved with science

925
01:08:30,260 --> 01:08:34,600
So that hasn't applied to psychiatry until

926
01:08:35,060 --> 01:08:38,677
syphilis comes along Now
we have the model that an

927
01:08:38,760 --> 01:08:45,760
infectious agent can cause
people's minds to go amok

928
01:08:46,480 --> 01:08:50,237
So The very person who
invents the basic distinction

929
01:08:50,320 --> 01:08:56,960
between kinds of psychoses we still use
today schizophrenia and bipolar disorder

930
01:08:57,960 --> 01:09:01,900
Emil Kraepelin begins to think "You
know there may be something infectious

931
01:09:02,020 --> 01:09:04,170
about the mental
illnesses we're treating."

932
01:09:05,060 --> 01:09:07,300
And one of the people he trains is a young

933
01:09:08,360 --> 01:09:12,297
psychiatrist from the United
States named Henry Cotton Who's also

934
01:09:12,380 --> 01:09:16,227
been trained by Adolf
Meyer who is the leading

935
01:09:16,310 --> 01:09:19,920
American psychiatrist of the first
forty years of the twentieth century

936
01:09:21,280 --> 01:09:24,360
And when he comes back from Germany
having spent a year there

937
01:09:25,020 --> 01:09:28,737
Meyer secures him a position as head
of the New Jersey State Mental

938
01:09:28,820 --> 01:09:34,720
Hospital at Trenton and Cotton
is an ambitious reforming man

939
01:09:35,260 --> 01:09:38,917
He wants to bring psychiatry
back to medicine He also

940
01:09:39,000 --> 01:09:42,720
wants to chuck out all
the old stuff He doesn't want

941
01:09:43,240 --> 01:09:47,210
chains in his hospital He doesn't
want If he can help it straight jackets

942
01:09:47,600 --> 01:09:54,257
So that goes away But nothing seems
to change fundamentally He still isn't

943
01:09:54,340 --> 01:09:58,097
curing patients And then
he comes across this idea of

944
01:09:58,180 --> 01:10:01,617
focal sepsis The idea that low grade

945
01:10:01,700 --> 01:10:05,280
infections can lurk in the body
and what they do is release

946
01:10:05,400 --> 01:10:08,720
toxins into the bloodstream
and the lymph And hey

947
01:10:09,180 --> 01:10:13,827
imagine if those toxins get
to the brain What's it going to do?

948
01:10:13,910 --> 01:10:17,700
It's gonna poison the brain
and the brain is then gonna act up

949
01:10:19,080 --> 01:10:23,320
so We don't have antibiotics So
what are we gonna do about this

950
01:10:24,480 --> 01:10:28,430
Well we can perhaps locate
the bacterial infection

951
01:10:29,460 --> 01:10:33,713
and then we can Get rid of it We
can engage in what he calls surgical

952
01:10:33,796 --> 01:10:34,629
bacteriology

953
01:10:35,760 --> 01:10:39,300
So the first obvious target here is teeth

954
01:10:40,460 --> 01:10:43,800
Your teeth look close to your
brain They're often infected

955
01:10:44,400 --> 01:10:50,520
That infection often goes untreated
for a time... So we pull a lot of teeth

956
01:10:52,200 --> 01:10:58,180
Patients don't get better Mm Maybe
the theory's wrong No Um tonsils

957
01:10:58,860 --> 01:11:03,700
well they're getting infected so we'll
remove them Still don't get better

958
01:11:05,140 --> 01:11:11,077
Well they're swallowing the bacteria so
we remove stomachs and we move spleens

959
01:11:11,160 --> 01:11:15,057
and we remove colons And we
claim to be curing eighty percent

960
01:11:15,140 --> 01:11:19,017
of our patients And rich patients
come from all over America

961
01:11:19,100 --> 01:11:22,440
to be treated with this
novel treatment - Crazy

962
01:11:22,740 --> 01:11:26,557
- Cotton gives A series of lectures
at Princeton There were not

963
01:11:26,640 --> 01:11:30,120
some lectures which are given
by Nobel Prize winners. There's a very

964
01:11:30,220 --> 01:11:31,260
prestigious series.

965
01:11:32,500 --> 01:11:36,377
Uh, it's published by Oxford University
Press and Princeton University Press.

966
01:11:36,460 --> 01:11:40,980
The New York Times hails it as a
great breakthrough. And in reality,

967
01:11:41,920 --> 01:11:46,080
45% of the people who get
the abdominal surgery die within a year.

968
01:11:46,360 --> 01:11:47,757
- They're cutting out stomachs.

969
01:11:47,840 --> 01:11:51,412
- Yep. He's cutting out stomachs. He
says--there's this passage in one of his

970
01:11:51,495 --> 01:11:55,557
papers where he says, "Stomachs are
like cement mixers on a construction

971
01:11:55,640 --> 01:11:59,600
site and could be dispensed with."
When you think, oh my God,

972
01:12:00,820 --> 01:12:04,557
if you were released
from Trenton and you had no

973
01:12:04,640 --> 01:12:09,800
teeth, people immediately knew you were
an ex-patient because the word had spread.

974
01:12:10,860 --> 01:12:17,697
And this goes on for--starting
in 1916, Cotton drops dead of a

975
01:12:17,780 --> 01:12:24,647
heart attack in 1933, but he's succeeded
by three people he's trained. They

976
01:12:24,730 --> 01:12:28,620
drop the abdominal surgery.
They use colonic irrigation, but

977
01:12:29,020 --> 01:12:34,100
but the teeth and the tonsils keep
being pulled. I interviewed the dentist

978
01:12:34,900 --> 01:12:38,717
who had come to the hospital
in 1916 and must have pulled several

979
01:12:38,800 --> 01:12:40,080
hundred thousand teeth.

980
01:12:41,200 --> 01:12:45,400
In nine-- and he retired in 1960,
which was when that finally stopped.

981
01:12:46,300 --> 01:12:51,700
And he was convinced Cotton should have
won the Nobel Prize for this. Oh, well.

982
01:12:51,980 --> 01:12:55,420
- Can you just give some intuition,
put ourselves in that

983
01:12:55,520 --> 01:12:59,160
mind space? I mean,
presumably these are smart

984
01:12:59,300 --> 01:13:02,757
human beings. Why were they
fraudulent in the reporting of how

985
01:13:02,840 --> 01:13:06,740
effective it is? Why are all
the people that are participating,

986
01:13:07,480 --> 01:13:10,300
both the doctors and general culture--

987
01:13:11,040 --> 01:13:13,400
- It's extraordinary. So obviously,

988
01:13:15,400 --> 01:13:19,317
many of the interventions I'm
talking about are very powerful

989
01:13:19,400 --> 01:13:24,400
interventions conducted by people in white
coats and stethoscopes and scalpels.

990
01:13:24,780 --> 01:13:28,617
- Powerful, by the way,
by the amount of impact

991
01:13:28,700 --> 01:13:31,797
they have on the human body, not powerful
in terms of how effective they are.

992
01:13:31,880 --> 01:13:35,240
- Yes, powerful as well
in terms of placebo effect.

993
01:13:36,140 --> 01:13:40,077
Look, what I am going to do to you,
and yes, it's gonna hurt

994
01:13:40,160 --> 01:13:43,260
and it's very intimate,
but it's going to make you better.

995
01:13:44,390 --> 01:13:47,787
So that's always-- this is
a problem that persists in

996
01:13:47,870 --> 01:13:50,350
contemporary psychiatry,
trying to figure out

997
01:13:51,170 --> 01:13:53,170
how much of the improvement we're seeing

998
01:13:54,090 --> 01:13:58,007
is the placebo effect and how-- how
much of it is the active effect of

999
01:13:58,090 --> 01:13:59,140
whatever we're doing.

1000
01:13:59,550 --> 01:14:03,947
- But by the way, on that small tangent,
let's return to that perhaps often.

1001
01:14:04,030 --> 01:14:08,490
- Yes. - I for one can tell
you that for me, for my mind,

1002
01:14:10,030 --> 01:14:14,910
the placebo effect even when you
tell me it's placebo will work.

1003
01:14:15,130 --> 01:14:18,920
- Yes! - But now if you have
combined an actual gigantic

1004
01:14:19,030 --> 01:14:25,107
operation that is physically,
mentally, in every way life changing -

1005
01:14:25,190 --> 01:14:29,127
... everybody around you in lab
coats, all of society's telling

1006
01:14:29,210 --> 01:14:32,810
you this is going to be life changing.
I get it. That's like the most

1007
01:14:32,990 --> 01:14:34,410
pure kind of placebo effect.

1008
01:14:34,620 --> 01:14:39,167
- It's placebo effect that comes from both
the patient who wants to be better-

1009
01:14:39,250 --> 01:14:42,687
... and wants to believe this is gonna
make them, and from the person

1010
01:14:42,770 --> 01:14:46,110
conducting. And it's
easy to deceive yourself,

1011
01:14:46,810 --> 01:14:52,370
to see what you want to see.
So anyway, that was one episode. Um,

1012
01:14:53,640 --> 01:14:57,007
we talk about triumphs of medicine
so let me talk about one of

1013
01:14:57,090 --> 01:15:01,750
the real triumphs of 20th century medicine

1014
01:15:03,790 --> 01:15:08,470
which is interesting to refer
to because it wasn't a cure,

1015
01:15:09,910 --> 01:15:13,410
just like psychiatric drugs
aren't a cure for mental illness.

1016
01:15:14,090 --> 01:15:17,710
It was a symptomatic treatment
but it transformed lives

1017
01:15:18,350 --> 01:15:22,050
and that was discovery
of insulin in the 1920s.

1018
01:15:23,010 --> 01:15:26,550
Previously particularly
what we now call type

1019
01:15:26,670 --> 01:15:29,570
one or juvenile diabetes
was a death sentence.

1020
01:15:30,670 --> 01:15:34,307
You got it and whatever you
did, you tried various quack

1021
01:15:34,390 --> 01:15:38,227
remedies, you tried diet,
you tried all sorts of things. The

1022
01:15:38,310 --> 01:15:42,490
inevitable thing was it killed you.
And then came insulin.

1023
01:15:43,460 --> 01:15:48,110
Now insulin doesn't mean you're cured
of dia- your diabetes but what it means is

1024
01:15:49,010 --> 01:15:52,790
you can live a relatively
normal life and your lifespan is

1025
01:15:52,910 --> 01:15:59,370
greatly expanded. So by any measure you
have to say that's dramatic progress.

1026
01:16:00,290 --> 01:16:04,787
But insulin is something
our bodies produce we hope

1027
01:16:04,870 --> 01:16:08,657
unless we're really seriously
diabetic. Those of us with Type

1028
01:16:08,740 --> 01:16:12,667
Two diabetes, our bodies
resist insulin and we have

1029
01:16:12,750 --> 01:16:16,650
to resort to other ways
of trying to cope. But

1030
01:16:16,750 --> 01:16:20,730
if you get too much insulin,
it makes you unconscious

1031
01:16:21,850 --> 01:16:27,330
and that's how another one of these
desperate remedies came along.

1032
01:16:28,710 --> 01:16:32,330
A man named Sakel
working in a German clinic

1033
01:16:32,870 --> 01:16:36,707
for drug addicts they were using putting

1034
01:16:36,790 --> 01:16:40,307
people under mild comas
to help them through the

1035
01:16:40,390 --> 01:16:44,087
withdrawal symptoms once they got
over their addiction. So he was

1036
01:16:44,170 --> 01:16:47,767
familiar with that.
And when he moved to Austria, he

1037
01:16:47,850 --> 01:16:51,890
decided he'd try this as a
treatment for schizophrenia.

1038
01:16:52,870 --> 01:16:56,687
And so he put people into
comas sometimes comas that would

1039
01:16:56,770 --> 01:17:01,770
last hours days um they would
be revived by giving them glucose

1040
01:17:02,730 --> 01:17:06,467
usually intravenously sometimes not. Um

1041
01:17:06,550 --> 01:17:10,207
during the time they were
in comas they often seized had

1042
01:17:10,290 --> 01:17:14,150
seizures.
He saw that as a therapeutic sign.

1043
01:17:14,250 --> 01:17:17,650
And he claimed that this
Insulin Coma Treatment

1044
01:17:18,630 --> 01:17:22,507
cured eighty percent of his -- eighty
percent tends to come up again and again

1045
01:17:22,590 --> 01:17:25,550
in these treatments as a sort
of percentage that you cure.

1046
01:17:26,690 --> 01:17:30,550
And he was invited to New York

1047
01:17:31,130 --> 01:17:34,530
and demonstrated this at the
Harlem Valley Mental Hospital.

1048
01:17:35,290 --> 01:17:38,987
It spread. This is in the thirties?
This was starting in

1049
01:17:39,070 --> 01:17:42,830
nineteen thirty-three. The visit
to America was I believe nineteen thirty-

1050
01:17:43,070 --> 01:17:46,840
six and Sakel ended up
settling here. He had a very

1051
01:17:46,950 --> 01:17:50,787
lucrative private practice
in New York and when he died he

1052
01:17:50,870 --> 01:17:54,687
left his partner I think an estate
of about two million dollars which

1053
01:17:54,770 --> 01:17:58,607
in the early sixties
was a very substantial amount

1054
01:17:58,690 --> 01:18:02,327
of money that he'd earned
from practice, right? So

1055
01:18:02,410 --> 01:18:06,187
insulin coma therapy
was widely adopted. What kept it

1056
01:18:06,270 --> 01:18:10,167
from being a large scale thing
was it required an enormous

1057
01:18:10,250 --> 01:18:14,107
amount of nursing and medical
attention 'cause people were literally

1058
01:18:14,190 --> 01:18:17,807
hovering on the brink of life and death.
They could go into a permanent

1059
01:18:17,890 --> 01:18:21,150
coma, they could just die. Um, so they had

1060
01:18:21,750 --> 01:18:25,527
vital signs had to be monitored.
They had to be brought around very

1061
01:18:25,610 --> 01:18:31,847
quickly if need be. And there's some
evidence that the treatment killed

1062
01:18:31,930 --> 01:18:35,387
brain cells. And when Sakel was told
that, he said, "Yes, that's probably

1063
01:18:35,470 --> 01:18:39,227
true. They're killing the schizophrenic
brain cells." That's just

1064
01:18:39,310 --> 01:18:41,727
nonsense, of course.
That's just nonsense, but that's

1065
01:18:41,810 --> 01:18:45,427
his rationale.
Insulin comas weren't subjected to a

1066
01:18:45,510 --> 01:18:48,407
randomized controlled
trial until the nineteen

1067
01:18:48,490 --> 01:18:52,187
fifties. And when they were
subjected to a controlled

1068
01:18:52,270 --> 01:18:56,147
trial, they failed it, and so it died out.

1069
01:18:56,230 --> 01:19:00,037
And that's, I guess, scientific
progress again in a way, but

1070
01:19:00,120 --> 01:19:02,947
took a long time. One of the people who

1071
01:19:03,030 --> 01:19:08,342
received insulin coma therapy—have you
seen the film A Beautiful Mind? Mm-hmm,

1072
01:19:08,426 --> 01:19:08,927
he did.

1073
01:19:09,010 --> 01:19:13,300
Receive insulin coma therapy. Ironically,
actually at Trenton State Hospital where

1074
01:19:13,383 --> 01:19:15,337
Cotton had been, so John Nash received

1075
01:19:15,420 --> 01:19:19,430
John Nash got insulin comas,
and they were going to lobotomize him,

1076
01:19:20,710 --> 01:19:25,707
and they didn't, but he
was at risk of that. We should say

1077
01:19:25,790 --> 01:19:29,230
that this treatment,
patients would thrash, moan,

1078
01:19:29,314 --> 01:19:34,839
and convulse before falling into a coma.
The treatment required a course of up

1079
01:19:34,922 --> 01:19:40,376
to sixty comas. It turned out to have
a mortality rate of one to five percent

1080
01:19:40,460 --> 01:19:44,259
and caused significant brain
damage and obesity. Yeah,

1081
01:19:44,343 --> 01:19:48,010
yet was hailed as a miracle
cure for schizophrenia.

1082
01:19:48,490 --> 01:19:52,850
Yes, that's right. Performed
on John Nash, one of the great

1083
01:19:53,390 --> 01:19:57,970
- minds of the 20th century. - Yes,
and Nash clearly did become delusional,

1084
01:19:58,970 --> 01:20:02,770
but that was one of the
treatments he was subjected to,

1085
01:20:03,130 --> 01:20:07,510
and well represented, actually,
in the film of A Beautiful Mind.

1086
01:20:08,470 --> 01:20:13,290
So I mentioned seizures.
Also in Austria-Hungary in this period,

1087
01:20:14,110 --> 01:20:20,567
another psychiatrist decided
that you couldn't be both

1088
01:20:20,650 --> 01:20:27,150
schizophrenic and epileptic. That there
was somehow an antagonism between the two.

1089
01:20:28,170 --> 01:20:31,147
So if you had epilepsy, you didn't
have schizophrenia. If you had

1090
01:20:31,230 --> 01:20:33,450
schizophrenia, you couldn't have epilepsy.

1091
01:20:34,490 --> 01:20:38,730
Uhh... I should say at the outset, that's
not true, but that's what he believed.

1092
01:20:39,550 --> 01:20:43,487
So then, the logical next step
was, "Well, if we could create

1093
01:20:43,570 --> 01:20:48,510
an artificial epileptic seizure, maybe
we would drive out the schizophrenia."

1094
01:20:50,430 --> 01:20:53,950
So, what to do? He first tries injecting

1095
01:20:54,070 --> 01:20:57,727
camphor, a natural substance.
Natural substances aren't necessarily

1096
01:20:57,810 --> 01:21:01,687
benign substances.
That caused abscesses, and it

1097
01:21:01,770 --> 01:21:05,547
wasn't very effective.
He sought an alternative, and he settled

1098
01:21:05,630 --> 01:21:09,450
on something that was,
um, called Cardiazol

1099
01:21:11,150 --> 01:21:14,350
or Metrazol, depended which
side of the Atlantic you were on.

1100
01:21:15,390 --> 01:21:19,007
And injecting that into
a patient usually caused a

1101
01:21:19,090 --> 01:21:22,767
seizure, a big seizure like
a grand mal seizure, where

1102
01:21:22,850 --> 01:21:27,110
your body arcs back,
your legs contract dramatically.

1103
01:21:27,230 --> 01:21:30,510
- You can fracture
spines and hips and bones.

1104
01:21:30,950 --> 01:21:34,887
- And you ended up, yes,
with fractures of vertebrae, fractures

1105
01:21:34,970 --> 01:21:38,767
of the hip socket.
Because when muscles in the

1106
01:21:38,850 --> 01:21:42,627
thigh contract that badly,
what happens? The thigh bone

1107
01:21:42,710 --> 01:21:46,530
is driven into the socket
at such a rate that it fractures,

1108
01:21:46,910 --> 01:21:50,727
right? So these were among
the complications that Metrazol

1109
01:21:50,810 --> 01:21:54,730
produced. More than that,
he himself conceded

1110
01:21:55,530 --> 01:21:59,260
that between the injection
and the seizure, the

1111
01:21:59,390 --> 01:22:03,990
patient felt as though he were on--
or she was on the brink of death.

1112
01:22:04,790 --> 01:22:07,960
Now imagine, pretend
you're a mental patient.

1113
01:22:08,043 --> 01:22:10,787
You're brought in in a straitjacket, a

1114
01:22:10,870 --> 01:22:14,850
man in a white coat with a big
hypodermic injects something into you,

1115
01:22:16,330 --> 01:22:18,130
You feel as though you're gonna die.

1116
01:22:18,810 --> 01:22:22,687
And maybe that lingers for two,
three, ten minutes, and then

1117
01:22:22,770 --> 01:22:26,350
you seize, with those
possible fractures following.

1118
01:22:27,090 --> 01:22:28,007
- Violent seizures.

1119
01:22:28,090 --> 01:22:34,290
- It's violent and hard to witness
and is very unpredictable.

1120
01:22:35,170 --> 01:22:39,047
So it's used, but people are
not very happy, and that's

1121
01:22:39,130 --> 01:22:45,373
how we get electroconvulsive therapy,
electroshock, as it's first called.

1122
01:22:45,457 --> 01:22:46,410
Two Italian

1123
01:22:46,930 --> 01:22:50,480
psychiatrists, Cerletti and Bini,
experiment with electricity, and they

1124
01:22:50,650 --> 01:22:52,250
first experiment on dogs.

1125
01:22:53,330 --> 01:22:56,644
And they make a mistake initially.
They have an electrode on the head,

1126
01:22:56,728 --> 01:22:57,267
an electrode

1127
01:22:57,350 --> 01:23:01,227
on the anus. The electric current passes
through the body, it stops the heart, the

1128
01:23:01,310 --> 01:23:02,143
dogs die.

1129
01:23:03,410 --> 01:23:06,500
So that seems a dead end.
And then somebody says to them, "You know,

1130
01:23:06,583 --> 01:23:07,267
you should go to

1131
01:23:07,350 --> 01:23:11,067
the Rome slaughterhouse and see the pigs
being slaughtered, 'cause you'll learn

1132
01:23:11,150 --> 01:23:14,947
something very interesting." So they go,
and the pigs are dangling by their

1133
01:23:15,030 --> 01:23:20,770
hind legs, and as they come by,
two electrodes cross their head.

1134
01:23:21,490 --> 01:23:25,127
Electroshock, they convulse,
they're unconscious, their

1135
01:23:25,210 --> 01:23:32,210
throats are slit and pork arrives. So, um,
they try that on dogs, and current passing

1136
01:23:35,330 --> 01:23:37,880
through the brain,
it turns out, doesn't kill them.

1137
01:23:38,170 --> 01:23:41,567
So they decide to try it out.
They pick up a transient

1138
01:23:41,650 --> 01:23:46,590
homeless person at the Rome train
station and they bring him in.

1139
01:23:48,250 --> 01:23:52,087
And they try it, and at first
they don't use enough current.

1140
01:23:52,170 --> 01:23:56,007
And nothing very much happens.
And they're very white-

1141
01:23:56,090 --> 01:23:59,244
faced, they're quite worried off in the
corner. We have descriptions of this,

1142
01:23:59,328 --> 01:23:59,747
and they're

1143
01:23:59,830 --> 01:24:03,587
talking, "What should we do?" "Well,
we'll up the current." And the patient

1144
01:24:03,670 --> 01:24:08,729
hears that and says, "No, another one,
that's deadly." They do it anyway,

1145
01:24:08,812 --> 01:24:10,010
and he convulses.

1146
01:24:10,710 --> 01:24:14,107
Another grand mal seizure,
with the same problems of spinal fractures

1147
01:24:14,190 --> 01:24:19,930
and hip fractures and so on. Not
universally, obviously, but often enough.

1148
01:24:21,030 --> 01:24:25,270
And he stops breathing.
You can imagine the scene.

1149
01:24:27,230 --> 01:24:31,110
And then he spontaneously starts
breathing again, and when he comes around,

1150
01:24:32,190 --> 01:24:36,127
he's in contact with reality.
They got this miracle cure,

1151
01:24:36,210 --> 01:24:39,110
and it's very easy to administer, cheap,

1152
01:24:40,430 --> 01:24:46,830
doesn't involve injecting things into
people's bodies. So that quickly spreads

1153
01:24:47,930 --> 01:24:50,940
across the Atlantic
and other parts of Europe.

1154
01:24:52,050 --> 01:24:57,840
And ECT becomes a very
widely used intervention.

1155
01:24:59,210 --> 01:25:00,960
Couple of things to say about this.

1156
01:25:02,050 --> 01:25:05,890
It turns out it's not very
useful for schizophrenia.

1157
01:25:07,390 --> 01:25:10,907
Remember the connection
between seizures and

1158
01:25:10,990 --> 01:25:14,710
seizure and schizophrenia
that was originally posited

1159
01:25:15,290 --> 01:25:18,470
posited, but it seems
to work in cases of, um,

1160
01:25:18,810 --> 01:25:21,650
depression, suicidal
depression particularly.

1161
01:25:22,010 --> 01:25:25,540
- Fast forwarding to the modern day.
Mm-hmm. And this is something I

1162
01:25:26,790 --> 01:25:31,840
learned by reading a bunch recently.
It seems to be one of the

1163
01:25:32,970 --> 01:25:36,807
few evidence-based, like scientifically
backed methods that actually

1164
01:25:36,890 --> 01:25:39,840
worked for clinical depression,
for serious depression.

1165
01:25:40,030 --> 01:25:43,827
- Um, yes, if we fast forward,
we're looking at in some

1166
01:25:43,910 --> 01:25:47,227
respects a different animal
for reasons I'll explain. Okay.

1167
01:25:47,310 --> 01:25:48,700
- This is unmodified ECT.

1168
01:25:49,170 --> 01:25:53,630
- Yeah, so we're talking about
unmodified ECT, which rules the roost

1169
01:25:54,930 --> 01:25:58,207
really well into the 1950s,
and some places even into the

1170
01:25:58,290 --> 01:26:02,050
1960s. And so it is associated
with all the problems of

1171
01:26:02,170 --> 01:26:05,887
fractures that we've talked about.
It's also associated with memory

1172
01:26:05,970 --> 01:26:09,727
problems. People often
lose memory. There's some

1173
01:26:09,810 --> 01:26:13,727
dispute about how serious that is,
but it's pretty widely recognized

1174
01:26:13,810 --> 01:26:17,010
that's one of the prices you're
going to pay for that treatment.

1175
01:26:17,330 --> 01:26:22,110
The thing is, for mental
hospitals in the '40s and '50s,

1176
01:26:23,110 --> 01:26:26,230
ECT was much more used as a

1177
01:26:26,930 --> 01:26:30,347
device to control people's
behavior, than as a therapeutic

1178
01:26:30,430 --> 01:26:37,430
intervention. It was quite punitive, seen
as such. Patients didn't want to repeat,

1179
01:26:39,030 --> 01:26:43,870
and so they--...sort of controlled
themselves a bit. But yes,

1180
01:26:44,750 --> 01:26:51,750
we don't know why it, quote, "works,"
but more recent work starting in

1181
01:26:52,810 --> 01:26:56,462
probably the 1990s -- and I'm going to get
in trouble with some people for saying

1182
01:26:56,546 --> 01:26:59,790
this because you mentioned patients and

1183
01:27:00,150 --> 01:27:05,330
psychiatrists who swear by ECT.
There are others who swear at it.

1184
01:27:05,690 --> 01:27:09,507
Um, partly because of the
memory problems I alluded

1185
01:27:09,590 --> 01:27:13,190
to, and partly because
of claims that it may cause

1186
01:27:13,630 --> 01:27:17,570
brain damage. Passing an electric
current through the brain is possible.

1187
01:27:18,270 --> 01:27:25,250
What changed ECT a bit, quite a bit
actually, was giving muscle relaxants

1188
01:27:26,270 --> 01:27:30,207
so that people didn't thrash about,
and the fractures were largely a thing of

1189
01:27:30,290 --> 01:27:35,130
the past. When you introduce these muscle
relaxers, originally they used curare,

1190
01:27:36,110 --> 01:27:39,727
but then they used other,
more modern drugs

1191
01:27:39,810 --> 01:27:43,570
to paralyze the muscles temporarily.
The problem is, that would also

1192
01:27:43,710 --> 01:27:47,010
paralyze your breathing muscles,
so that's not too good.

1193
01:27:47,910 --> 01:27:51,307
So it became a more complicated
procedure because you needed

1194
01:27:51,390 --> 01:27:55,367
anesthesiologists,
breathing support, and so forth

1195
01:27:55,450 --> 01:27:59,147
during the procedure.
But you did eliminate the

1196
01:27:59,230 --> 01:28:02,687
fractures. It still was a very widely

1197
01:28:02,770 --> 01:28:06,387
disdained practice, I think,
particularly when they had drugs

1198
01:28:06,470 --> 01:28:10,367
available. The thinking was that,
well, we'd sooner use those, but

1199
01:28:10,450 --> 01:28:14,047
the drugs turn out to be
only partially effective,

1200
01:28:14,130 --> 01:28:17,787
and pretty ineffective very
often for suicidal cases or in

1201
01:28:17,870 --> 01:28:21,607
cases of extreme melancholia.
Now, a couple of

1202
01:28:21,690 --> 01:28:25,167
things to say: Very often,
ECT has to be repeated at

1203
01:28:25,250 --> 01:28:28,310
intervals, as a kind
of maintenance therapy.

1204
01:28:28,490 --> 01:28:32,127
So it hasn't cured things,
but it temporarily

1205
01:28:32,210 --> 01:28:36,060
alleviates the symptoms, and the
temporary may be fairly lengthy, but

1206
01:28:36,150 --> 01:28:42,070
nonetheless, very often things will recur.
The memory problems can be quite severe.

1207
01:28:43,190 --> 01:28:46,820
The worries about brain
damage are, I think,

1208
01:28:47,970 --> 01:28:51,830
certainly things we have
to be very cautious about.

1209
01:28:52,650 --> 01:28:55,880
And when we talk about
treatment-resistant depression,

1210
01:28:56,850 --> 01:29:00,547
that's an interesting concept to me.
What it means is those are the

1211
01:29:00,630 --> 01:29:02,840
patients who don't respond to drugs.

1212
01:29:03,670 --> 01:29:07,587
They may not have a different
disease, but the drugs

1213
01:29:07,670 --> 01:29:10,290
don't work for them,
hence treatment resistant.

1214
01:29:11,090 --> 01:29:18,090
And the numbers of psychiatrists who
are willing to give ECT are rather small,

1215
01:29:19,470 --> 01:29:23,130
and in many states it's hedged around with

1216
01:29:23,270 --> 01:29:27,550
lots of legal restrictions.
In California, for example, um,

1217
01:29:28,350 --> 01:29:31,550
ECT now almost can't be given to

1218
01:29:31,670 --> 01:29:38,220
involuntarily confined patients 'cause
you have to, you have to volunteer for it.

1219
01:29:38,690 --> 01:29:42,627
So as-- so it's unusual
in that most medical procedures

1220
01:29:42,710 --> 01:29:46,467
aren't hedged about by legal
constraints like that. And

1221
01:29:46,550 --> 01:29:50,370
there clearly is a very
powerful group of people,

1222
01:29:50,910 --> 01:29:54,110
some of them psychiatrists,
many of them ex-patients,

1223
01:29:55,190 --> 01:29:59,127
many of them other people who just
are suspicious of modern medicine and

1224
01:29:59,210 --> 01:30:06,087
science, who form a group who are
very powerfully opposed to ECT. So

1225
01:30:06,170 --> 01:30:12,150
although it's fair to say
there are, Trials now that

1226
01:30:13,030 --> 01:30:16,347
seem to provide decent
evidence that for some patients

1227
01:30:16,430 --> 01:30:19,907
this works and that those
patients are deeply

1228
01:30:19,990 --> 01:30:23,877
distressed before
the treatment it's also still

1229
01:30:23,960 --> 01:30:26,607
a controversial treatment,
I think it's fair to say.

1230
01:30:26,690 --> 01:30:32,258
- Like basically every
single topic, treatment,

1231
01:30:32,341 --> 01:30:36,790
problem subfield of psychiatry today.

1232
01:30:36,910 --> 01:30:41,107
- Yes, yes. - For everything, everything
we say today, there will be at least

1233
01:30:41,190 --> 01:30:43,867
one person upset-...and writing a letter.

1234
01:30:43,950 --> 01:30:48,550
- I think lots of people upset.
So if we talk about drugs,

1235
01:30:49,770 --> 01:30:52,270
there'll be two kinds
of people who will be upset,

1236
01:30:53,490 --> 01:30:57,350
those who think the drugs
are more powerful than they

1237
01:30:57,470 --> 01:31:00,997
are or who have been
successfully treated by the

1238
01:31:01,080 --> 01:31:04,710
drugs and go, "Well,
it worked for me, so, you know,

1239
01:31:05,070 --> 01:31:09,047
stop criticizing it 'cause it really
is an effective treatment." And then

1240
01:31:09,130 --> 01:31:12,810
on the other side of the coin,
there are those who

1241
01:31:13,450 --> 01:31:17,107
either the drug treatment has been
used and it's failed, or they're being

1242
01:31:17,190 --> 01:31:20,130
left with terrible side
effects that don't go away,

1243
01:31:21,130 --> 01:31:24,467
or they're part of a general
group of people that

1244
01:31:24,550 --> 01:31:31,130
unfortunately is of a growing number
these days who are so suspicious

1245
01:31:31,530 --> 01:31:34,670
of medical science
and of the drug companies

1246
01:31:35,510 --> 01:31:41,010
that no amount of evidence will
sway them. They are convinced that

1247
01:31:43,070 --> 01:31:46,570
you know, the drug
treatments are poisonous.

1248
01:31:47,150 --> 01:31:53,930
The Scientologists being a very extreme
example of that, who they have a whole

1249
01:31:54,890 --> 01:32:00,690
museum in Los Angeles and the title
is Psychiatry Industry of Death.

1250
01:32:01,690 --> 01:32:05,527
And then if you think about all
the resistance, for example, that

1251
01:32:05,610 --> 01:32:09,047
has surfaced to vaccination in

1252
01:32:09,130 --> 01:32:12,667
contemporary US and how
the trust in vaccination has been

1253
01:32:12,750 --> 01:32:16,110
destroyed for a substantial
number of people,

1254
01:32:16,870 --> 01:32:21,030
it's very difficult to convince
them that they're mistaken.

1255
01:32:21,130 --> 01:32:24,947
- And not just the trust
in vaccination consequence of that is

1256
01:32:25,030 --> 01:32:27,907
a general distrust in science-
- A general distrust, exactly.

1257
01:32:27,990 --> 01:32:29,990
-... and distrust in medicine and so on.

1258
01:32:30,150 --> 01:32:37,150
- That's one of my great worries about
our contemporary situation, that we're

1259
01:32:37,370 --> 01:32:39,020
only-- we're less than a year in.

1260
01:32:40,050 --> 01:32:43,547
After four years of this,
first of all, the degree of

1261
01:32:43,630 --> 01:32:47,567
mistrust will have grown exponentially,
and once trust is lost, it's

1262
01:32:47,650 --> 01:32:53,447
very hard to recover. Secondly,
the science itself is being

1263
01:32:53,530 --> 01:32:58,827
destroyed. Clinical trials
that were midway through were

1264
01:32:58,910 --> 01:33:02,827
aborted, so that knowledge
has been lost. You would have

1265
01:33:02,910 --> 01:33:09,850
to start from square one, and that's years
of work. Scientists aren't being trained

1266
01:33:11,170 --> 01:33:15,030
because funding has been cut. Scientists

1267
01:33:15,250 --> 01:33:20,070
with successful careers no longer have
the funding necessary to do their work,

1268
01:33:21,050 --> 01:33:26,050
and it takes at least six
or seven years to train

1269
01:33:27,130 --> 01:33:29,590
a scientist at the beginning
of their career.

1270
01:33:30,590 --> 01:33:33,970
And so if you have four years
with nobody being trained,

1271
01:33:34,470 --> 01:33:41,327
you're talking about a decade being
lost, and what's lost is invisible--

1272
01:33:41,410 --> 01:33:45,347
...because it's counterfactuals.
We don't know what that science

1273
01:33:45,430 --> 01:33:49,147
will lead to or what
that medical treatment might

1274
01:33:49,230 --> 01:33:53,087
lead to, and very many
times they fail. That's

1275
01:33:53,170 --> 01:33:57,010
the nature of science. It's the nature of

1276
01:33:57,110 --> 01:34:00,887
medicine and medical
research that not every bright

1277
01:34:00,970 --> 01:34:04,830
idea we have is going
to eventuate in a breakthrough.

1278
01:34:05,050 --> 01:34:08,930
It would be really simple and wonderful
if that opposite were the case.

1279
01:34:09,570 --> 01:34:13,407
But the reality is we have to go
down lots of blind alleys, we

1280
01:34:13,490 --> 01:34:16,710
have to try lots of different
things, and we have to take

1281
01:34:17,070 --> 01:34:23,403
years to move from the laboratory
to practical application.

1282
01:34:23,486 --> 01:34:25,770
And when we eliminate

1283
01:34:26,090 --> 01:34:33,090
a whole segment of that, and when on top
of that we diminish people's trust--

1284
01:34:35,610 --> 01:34:40,850
...in science, that's a really,
I think, a profoundly

1285
01:34:42,230 --> 01:34:45,827
devastating thing that
probably given my advanced

1286
01:34:45,910 --> 01:34:49,450
age, I won't live to see
the consequences of, but

1287
01:34:49,590 --> 01:34:53,510
my children and grandchildren will.
It really

1288
01:34:53,630 --> 01:34:59,610
is something cultural that
you've got to build up trust.

1289
01:35:00,030 --> 01:35:03,767
And it can be destroyed very easily.
So one of the things, to go back to the

1290
01:35:03,850 --> 01:35:10,347
very first question you asked me about, is
psychiatry in crisis? Well, genetics was

1291
01:35:10,430 --> 01:35:14,150
supposed to provide a clear
picture of the origins

1292
01:35:14,250 --> 01:35:17,807
of various mental diseases
'cause they do seem to run in

1293
01:35:17,890 --> 01:35:21,607
families. So the expectation
was once we decoded the

1294
01:35:21,690 --> 01:35:25,067
human genome and we could examine bits
and pieces of it, that we would very

1295
01:35:25,150 --> 01:35:28,887
quickly find a Mendelian gene or set of

1296
01:35:28,970 --> 01:35:32,350
genes for schizophrenia,
let us say. Hasn't happened.

1297
01:35:33,410 --> 01:35:37,367
We now use genome-wide association
studies, that is throwing

1298
01:35:37,450 --> 01:35:40,730
everything in the kitchen soup
into, into the picture, and then

1299
01:35:41,250 --> 01:35:44,730
without any preconditions and seeing
what relates to what. And if we

1300
01:35:44,870 --> 01:35:48,747
use three hundred small variations in

1301
01:35:48,830 --> 01:35:52,690
the genome, we can account for about
ten percent of schizophrenia.

1302
01:35:53,650 --> 01:36:00,310
That's not very powerful.
Beyond that, what psychiatric genetics has

1303
01:36:00,950 --> 01:36:04,830
tended to throw up
is something that undermines the

1304
01:36:04,930 --> 01:36:09,670
distinctions that we've made based
on symptomatology. So if you look,

1305
01:36:10,810 --> 01:36:14,130
there is a great deal of overlap
in the kinds of genetic

1306
01:36:14,290 --> 01:36:17,947
abnormalities that heighten
the susceptibility

1307
01:36:18,030 --> 01:36:23,610
to bipolar disorder or schizophrenia
or autism. There's a lot of overlap there.

1308
01:36:24,410 --> 01:36:28,370
What that suggests is these aren't
distinctive entities in the way

1309
01:36:28,570 --> 01:36:32,730
that, you know... Schizophrenia,
as my friend Robin Murray,

1310
01:36:33,550 --> 01:36:36,827
a British psychiatrist, has to say,
"It really seems to be the

1311
01:36:36,910 --> 01:36:40,827
extreme end of psychosis,
the most serious." But it's sort

1312
01:36:40,910 --> 01:36:47,007
of on a continuum, you know. And so
if psychiatry has to say in ten years,

1313
01:36:47,090 --> 01:36:49,680
as some leading
psychiatrists are speculating,

1314
01:36:50,480 --> 01:36:54,147
that there's no such thing
as schizophrenia, there's no such thing as

1315
01:36:54,230 --> 01:36:57,907
bipolar disorder, that will tend, I

1316
01:36:57,990 --> 01:37:02,187
suspect, to have pretty bad
effects on people's trust-

1317
01:37:02,270 --> 01:37:06,070
...in psychiatry, and yet that's
where the science may lead them.

1318
01:37:06,850 --> 01:37:13,850
So it's a complicated picture, but
this issue of, of trust and its absence

1319
01:37:15,150 --> 01:37:20,907
and is, is vital, I think,
in looking at not just what

1320
01:37:20,990 --> 01:37:24,380
we're talking about today,
but across a whole spectrum of things,

1321
01:37:25,050 --> 01:37:31,690
even outside the medical realm altogether.
If you lose trust in institutions,

1322
01:37:32,310 --> 01:37:36,270
trust in science, trust in history. So

1323
01:37:36,430 --> 01:37:40,087
I think more humility
and less arrogance, more

1324
01:37:40,170 --> 01:37:47,170
willingness to confess the limits of what
we can do, more awareness of the dangers

1325
01:37:48,050 --> 01:37:55,050
of enthusiasm, more skepticism when
we're told something is a breakthrough.

1326
01:37:59,190 --> 01:38:05,990
One of the things I worry about is the
tendency of science journalism and medical

1327
01:38:06,090 --> 01:38:10,440
journalism to hype things and then

1328
01:38:11,250 --> 01:38:15,790
When the hype turns out to be
just that, that undermines trust.

1329
01:38:16,750 --> 01:38:20,850
You know? So be cautious when
things come along-... don't be

1330
01:38:21,750 --> 01:38:28,290
so sure that it represents a breakthrough.
I'm very worried at the moment. I see,

1331
01:38:29,170 --> 01:38:35,160
Ketamine and psychedelics being propounded
as a miracle cure for depression,

1332
01:38:36,010 --> 01:38:39,827
and the evidence for that is
enormously weak is the best

1333
01:38:39,910 --> 01:38:43,590
way to put it. And I've seen
this movie before too many

1334
01:38:43,710 --> 01:38:49,990
times. You know? I mentioned that 80%
cure for Cotton's work, 80% cure

1335
01:38:51,130 --> 01:38:55,570
for insulin coma therapy,
80% cure for the early asylums.

1336
01:38:56,840 --> 01:39:00,260
This is overblown rhetoric,
and the reality is

1337
01:39:00,350 --> 01:39:03,720
usually progress comes in small steps.

1338
01:39:03,920 --> 01:39:07,830
Sometimes it comes in big steps.
Penicillin, I think

1339
01:39:08,630 --> 01:39:12,990
was a huge step. Uh,
I was lucky enough to grow up

1340
01:39:13,950 --> 01:39:17,667
in the era when penicillin
and other antibiotics

1341
01:39:17,750 --> 01:39:21,647
became widely available.
They hadn't been overused by then.

1342
01:39:21,730 --> 01:39:25,587
And so if I had a strep throat,
I had something that got rid of

1343
01:39:25,670 --> 01:39:29,547
it right away. I didn't run
the risk of heart valve damage, which

1344
01:39:29,630 --> 01:39:33,490
in previous times would've
been the case. So you know,

1345
01:39:33,670 --> 01:39:36,930
once in a while you do
have these dramatic shifts,

1346
01:39:37,770 --> 01:39:41,607
and maybe AI will help
us in that regard, but

1347
01:39:41,690 --> 01:39:45,870
maybe it won't. It's another
potential double-edged sword.

1348
01:39:46,410 --> 01:39:50,107
- I should mention that
psychedelics, psilocybin in

1349
01:39:50,190 --> 01:39:52,263
particular, has been
demonized for a long time.

1350
01:39:52,346 --> 01:39:54,087
And so there's studies now out of John

1351
01:39:54,170 --> 01:39:59,030
Johns Hopkins-... that are
doing serious studies on cases

1352
01:39:59,210 --> 01:40:02,767
where it is effective.
I think it's nice to give a

1353
01:40:02,850 --> 01:40:08,547
chance to the different treatments with
the rigor of science, but with caution -

1354
01:40:08,630 --> 01:40:12,090
... and basically ignoring like
you're saying, science journalists

1355
01:40:12,570 --> 01:40:16,097
who are basically hyping every new thing
'cause they have to get clicks and all-

1356
01:40:16,180 --> 01:40:17,530
... this kind of stuff and-

1357
01:40:17,710 --> 01:40:21,727
... Look at the actual science
in the modern day. So the-

1358
01:40:21,810 --> 01:40:25,487
... in the past, the rigor was not there.
In the modern day, there's more.

1359
01:40:25,570 --> 01:40:30,237
- Yes. We can add beyond
the realm of science journalists.

1360
01:40:30,320 --> 01:40:32,450
I think Science and Nature

1361
01:40:33,430 --> 01:40:37,347
make choices about what they're
gonna foreground, and they too

1362
01:40:37,430 --> 01:40:42,030
have this tendency to look
for things that make a big splash.

1363
01:40:42,370 --> 01:40:44,877
- Oh, you mean the, the editors
and the-... the major journals.

1364
01:40:44,960 --> 01:40:48,847
- I think the editors, the major journals,
that's what they're looking for. As,

1365
01:40:48,930 --> 01:40:49,763
you know, I mean

1366
01:40:50,990 --> 01:40:55,040
negative findings are very important in
science. They're, they're the things that

1367
01:40:55,230 --> 01:40:58,967
help us avoid mistakes,
but they're not the

1368
01:40:59,050 --> 01:41:01,587
things that are going to get
you published in the journal.

1369
01:41:01,670 --> 01:41:05,727
- Right. So it's not just
the surface level science journalism.

1370
01:41:05,810 --> 01:41:09,800
It is also the extra journals and the
conferences and the publication process.

1371
01:41:10,410 --> 01:41:13,470
- Having lots of scientists working on

1372
01:41:14,350 --> 01:41:17,910
these problems in different
sites and different places

1373
01:41:19,490 --> 01:41:22,707
turns out to be very important,
I think, as a check on

1374
01:41:22,790 --> 01:41:28,190
enthusiasm, as a check on premature
claims that turn out to be unfounded.

1375
01:41:29,210 --> 01:41:33,127
And also because you're often
partially right but you're not

1376
01:41:33,210 --> 01:41:37,440
fully right and someone
else following the same idea-

1377
01:41:37,530 --> 01:41:42,510
... is, is perhaps gonna be a little
closer to the truth than you were. And so

1378
01:41:43,130 --> 01:41:46,880
it's, it's very helpful to have
multi-centered things and not

1379
01:41:47,230 --> 01:41:50,730
everything under one all-knowing-... uh,

1380
01:41:51,050 --> 01:41:54,667
thing. And that's a problem
with funding agencies. The

1381
01:41:54,750 --> 01:41:59,090
maverick scientist has
a hard time-... very often-

1382
01:41:59,270 --> 01:42:02,547
... getting a hearing. And we know of lots

1383
01:42:02,630 --> 01:42:06,507
of examples of that in
history where after the

1384
01:42:06,590 --> 01:42:10,507
fact we go "oh well yes,"
we should have supported that line of

1385
01:42:10,590 --> 01:42:15,670
research, but we didn't." - Uh,
very well put. Let us return to,

1386
01:42:15,810 --> 01:42:19,707
the origins of ECT and how it was applied.
But first, if it's okay,

1387
01:42:19,790 --> 01:42:20,940
a quick bathroom break.

1388
01:42:21,870 --> 01:42:23,829
Quick ten second thank
you to our sponsors.

1389
01:42:23,912 --> 01:42:25,627
Check them out in the description. It

1390
01:42:25,710 --> 01:42:28,407
really is the best way
to support this podcast. Go to

1391
01:42:28,490 --> 01:42:31,927
lexfridman.com/sponsors. And now dear

1392
01:42:32,010 --> 01:42:38,220
friends back to my conversation
with Andrew Scull. Now we're back

1393
01:42:39,070 --> 01:42:42,367
just to talk a little bit more about
ECT and One Flew Over the Cuckoo's

1394
01:42:42,450 --> 01:42:46,187
Nest. So what can we say about
that, that little cultural

1395
01:42:46,270 --> 01:42:50,030
moment, one of the most famous
moments about psychiatry?

1396
01:42:50,430 --> 01:42:54,327
First of all, Ken Kesey wrote
this book about his own experience

1397
01:42:54,410 --> 01:42:56,860
in a mental institution.
- Yeah, Menlo Park. Yes.

1398
01:42:57,110 --> 01:43:00,490
- How representative is it
of the system at the time?

1399
01:43:01,350 --> 01:43:08,190
- Mental hospitals have had a very
patchy and complicated history.

1400
01:43:09,090 --> 01:43:11,930
He was working actually
in a hospital for veterans.

1401
01:43:12,910 --> 01:43:16,010
Those were largely created
after the Second World War

1402
01:43:16,790 --> 01:43:20,550
when there were very many more
psychiatric casualties among

1403
01:43:20,690 --> 01:43:27,327
American troops than even the First World
War. The interesting thing is we all by

1404
01:43:27,410 --> 01:43:31,247
osmosis know that in the First
World War there was something called

1405
01:43:31,330 --> 01:43:34,887
shell shock that afflicted
the troops and that the

1406
01:43:34,970 --> 01:43:41,030
military initially resisted recognizing
and ultimately were forced to grasp.

1407
01:43:41,850 --> 01:43:45,550
But in World War II, American psychiatric

1408
01:43:45,750 --> 01:43:49,650
casualties among the troops were two
to three times as high as in World War I,

1409
01:43:50,610 --> 01:43:54,547
and that's an important part
of the history of psychiatry. But the

1410
01:43:54,630 --> 01:43:58,390
upshot of that was that post-war the VA

1411
01:43:58,490 --> 01:44:02,030
was heavily involved in,
first of all, paying to train

1412
01:44:02,290 --> 01:44:08,587
psychiatrists and even psychologists,
and then had in its mental hospital

1413
01:44:08,670 --> 01:44:14,150
system a considerable involvement
with psychiatric disorders.

1414
01:44:15,050 --> 01:44:20,260
Kesey-- Well, the book is different
than the film is the first thing to say.

1415
01:44:21,140 --> 01:44:25,740
Obviously, the film is heavily indebted to
the book, but it changes various things.

1416
01:44:26,200 --> 01:44:29,280
- Uh, if I may just go into
Perplexity, "The book and the

1417
01:44:29,380 --> 01:44:33,120
1975 film tell the same
basic story of McMurphy

1418
01:44:33,680 --> 01:44:37,457
challenging an oppressive psychiatric
ward, but they differ sharply in

1419
01:44:37,540 --> 01:44:41,360
point of view, tone, and what
the story is about. The novel is

1420
01:44:41,460 --> 01:44:45,180
weirder, more political,
and more about Chief Bromden's

1421
01:44:45,340 --> 01:44:51,474
inner world and the combine while the film
is more naturalistic, character-driven,

1422
01:44:51,557 --> 01:44:53,840
and turns McMurphy into the central hero."

1423
01:44:54,700 --> 01:44:56,260
- Yes, I think that's right.

1424
01:44:56,540 --> 01:45:00,100
- McMurphy is the person that received
ECT played by Jack Nicholson.

1425
01:45:00,300 --> 01:45:03,160
- Yes. And you have a nurse
figure in Nurse Ratched.

1426
01:45:03,260 --> 01:45:08,020
- Yeah. Yeah. - Louise Fletcher, uh, I
think is an equally powerful performance.

1427
01:45:08,120 --> 01:45:11,400
- It's one of the greatest films
of all time who happens to be--

1428
01:45:12,010 --> 01:45:14,387
which is unfortunate for,
you know, maybe psychiatry.

1429
01:45:14,470 --> 01:45:18,337
- Psychiatry, yes. It's very interesting.
I used to teach, um, a

1430
01:45:18,420 --> 01:45:25,040
class called Madness In The Movies,
and, um, I didn't just use... In fact,

1431
01:45:25,180 --> 01:45:32,180
I used relatively few contemporary films
and all among all the films from back

1432
01:45:33,040 --> 01:45:36,837
then, the one almost
everybody in the class had

1433
01:45:36,920 --> 01:45:43,400
seen was One Flew Over the Cuckoo's Nest.
So 18, 19, and 20-year-olds,

1434
01:45:44,280 --> 01:45:48,117
In two thousand and fifteen If I

1435
01:45:48,200 --> 01:45:52,017
showed them Alfred Hitchcock's
Spellbound, no chance they'd ever

1436
01:45:52,100 --> 01:45:53,480
seen that, maybe one,

1437
01:45:54,600 --> 01:45:58,377
because they were a class of people
interested in film. But everybody had

1438
01:45:58,460 --> 01:46:00,780
seen One Flew Over the Cuckoo's Nest.

1439
01:46:01,100 --> 01:46:06,020
- On that tangent really quick, what is
the greatest film on madness in your view?

1440
01:46:06,320 --> 01:46:08,777
- Oh, well... - Would that be
One Flew Over the Cuckoo's Nest?

1441
01:46:08,860 --> 01:46:11,380
- I think One Flew Over
the Cuckoo's Nest, I think

1442
01:46:12,540 --> 01:46:16,457
oddly a very different film
appeared at about the same

1443
01:46:16,540 --> 01:46:19,860
time was I Never Promised
You a Rose Garden,

1444
01:46:20,560 --> 01:46:24,277
which is a much more sympathetic
portrait of a different

1445
01:46:24,360 --> 01:46:28,157
kind of psychiatry,
a very Freudian psychiatrist,

1446
01:46:28,240 --> 01:46:31,940
really about Frieda
Fromm-Reichmann who worked

1447
01:46:32,100 --> 01:46:35,750
at Chestnut Lodge in Maryland and treated

1448
01:46:35,880 --> 01:46:39,640
schizophrenia with psychotherapy
rather than with drugs

1449
01:46:39,800 --> 01:46:46,026
or other forms of physical intervention.
And that was a bestselling novel by

1450
01:46:46,109 --> 01:46:46,942
a young

1451
01:46:47,100 --> 01:46:54,100
girl who had been her patient
with some fairly serious delusions

1452
01:46:55,220 --> 01:47:00,620
and a very complicated family
background, and again the film

1453
01:47:01,540 --> 01:47:07,177
changed a lot of things in the novel.
That's what films do. My book

1454
01:47:07,260 --> 01:47:11,090
Madhouse at one point interested
Hollywood, and one of the

1455
01:47:11,180 --> 01:47:15,030
two principals said to me, "I really
like this story. It's got a great

1456
01:47:15,120 --> 01:47:18,820
first act and a great second act,
but where's the third act?" Meaning,

1457
01:47:18,940 --> 01:47:22,657
"Where's the happy ending?"
And I had to say there wasn't any happy

1458
01:47:22,740 --> 01:47:25,980
ending to that story.
It was just rather grim.

1459
01:47:26,080 --> 01:47:30,280
- Madhouse: A Tragic Tale
of Megalomania and Modern Medicine

1460
01:47:31,140 --> 01:47:32,826
is the book you're referring to.
Yes, that's right.

1461
01:47:32,910 --> 01:47:35,177
Now that reminds me
of Flowers for Algernon. That

1462
01:47:35,260 --> 01:47:38,757
doesn't have a happy ending,
and it's not about mental health

1463
01:47:38,840 --> 01:47:42,777
necessarily, but it's about the journey
of institution in relation to

1464
01:47:42,860 --> 01:47:47,610
the health of a patient. - Yes, Pat
Barker's trilogy of novels about World War

1465
01:47:48,200 --> 01:47:51,177
I was turned into a film.
I think it was called

1466
01:47:51,260 --> 01:47:55,217
Regeneration, and that was quite powerful.

1467
01:47:55,300 --> 01:47:59,140
It was about World War I and the
treatment of shell shock. Mm-hmm.

1468
01:47:59,580 --> 01:48:06,480
And I thought was quite well done. And my
friend Patrick McGrath, who's a novelist,

1469
01:48:07,400 --> 01:48:11,220
wrote a book called Asylum.
Patrick grew up

1470
01:48:11,740 --> 01:48:15,457
in the grounds of Broadmoor.
Broadmoor is England's

1471
01:48:15,540 --> 01:48:17,820
premier hospital
for the criminally insane,

1472
01:48:18,660 --> 01:48:20,817
and he was babysat
by some of the patients.

1473
01:48:20,901 --> 01:48:22,577
And when you read his novels, you

1474
01:48:22,660 --> 01:48:29,660
can see how that upbringing affected his
rather macabre imagination. But anyway,

1475
01:48:31,440 --> 01:48:35,330
so One Flew Over the Cuckoo's Nest,
the poverty of the environment,

1476
01:48:36,100 --> 01:48:42,660
room that the patients were in,
I think fairly successfully recreates that

1477
01:48:44,700 --> 01:48:50,949
way in which staff very often put
patients down, didn't listen to them,

1478
01:48:51,032 --> 01:48:52,337
or poked fun at

1479
01:48:52,420 --> 01:48:56,520
them, or even were physically abusive,
although you don't see that.

1480
01:48:58,140 --> 01:49:03,180
Those were all features of mental
hospitals. The general boredom of life,

1481
01:49:04,540 --> 01:49:07,580
sort of there, but yeah, hard to reprea--

1482
01:49:09,340 --> 01:49:14,457
putting boredom on the screen will
turn an audience off rather fast.

1483
01:49:14,540 --> 01:49:18,640
- What about nurses and this kind
of abusive element, you know?

1484
01:49:18,940 --> 01:49:22,417
- Yeah, I think there was an abusive
element in a lot of mental

1485
01:49:22,500 --> 01:49:29,500
hospitals, and it was almost
inevitable. Look at who had the

1486
01:49:30,820 --> 01:49:34,780
most contact with the patients:
it was the lowest paid,

1487
01:49:35,940 --> 01:49:42,940
least respected ward attendants,
very few even RNs, and you know,

1488
01:49:43,740 --> 01:49:50,740
ratio of doctor to patient in the large
state mental hospitals meant that patients

1489
01:49:51,220 --> 01:49:53,250
hardly ever saw a physician, you know.

1490
01:49:54,120 --> 01:49:57,877
Remarkable about the film,
there are many remarkable

1491
01:49:57,960 --> 01:50:01,060
things about the film
as well as its polemical edge,

1492
01:50:02,240 --> 01:50:06,137
think is that chief
psychiatrist that you see

1493
01:50:06,220 --> 01:50:11,180
in the film is the real head of Oregon
State Mental Hospital. He really was

1494
01:50:12,860 --> 01:50:16,520
introduction to acting, and I thought
he was pretty remarkable, actually.

1495
01:50:17,240 --> 01:50:20,660
Obviously, there's a lot
of exaggeration there, but

1496
01:50:20,980 --> 01:50:24,820
ECT was used in the fifties and sixties

1497
01:50:24,940 --> 01:50:28,860
as a tool of discipline
in the hospitals. It was also

1498
01:50:28,960 --> 01:50:32,680
used therapeutically,
but overwhelmingly it was used

1499
01:50:33,840 --> 01:50:39,300
a tool of discipline and control.
And that's true to life. Lobotomy...

1500
01:50:40,760 --> 01:50:43,890
One of the interesting things we haven't
talked about with all these treatments

1501
01:50:43,973 --> 01:50:48,000
we've been discussing
is that almost invariably,

1502
01:50:49,260 --> 01:50:53,117
except for the case of the syphilitic
patients, for obvious reasons, men

1503
01:50:53,200 --> 01:50:56,320
were more troubled
by that condition than women,

1504
01:50:57,280 --> 01:51:01,057
it was women that got the brunt
of these experiments. So

1505
01:51:01,140 --> 01:51:04,790
Henry Cotton, about 70% of his
patients who were treated were

1506
01:51:04,940 --> 01:51:08,810
female. Lobotomy patients,
it's hard to get

1507
01:51:08,920 --> 01:51:12,857
overall numbers,
but those of us who've looked at

1508
01:51:12,940 --> 01:51:16,717
the records of a number
of different hospitals again and

1509
01:51:16,800 --> 01:51:23,800
again discover, again, 60 or 70%
of the patients are female. ECT

1510
01:51:24,660 --> 01:51:28,860
tends to be heavily female.
That's complicated by the fact that

1511
01:51:29,780 --> 01:51:33,577
it's used primarily as,
as we were discussing in

1512
01:51:33,660 --> 01:51:37,477
serious cases of depression
and so-called treatment-resistant

1513
01:51:37,560 --> 01:51:41,450
depression, and depression
is a diagnosis that is

1514
01:51:41,980 --> 01:51:45,757
more to be found among women than men.
Not that there aren't very many

1515
01:51:45,840 --> 01:51:49,617
men with depression, but again,
the ratio is such. Men

1516
01:51:49,700 --> 01:51:52,880
tend to get a different--
they get different diagnoses.

1517
01:51:53,480 --> 01:51:58,360
Personality disorders, for example,
are very, very common and are more a male

1518
01:51:59,220 --> 01:52:06,220
diagnosis. Um, ADHD-...is more
male than female and so on. So

1519
01:52:08,780 --> 01:52:13,020
it's good to point that out.
Uh, I think it helped

1520
01:52:14,260 --> 01:52:18,020
end interest in ECT, except for a

1521
01:52:18,140 --> 01:52:22,530
small handful of enthusiasts
for decades, that film.

1522
01:52:22,960 --> 01:52:29,960
Um, and probably even now it creates
hesitation in people about the

1523
01:52:30,260 --> 01:52:35,500
treatment. So it's one that has

1524
01:52:35,840 --> 01:52:39,657
had a very powerful
and long-lasting effect, I think.

1525
01:52:39,740 --> 01:52:43,437
- I think the surprising thing is I
recently learned a friend of mine tried

1526
01:52:43,520 --> 01:52:47,360
everything, about 20 years
ago, tried everything to

1527
01:52:47,620 --> 01:52:53,640
--with depression, and ECT is the last
thing he tried, and it changed his life-

1528
01:52:54,020 --> 01:52:57,817
...for the better. - That's
not an uncommon story. Yeah.

1529
01:52:57,900 --> 01:53:01,277
- And then I looked online
and there's a lot of stories like this.

1530
01:53:01,360 --> 01:53:07,600
And I-- before learning of that, my,
I'm embarrassed to say, knowledge of ECT

1531
01:53:08,400 --> 01:53:11,260
was just "One Flew
Over the Cuckoo's Nest."

1532
01:53:11,600 --> 01:53:14,417
- You know, it has a terrible history-

1533
01:53:14,500 --> 01:53:18,867
in the, in the '40s, '50s and '60s.
There are lots of,- - Abuses

1534
01:53:18,950 --> 01:53:23,680
- Uh, the CIA funded
Ewen Cameron up in Canada,

1535
01:53:24,720 --> 01:53:28,397
and he was giving multiple ECTs a day and

1536
01:53:28,480 --> 01:53:32,357
reducing peoples to...
Well, they couldn't walk,

1537
01:53:32,440 --> 01:53:35,711
they couldn't talk, they couldn't
feed themselves, they were incontinent,

1538
01:53:35,795 --> 01:53:36,257
and then he

1539
01:53:36,340 --> 01:53:40,197
built them back up, or so he claimed, but
in many cases, they were left permanently

1540
01:53:40,280 --> 01:53:45,240
damaged. So I could recite lots
of real horror stories about ECT,

1541
01:53:45,880 --> 01:53:49,620
but it's also, if you're
honest about the thing,

1542
01:53:50,440 --> 01:53:57,270
what you just described, that is patients
who were on the brink of suicide,

1543
01:53:58,100 --> 01:54:01,390
who had long-running
depressions, some of them

1544
01:54:02,580 --> 01:54:07,136
had ECT and they
describe it as lifesaving.

1545
01:54:07,219 --> 01:54:12,550
And as I say when more controlled
trials have been done recently,

1546
01:54:13,540 --> 01:54:17,437
there's enough evidence now
that it's hard to say, "This never

1547
01:54:17,520 --> 01:54:21,240
works. This is just one of these
desperate remedies we should consign to

1548
01:54:21,360 --> 01:54:23,770
dark ages." The complicating thing is

1549
01:54:24,800 --> 01:54:29,077
we'd have no clue why it works.
It's a purely empirical treatment.

1550
01:54:29,160 --> 01:54:32,880
- Right. Right. - And that itself
I think tends to put people off.

1551
01:54:33,740 --> 01:54:37,627
If you have a curable form
of cancer and the surgeon says,

1552
01:54:37,710 --> 01:54:44,520
"Well, I'm gonna remove it," and she does,
that's that. But because we understand

1553
01:54:45,140 --> 01:54:48,860
even a little bit, even if
our knowledge of human biology is pretty

1554
01:54:49,000 --> 01:54:52,760
primitive, we do understand
a little bit that cancer is

1555
01:54:53,960 --> 01:54:57,770
cells dividing uncontrollably
and taking up and doing

1556
01:54:57,860 --> 01:55:00,160
damage to the body
and eventually killing you,

1557
01:55:00,680 --> 01:55:04,480
and the fact that we can
surgically remove it is a big

1558
01:55:04,600 --> 01:55:08,620
deal. There are lots of disorders.
I have high blood pressure.

1559
01:55:09,600 --> 01:55:16,350
If untreated, my blood pressure is like
a 20-year-old's thanks to treatment.

1560
01:55:17,920 --> 01:55:21,677
It's an ongoing thing. I take
the damn pill every day and it has a

1561
01:55:21,760 --> 01:55:25,530
few minor side effects,
but for me very minor ones. And it

1562
01:55:26,440 --> 01:55:30,140
turns what could have killed me
via a stroke or a heart attack

1563
01:55:30,280 --> 01:55:33,880
into a condition that's
very well controlled. So,

1564
01:55:34,320 --> 01:55:38,260
you know, it-- All of these things,
they're, they're complicated picture-

1565
01:55:38,440 --> 01:55:42,100
It's easy with some of these
things, with lobotomy,

1566
01:55:42,860 --> 01:55:45,720
with insulin comas, deep sleep treatments,

1567
01:55:46,810 --> 01:55:50,447
Henry Cotton's endeavors.
Those you can just say,

1568
01:55:50,530 --> 01:55:54,360
"Well, we'll throw them away."
And for a long time, I think ECT

1569
01:55:54,500 --> 01:55:59,460
would have formed part of that cast
of characters. So when I first

1570
01:56:00,900 --> 01:56:05,340
conceived the idea of writing
Desperate Remedies, the book,

1571
01:56:06,540 --> 01:56:10,320
it was back in 1981 and I was in London

1572
01:56:10,860 --> 01:56:14,777
on a Guggenheim Fellowship at the
Wellcome Institute. And I hadn't done

1573
01:56:14,860 --> 01:56:18,780
research in detail, but I was aware
there were all these things

1574
01:56:18,980 --> 01:56:22,797
lurking about that had happened
in the 1920s and '30s and I thought

1575
01:56:22,880 --> 01:56:26,757
that would be a very
interesting thing to study. And

1576
01:56:26,840 --> 01:56:31,680
luckily I didn't do it right away
or I did it piecemeal over the years

1577
01:56:33,060 --> 01:56:36,370
and I ended up writing a much
more comprehensive look at

1578
01:56:36,920 --> 01:56:40,360
psychiatry really from its origins to now.

1579
01:56:41,140 --> 01:56:44,697
And I couldn't have written
that book back then, and I would've

1580
01:56:44,780 --> 01:56:48,440
missed all the developments
from 1980 onwards, which are

1581
01:56:48,620 --> 01:56:52,257
very, very important to the,
to the overall picture.

1582
01:56:52,340 --> 01:56:56,537
- So forty years later,
2022. - Yes. Yes, exactly.

1583
01:56:56,620 --> 01:56:58,007
- Your own Desperate Remedies:
Psychiatry's- - Yeah. Yeah

1584
01:56:58,090 --> 01:57:00,077
-... Turmoil in Quest
to Cure Mental Illness.

1585
01:57:00,160 --> 01:57:02,900
- I've written a lot of books
and, and along the way--

1586
01:57:03,780 --> 01:57:07,360
part of the way, I think
I've been productive and kept

1587
01:57:07,460 --> 01:57:11,300
interested. I always had two...
at least two projects on the go at once.

1588
01:57:11,720 --> 01:57:15,557
You can't simultaneously write two
things, but I'd have one and I'd work

1589
01:57:15,640 --> 01:57:19,303
on it, and if I got tired of it, I'd pick
up the other one for a bit and then go

1590
01:57:19,386 --> 01:57:24,160
back. And it also meant when I
was working on one main project, I had

1591
01:57:24,280 --> 01:57:27,420
other things percolating in, in my head,

1592
01:57:28,420 --> 01:57:31,997
and I would, I would come
across things that were

1593
01:57:32,080 --> 01:57:37,640
relevant to them and I'd make a note and
then I'd go back. So when I finally did

1594
01:57:38,820 --> 01:57:42,820
Desperate Remedies, I'd been thinking
about those issues for forty years,

1595
01:57:43,820 --> 01:57:47,477
and that made a big difference,
I think, to the way I approached

1596
01:57:47,560 --> 01:57:51,340
things and to what I thought.
Uh, 'cause you just... You

1597
01:57:51,460 --> 01:57:55,317
either like Thomas says,
you say the same thing over and over

1598
01:57:55,400 --> 01:57:59,257
and over again for forty years or

1599
01:57:59,340 --> 01:58:03,020
you learn new things and you
broaden what you know, and you

1600
01:58:03,180 --> 01:58:07,137
think about things in a different
way because you realize you

1601
01:58:07,220 --> 01:58:10,400
haven't grasped the full complexity
of what you're looking at.

1602
01:58:11,220 --> 01:58:17,320
And so look, what I found with
psychiatry is there are really

1603
01:58:18,180 --> 01:58:21,780
a couple of fundamental things that
have kept me engaged with the field.

1604
01:58:22,740 --> 01:58:26,177
One, it's an arena where
there's tremendous human

1605
01:58:26,260 --> 01:58:29,600
suffering, and it spreads out and it's

1606
01:58:30,300 --> 01:58:33,857
as far as I know -- and I wrote a big
book called Madness in Civilization

1607
01:58:33,940 --> 01:58:37,677
about from the ancient Greeks
and ancient China to now -- in every

1608
01:58:37,760 --> 01:58:41,297
society I've studied they have
to cope with this. It takes

1609
01:58:41,380 --> 01:58:45,197
different forms. It's regarded
in different ways. It's treated

1610
01:58:45,280 --> 01:58:49,020
differently, but that there
are people that deviate

1611
01:58:49,480 --> 01:58:54,680
so far from the norm of what we
regard as culturally appropriate,

1612
01:58:55,780 --> 01:58:59,810
they exist everywhere. So the suffering,

1613
01:59:00,660 --> 01:59:05,580
the difficulty of studying it,
and then the fact that it is such

1614
01:59:06,560 --> 01:59:11,120
a complex and difficult
subject to understand.

1615
01:59:13,240 --> 01:59:16,940
The very fact that we have
such limits to our knowledge

1616
01:59:18,660 --> 01:59:22,440
means there's space there
to examine things in a, in a

1617
01:59:22,540 --> 01:59:26,860
very in what needs to be
a very complicated way.

1618
01:59:27,700 --> 01:59:31,317
And so it's, it's intellectual puzzles

1619
01:59:31,400 --> 01:59:35,857
attracted some very, very smart people,
but there's a long way to go.

1620
01:59:35,940 --> 01:59:39,187
- Yeah, we have glimmers of insights
about how the, mind works but-

1621
01:59:39,270 --> 01:59:43,017
....if you s-, if you look at the span of
human history, we're probably in the very

1622
01:59:43,100 --> 01:59:47,340
early days of understanding this
particular one. I have to, if it's okay-

1623
01:59:47,500 --> 01:59:52,437
- Yes, of course -...so that we've been
carrying multiple threads together. One

1624
01:59:52,520 --> 01:59:56,377
of the threads that I think,
uh, is really exciting to

1625
01:59:56,460 --> 02:00:01,657
me and really important to the history
of psychiatry is the psychotherapy side.

1626
02:00:01,740 --> 02:00:05,397
We have mentioned the psychopharmacology
that will also-- it would

1627
02:00:05,480 --> 02:00:11,617
be nice to discuss when the two clash
and there's a revolution where phar--

1628
02:00:11,700 --> 02:00:17,416
Psychopharmacology kinda wins
over psychoanalysis for a time.

1629
02:00:17,499 --> 02:00:19,020
But let us start

1630
02:00:19,840 --> 02:00:23,560
at the somewhat beginning,
in the nineteenth century

1631
02:00:23,960 --> 02:00:27,757
when talk therapy starts
coming to life maybe in the

1632
02:00:27,840 --> 02:00:32,180
religious context with Christian
Science and then psychoanalysis context.

1633
02:00:32,320 --> 02:00:36,037
- Yes. So I'd mentioned late nineteenth

1634
02:00:36,120 --> 02:00:40,017
century psychiatry confined as it
was to the mental hospital and

1635
02:00:40,100 --> 02:00:44,017
to people incarcerated in

1636
02:00:44,100 --> 02:00:47,957
those places had become very
biological. But there were people

1637
02:00:48,040 --> 02:00:55,040
experiencing mental troubles
of various kinds, sadness, confusion,

1638
02:00:56,160 --> 02:01:00,120
loss of social relationships
that were troubling them,

1639
02:01:00,580 --> 02:01:04,217
grief, all sorts of things
like that, that didn't

1640
02:01:04,300 --> 02:01:08,257
involve time in a mental
hospital but nonetheless

1641
02:01:08,340 --> 02:01:12,260
involved a good deal of distress
as they continued to do.

1642
02:01:13,240 --> 02:01:17,077
And one of the things that was interesting
about nineteenth century America

1643
02:01:17,160 --> 02:01:21,080
is it spawned a number of new
religions, sort of variants

1644
02:01:21,180 --> 02:01:26,240
of Christianity.
So you had Seventh Day Adventists

1645
02:01:27,260 --> 02:01:34,197
group that still exists who actually
spawned a sanitarium for their depressed

1646
02:01:34,280 --> 02:01:38,180
congregants that was
later taken over by two

1647
02:01:38,560 --> 02:01:41,780
prominent members of the Adventist
Church, the Kellogg family.

1648
02:01:42,560 --> 02:01:48,797
everybody knows them through cereal.
But they ran a huge sanitarium to which

1649
02:01:48,880 --> 02:01:52,180
Abraham Lincoln's widow went, Tarzan went,

1650
02:01:53,020 --> 02:01:56,877
Henry Ford went, lots of very
prominent industrialists

1651
02:01:56,960 --> 02:02:00,440
and politicians and,
you know, it was kind of a

1652
02:02:00,900 --> 02:02:04,817
a farm to go and recover
your mental stability and

1653
02:02:04,900 --> 02:02:10,680
health and it was all bound up
also with beliefs about diet and

1654
02:02:12,340 --> 02:02:16,057
defecation and all sorts
of things. There were the

1655
02:02:16,140 --> 02:02:20,037
Mormons or Church of Jesus
Christ of Latter-day Saints. Many

1656
02:02:20,120 --> 02:02:23,937
Christians don't believe they're really
Christian but they think they are and

1657
02:02:24,020 --> 02:02:27,780
call themselves such. So you have
a number of these and one of them

1658
02:02:28,680 --> 02:02:33,795
was Christian Science, which was the
invention of a woman named Mary Baker

1659
02:02:33,879 --> 02:02:34,712
Eddy.

1660
02:02:40,450 --> 02:02:44,267
Developed the idea, and there are still
Christian Science churches and Christian

1661
02:02:44,350 --> 02:02:46,880
Science reading rooms all across America,

1662
02:02:47,890 --> 02:02:51,587
that there wasn't such a thing
as disease. That it could be prayed

1663
02:02:51,670 --> 02:02:56,660
away; that it was just a lack
of sufficient faith. So faith healing,

1664
02:02:58,190 --> 02:03:01,907
tended to work, I think,
better if it worked at all for

1665
02:03:01,990 --> 02:03:08,990
psychiatric problems than it did if you
had, say, cancer. But Christian Science

1666
02:03:11,230 --> 02:03:14,430
achieved a considerable
number of followers

1667
02:03:15,430 --> 02:03:22,430
disproportionately women but not
only women. And it began to treat

1668
02:03:23,950 --> 02:03:27,920
many of the people suffering from what
we would think of as the milder

1669
02:03:28,370 --> 02:03:31,230
mental disorders. And it attracted

1670
02:03:32,770 --> 02:03:38,027
both adherents and severe
critics. Mark Twain, for

1671
02:03:38,110 --> 02:03:41,570
example, was thoroughly dismissive of

1672
02:03:42,050 --> 02:03:45,670
Mary Baker Eddy.
But it was very successful for a time.

1673
02:03:46,570 --> 02:03:50,350
There were other
religiously based attempts to

1674
02:03:51,270 --> 02:03:54,847
join in. The most important
of which in New England was

1675
02:03:54,930 --> 02:03:58,187
something called Emmanuel Movement
centered around the Church of the

1676
02:03:58,270 --> 02:04:03,947
Emmanuel in Boston, which
was an attempt actually initially to

1677
02:04:04,030 --> 02:04:10,650
bring medical and religious approaches
to helping the mentally troubled.

1678
02:04:12,190 --> 02:04:16,087
Rather quickly,
the doctors involved decided this

1679
02:04:16,170 --> 02:04:19,887
was veering too much in the
direction of medically-based

1680
02:04:19,970 --> 02:04:26,930
therapeutics. They kind of withdrew
from enterprise. It dispensed-- There were

1681
02:04:28,930 --> 02:04:34,690
talk therapies obviously with a strong
religious component around them.

1682
02:04:36,210 --> 02:04:40,930
This was also at a time when some...

1683
02:04:42,990 --> 02:04:46,340
guess we can call them psychiatrists,
they were often neurologists,

1684
02:04:47,290 --> 02:04:51,670
were beginning to get lots
of patients with these kinds of

1685
02:04:52,950 --> 02:04:59,259
difficult to treat disorders. Neurology
had emerged in America after the Civil

1686
02:04:59,342 --> 02:05:00,176
War.

1687
02:05:00,370 --> 02:05:03,967
Civil War provided a lot of naturalistic

1688
02:05:04,050 --> 02:05:07,880
experiments on what happens to the
human brain and the human nervous

1689
02:05:07,970 --> 02:05:11,647
system when trauma affect
- I don't mean psychological

1690
02:05:11,730 --> 02:05:15,160
trauma, I mean bullets
blowing holes in your brain. A

1691
02:05:16,330 --> 02:05:20,287
group of new specialists
emerged after the Civil War who

1692
02:05:20,370 --> 02:05:23,910
claimed expertise in the brain
and the nervous system.

1693
02:05:24,010 --> 02:05:30,710
Well, one of the other side parts of that
is insanity, because insanity is also seen

1694
02:05:30,830 --> 02:05:37,830
as a brain disease. So there is a
conflict that erupts in the 1870s and

1695
02:05:38,450 --> 02:05:41,790
'80s between neurologists
and psychiatrists.

1696
02:05:42,750 --> 02:05:46,447
But the neurologist can't, for the most
part, get into the asylum where the most

1697
02:05:46,530 --> 02:05:50,287
seriously ill patients are.
Gradually, what

1698
02:05:50,370 --> 02:05:54,050
comes to their waiting room
along with people like multiple

1699
02:05:54,170 --> 02:05:58,010
sclero-- suffering from things like
multiple sclerosis are people with

1700
02:05:58,110 --> 02:06:04,790
functional mental disorders. There's
the beginning of an outpatient practice,

1701
02:06:05,670 --> 02:06:12,670
um which initially involves
some drugs, the use of

1702
02:06:14,290 --> 02:06:18,167
electricity. Not ECT,
but the use, for example, of

1703
02:06:18,250 --> 02:06:21,527
static electricity,
because it produces obvious

1704
02:06:21,610 --> 02:06:27,144
physiological responses. Electricity
is seen as dominating the workings of

1705
02:06:27,227 --> 02:06:28,060
the body.

1706
02:06:30,050 --> 02:06:33,990
Sometimes tonics of one sort
or another. Most notoriously of

1707
02:06:34,090 --> 02:06:36,110
all, something called the rest cure.

1708
02:06:37,190 --> 02:06:40,857
Silas Weir Mitchell,
one of the leading lights of American

1709
02:06:40,940 --> 02:06:47,940
neurology, develops complete bedrest,
lots of calories, lots of food, complete

1710
02:06:48,810 --> 02:06:52,487
lack of intellectual stimulation.
Supposedly, this is going

1711
02:06:52,570 --> 02:06:57,930
to cure you. Mainly aimed at women.
I feel like that's another evidence-backed

1712
02:06:58,950 --> 02:07:02,900
technique that works well.
Well, you know, I've

1713
02:07:02,990 --> 02:07:05,410
partaken in this and I
know it has helped me.

1714
02:07:08,150 --> 02:07:11,807
Laying in bed doing nothing, eating
snacks. Virginia Woolf was one of the

1715
02:07:11,890 --> 02:07:15,647
people subjected to this. She claimed
it practically drove her mad or

1716
02:07:15,730 --> 02:07:18,896
made her worse, you know? Just to clarify,
we're talking about laying in bed,

1717
02:07:18,979 --> 02:07:23,887
eating snacks. Eating lots of snacks.
Very high calorie. Okay, Weir

1718
02:07:23,970 --> 02:07:27,070
Mitchell wrote two popular bestsellers,

1719
02:07:27,690 --> 02:07:31,587
self-help books, suppose you'd call
them in the modern genre. One was

1720
02:07:31,670 --> 02:07:37,670
called Wear and Tear. The pace
of modern life, the telegraph, the

1721
02:07:37,790 --> 02:07:41,127
railway was all too much.
Your nervous system was

1722
02:07:41,210 --> 02:07:45,047
overstressed.
Either your batteries ran down, that was

1723
02:07:45,130 --> 02:07:49,610
one analogy, or you overtaxed
your system and went bankrupt.

1724
02:07:50,810 --> 02:07:54,690
Wear and tear,
that was the problem. The solution

1725
02:07:54,810 --> 02:07:57,950
was Fat and Blood.
That was the title of the other book.

1726
02:07:59,270 --> 02:08:02,450
You got scrawny,
nouveau, nervous, twitchy.

1727
02:08:03,270 --> 02:08:07,070
And what you really needed
was to build back up your strength.

1728
02:08:07,250 --> 02:08:10,750
including your nervous strength.
Isn't it fascinating to look at that?

1729
02:08:11,010 --> 02:08:14,407
120 years plus ago? They're talking about

1730
02:08:14,490 --> 02:08:18,527
how anxiety inducing society is,
how much is going on.

1731
02:08:18,610 --> 02:08:21,774
And we in the modern day talk
in exact same way about social media,

1732
02:08:21,857 --> 02:08:23,587
the internet, all that kind of stuff.

1733
02:08:23,670 --> 02:08:28,974
Yeah, yeah, it is. We look back
on the nineteenth century and think of it

1734
02:08:29,057 --> 02:08:33,328
in idyllic terms of a much
slower pace of life, and people,

1735
02:08:33,412 --> 02:08:37,461
they thought it was stressful
in exactly the ways we do.

1736
02:08:37,545 --> 02:08:42,922
There was a class of potential patients.
Some of them were seeking help in

1737
02:08:43,006 --> 02:08:48,015
the neurologists and a few psychiatrists
who moved out of the asylum.

1738
02:08:48,098 --> 02:08:51,050
But there were also these mental healing

1739
02:08:51,940 --> 02:08:55,300
groups that were religious,
and they're all around

1740
02:08:55,980 --> 02:09:02,597
at the beginning of the 20th century.
And in 1909, a Viennese gentleman

1741
02:09:02,680 --> 02:09:06,537
and two of his close
colleagues travel across the

1742
02:09:06,620 --> 02:09:10,437
Atlantic on a German
steamer and arrive in New

1743
02:09:10,520 --> 02:09:15,000
York and then transport themselves
up to Worcester, Massachusetts,

1744
02:09:16,080 --> 02:09:20,880
where Clark University
is celebrating its 20th anniversary.

1745
02:09:21,740 --> 02:09:25,517
Clark University was then set
up-- it still exists, but it was

1746
02:09:25,600 --> 02:09:29,190
set up to copy the German
research university. The

1747
02:09:29,920 --> 02:09:36,477
only comparable example at the time was
Johns Hopkins in Baltimore, and Hopkins

1748
02:09:36,560 --> 02:09:40,017
developed the leading
medical school of the time

1749
02:09:40,100 --> 02:09:45,693
borrowing from that German concept of
mixing research and teaching and patient

1750
02:09:45,776 --> 02:09:49,160
care. - I like how you're
telling this in a cinematic way

1751
02:09:50,200 --> 02:09:52,917
the story of Sigmund Freud and Carl Jung--

1752
02:09:53,000 --> 02:09:56,837
...coming to America to give a lecture.
I like, I like how it's like

1753
02:09:56,920 --> 02:09:59,855
the movie opens and there, yeah.
Yeah, well, here he is, you know, like,

1754
02:09:59,938 --> 02:10:00,817
how do you feel who he

1755
02:10:00,900 --> 02:10:04,837
is? He's fairly obscure. We should say
the reason you're actually telling it that

1756
02:10:04,920 --> 02:10:11,800
way is America has been a really
defining place for psychiatry.

1757
02:10:12,340 --> 02:10:15,997
Yes. And then Freud had his own
views on America and so on. But this--

1758
02:10:16,080 --> 02:10:23,080
this was, in terms of the history, yes,
psychiatric medicine, America as central.

1759
02:10:23,620 --> 02:10:26,740
Right. Many of the in-house
histories of psychiatry

1760
02:10:27,000 --> 02:10:30,920
portray this as Freud conference.

1761
02:10:31,780 --> 02:10:35,560
But it wasn't. Freud was almost
an afterthought of the conference.

1762
02:10:35,880 --> 02:10:39,617
Um, the head of Clark
was a psychologist, and he was

1763
02:10:39,700 --> 02:10:43,277
interested in Freud,
but actually there were

1764
02:10:43,360 --> 02:10:47,017
about thirty speakers
at the Clark conference, two

1765
02:10:47,100 --> 02:10:51,057
Nobel Prize winners
in physics, Franz Boas, who

1766
02:10:51,140 --> 02:10:54,760
was the leading anthropologist
of his generation, and a

1767
02:10:54,900 --> 02:10:58,300
host of other scholars,
including a couple of Freud's

1768
02:10:58,620 --> 02:11:02,477
fierce critics, one of whom,
Stern, was on the same boat as

1769
02:11:02,560 --> 02:11:06,477
him. And they avoided one another
like the plague. But anyway, it's

1770
02:11:06,560 --> 02:11:10,247
important to see that,
and Freud, it's a mark of how

1771
02:11:10,330 --> 02:11:14,157
important German science and German
medical science was in the late

1772
02:11:14,240 --> 02:11:18,250
nineteenth, early twentieth century,
where it was THE most advanced

1773
02:11:19,060 --> 02:11:23,240
in the world, that Freud
delivered his lectures IN GERMAN,

1774
02:11:24,600 --> 02:11:28,151
AND THE AUDIENCE, THAT WASN'T A PROBLEM
FOR THE AUDIENCE 'CAUSE THEY'D ALL LEARNED

1775
02:11:28,234 --> 02:11:32,377
GERMAN so they could read German
literature on medicine. So quite an

1776
02:11:32,460 --> 02:11:35,860
extraordinary thing.
Um William James attends

1777
02:11:36,440 --> 02:11:40,397
one of Freud's lectures and has
a conversation with him. William

1778
02:11:40,480 --> 02:11:44,157
James is one of the people
thinking about the psychology of the

1779
02:11:44,240 --> 02:11:51,240
human mind in interesting ways. He's not
impressed by Freud, and he also has a bad

1780
02:11:51,540 --> 02:11:55,297
heart condition. He dies not
all that long afterwards, but

1781
02:11:55,380 --> 02:11:59,147
he's not impressed by Freud.
A handful of people are,

1782
02:11:59,230 --> 02:12:02,897
some of the neurologists.
And Freud's lectures explicitly

1783
02:12:02,980 --> 02:12:06,417
attack religiously
based psychotherapy, says

1784
02:12:06,500 --> 02:12:10,940
psychotherapy is like a surgical
operation on the mind. And only us doctors

1785
02:12:11,760 --> 02:12:15,657
or only us thoroughly trained
people cause actually he

1786
02:12:15,740 --> 02:12:19,537
doesn't believe that psychoanalysis
is only something that can be practiced

1787
02:12:19,620 --> 02:12:23,610
by medically qualified,
but the lecture is on

1788
02:12:23,700 --> 02:12:27,297
psychoanalysis. Yes,
it's five lectures. They're

1789
02:12:27,380 --> 02:12:31,030
published subsequently,
and he makes a very important

1790
02:12:31,160 --> 02:12:38,000
convert there. Um James Jackson Putnam is
a Boston Brahmin, one of the upper-class

1791
02:12:38,340 --> 02:12:41,777
Bostonians who's extremely
well connected and is

1792
02:12:41,860 --> 02:12:45,517
professor of neurology
at Harvard, and he becomes a

1793
02:12:45,600 --> 02:12:50,760
Freudian at that conference.
So mainstream American psychiatry

1794
02:12:51,960 --> 02:12:55,760
pays very little attention
to to Freud's arrival on the scene.

1795
02:12:56,080 --> 02:13:03,080
And when he becomes a bit more visible,
they tend to be very dismissive. They uh

1796
02:13:04,220 --> 02:13:08,037
They regard the idea of talk therapy
for something they regard as a biological

1797
02:13:08,120 --> 02:13:12,017
condition as a ridiculous idea.
Maybe just uh mention a few

1798
02:13:12,100 --> 02:13:15,917
things. Sigmund Freud, of course,
is widely acknowledged to be the father of

1799
02:13:16,000 --> 02:13:19,800
psychoanalysis. And uh he has
a bunch of ideas, one of which

1800
02:13:19,900 --> 02:13:23,797
is there's this unconscious
mind that is the source of many

1801
02:13:23,880 --> 02:13:27,737
of our uh behaviors. Exactly.
And then psychoanalysis is a way to

1802
02:13:27,820 --> 02:13:31,797
delve deep into that mind,
and the tools he used to do

1803
02:13:31,880 --> 02:13:36,440
that is talking. Yes, Freud
was trained as a neurologist himself

1804
02:13:37,400 --> 02:13:41,280
uh and studied under the most famous late

1805
02:13:41,480 --> 02:13:45,260
Nineteenth-century
neurologist Charcot in Paris

1806
02:13:45,880 --> 02:13:49,657
and translated Charcot into
German and endeared himself to

1807
02:13:49,740 --> 02:13:53,020
Charcot, by doing that,
that's, um, a clever way to

1808
02:13:54,360 --> 02:13:59,120
help your career along.
But his Viennese colleagues didn't think

1809
02:13:59,940 --> 02:14:03,620
much of Charcot, and they didn't
think much of Freud's ideas either.

1810
02:14:03,760 --> 02:14:08,040
So he had a bit of a hard time,
but he did develop a successful

1811
02:14:09,300 --> 02:14:14,340
practice in the sense that patients
came to him. He was accompanied by

1812
02:14:15,300 --> 02:14:21,160
two of his close disciples to the Clark
conference, one of them Carl Jung.

1813
02:14:21,600 --> 02:14:25,537
was then anointed the crown
prince. He was supposed

1814
02:14:25,620 --> 02:14:32,313
to inherit Freud's enterprise until
the men had a very serious falling out,

1815
02:14:32,396 --> 02:14:33,277
mm-hmm, uh

1816
02:14:33,360 --> 02:14:39,360
just a little bit later in 1913, and Freud
and Jung went their separate ways.

1817
02:14:40,520 --> 02:14:43,397
That's a complicated story.
Freud, as one of his

1818
02:14:43,480 --> 02:14:47,397
close, uh, friends and collaborators,
put it, was a great

1819
02:14:47,480 --> 02:14:51,220
Hater, if you fell out
with Freud, it was bad news.

1820
02:14:51,580 --> 02:14:54,272
hater. If you fell out with Freud,
it was bad news. Oh yeah, yeah,

1821
02:14:54,355 --> 02:14:57,405
you were excommunicated if it
was Adler, but Jung especially.

1822
02:14:57,950 --> 02:15:01,827
- Jung was Swiss and he worked
in the major mental hospital

1823
02:15:01,910 --> 02:15:04,807
in Zurich, and he was attracted to

1824
02:15:04,890 --> 02:15:08,287
psychoanalysis and to Freud.
And for the first few

1825
02:15:08,370 --> 02:15:11,450
years there, there
was this obvious close alliance.

1826
02:15:12,370 --> 02:15:16,350
Anyway, so Jung was the person
who actually persuaded Freud to go

1827
02:15:16,470 --> 02:15:19,947
to America. Freud initially--
Freud had a very low opinion of

1828
02:15:20,030 --> 02:15:23,887
America. He said it should
be renamed Dollaría because

1829
02:15:23,970 --> 02:15:27,607
it was only interested in the dollar.
And American women were far too

1830
02:15:27,690 --> 02:15:31,470
pushy and powerful, and American food
was dreadful and it poisoned him, and

1831
02:15:32,170 --> 02:15:35,510
on and on. Um-- - So as you said,
Freud was a master hater.

1832
02:15:35,790 --> 02:15:39,727
- Yeah, he was. And one of the things
he hated was America, even though

1833
02:15:39,810 --> 02:15:43,510
America brought him some
fairly rich patients. But--

1834
02:15:43,610 --> 02:15:49,280
...the richest patients of all
went to Jung, not to Freud.

1835
02:15:49,730 --> 02:15:53,290
Um, and I think that probably
exacerbated this split.

1836
02:15:53,550 --> 02:15:57,087
- Let's actually focus first before
the conference on the actual ideas of

1837
02:15:57,170 --> 02:16:00,847
psychoanalysis. So Freud was the
originator of psychoanalysis. This is

1838
02:16:00,930 --> 02:16:04,910
19th century. So tell me
about the original case of Anna

1839
02:16:05,010 --> 02:16:07,387
O. and like what is psychoanalysis?

1840
02:16:07,470 --> 02:16:12,550
- Yeah. So Freud's academic
career had been failing in Vienna,

1841
02:16:13,730 --> 02:16:17,367
and he faced a prospect
of either having to emigrate to

1842
02:16:17,450 --> 02:16:20,790
America, which he regarded
with horror in the 1880s,

1843
02:16:21,790 --> 02:16:25,327
or perhaps reviving
his career by going and

1844
02:16:25,410 --> 02:16:30,050
studying under the most famous neurologist
of the era, Jean-Martin Charcot,

1845
02:16:30,850 --> 02:16:34,570
who was then delivering
lectures on hysteria in Paris.

1846
02:16:35,250 --> 02:16:38,530
And so Freud went
and spent some months there

1847
02:16:39,570 --> 02:16:44,360
and came back imbued with
Charcot's ideas about hysteria

1848
02:16:45,670 --> 02:16:50,429
and found a Viennese
medical establishment.

1849
02:16:50,512 --> 02:16:53,890
He started a consulting career

1850
02:16:54,030 --> 02:16:58,490
and that involved-- He had
a close friend named Josef Breuer.

1851
02:16:59,380 --> 02:17:06,380
And Breuer was more senior, had a very
large practice, and referred patients to

1852
02:17:06,690 --> 02:17:11,907
Freud. And the two of them began
to be interested in this problem

1853
02:17:11,990 --> 02:17:15,490
of hysteria. Breuer had treated

1854
02:17:16,710 --> 02:17:20,647
a woman who's now known as the sort
of foundation patient for-- the

1855
02:17:20,730 --> 02:17:25,890
Ur patient for psychoanalysis,
who was known to us as Anna O.

1856
02:17:26,890 --> 02:17:30,750
She-- We actually know she was Bertha
von Pappenheim, but that was

1857
02:17:31,070 --> 02:17:34,010
hidden for a long time.
A lot of these patients had

1858
02:17:34,810 --> 02:17:41,180
pseudonyms because obviously the cases
exposed a lot about their inner psychology

1859
02:17:42,030 --> 02:17:45,710
and quite reasonably,
even without the modern

1860
02:17:45,830 --> 02:17:50,090
concerns about privacy, there
was a reluctance to identify them.

1861
02:17:50,590 --> 02:17:54,407
So Anna O. had nursed her father. She was

1862
02:17:54,490 --> 02:17:58,307
Breuer's patient, not Freud's.
She'd nursed her father through an

1863
02:17:58,390 --> 02:18:00,470
illness, and he'd ended up dying, and she

1864
02:18:01,350 --> 02:18:05,267
developed various physical
symptoms that troubled

1865
02:18:05,350 --> 02:18:10,390
her a great deal and was also somewhat
depressed. And Breuer and Freud

1866
02:18:11,650 --> 02:18:15,147
dealt with that by developing
a notion that what she was

1867
02:18:15,230 --> 02:18:18,540
suffering from was repressed
memories and trauma.

1868
02:18:19,910 --> 02:18:23,547
And this would become
central to psychoanalysis, the

1869
02:18:23,630 --> 02:18:27,170
idea of half-muttered memories
lurking in your subconscious

1870
02:18:27,910 --> 02:18:31,170
that emerged in distorted forms of

1871
02:18:32,190 --> 02:18:35,607
psychological symptoms and ways
of being in the world that

1872
02:18:35,690 --> 02:18:39,527
were disruptive. Freud,
of course, develops a much more

1873
02:18:39,610 --> 02:18:43,467
elaborate theory
of this in years to come. And

1874
02:18:43,550 --> 02:18:47,160
Breuer collaborate on a book
called Studies in Hysteria,

1875
02:18:48,290 --> 02:18:53,820
and they're a series of case vignettes
in there of patients Freud has treated.

1876
02:18:54,650 --> 02:18:58,517
And he develops the notion
that people have these

1877
02:18:58,600 --> 02:19:02,287
past experiences. Initially,
he thinks they're real, that they're-- For

1878
02:19:02,370 --> 02:19:05,330
example, they have been
sexually assaulted as a child,

1879
02:19:06,170 --> 02:19:10,047
and that they can't face that,
and so they hide it away

1880
02:19:10,130 --> 02:19:14,000
from themselves. But they can't
completely, so it emerges in this tortured

1881
02:19:14,090 --> 02:19:16,750
series of forms. And

1882
02:19:18,030 --> 02:19:23,667
as things develop, the notion of
resistances emerges, that you can't easily

1883
02:19:23,750 --> 02:19:27,387
retrieve these memories,
and indeed, you resist them

1884
02:19:27,470 --> 02:19:31,410
surfacing, and you have a hard
time acknowledging them. And only

1885
02:19:31,510 --> 02:19:37,490
with long and painful work will
it become possible for-- But as you

1886
02:19:38,830 --> 02:19:42,710
bring them into-- from the unconscious
into the conscious world,

1887
02:19:43,250 --> 02:19:47,087
you learn to cope with them in a
different way and, and your personality

1888
02:19:47,170 --> 02:19:49,070
is transformed and you're made better.

1889
02:19:49,310 --> 02:19:53,330
- But crucially, the stuff that
happens in childhood is important.

1890
02:19:53,470 --> 02:19:57,869
- Yes. The early experiences
have a dramatic effect,

1891
02:19:57,952 --> 02:20:00,710
and I think even some biological

1892
02:20:00,810 --> 02:20:04,747
psychiatrists would agree
with that notion these days. That,

1893
02:20:04,830 --> 02:20:08,547
you know, to the extent we abolish
this distinction between mind and

1894
02:20:08,630 --> 02:20:13,260
body and, and acknowledge that they
are closely tied together, um,

1895
02:20:14,390 --> 02:20:18,147
traumatic experiences in childhood,
various socialization

1896
02:20:18,230 --> 02:20:24,922
experiences, loss and so on deeply
mark the human psyche, I think, and,

1897
02:20:25,005 --> 02:20:26,150
and can have

1898
02:20:27,430 --> 02:20:30,590
long-term effects that are,
are very powerful.

1899
02:20:31,050 --> 02:20:34,607
- Of course Freud added
a bunch of stuff in the realm of

1900
02:20:34,690 --> 02:20:37,910
psychosexual stages of childhood.

1901
02:20:38,130 --> 02:20:41,870
- Yes. As he begins to develop
his theories, he more and more

1902
02:20:42,010 --> 02:20:48,346
comes to see at first the libido, which
gets sort of transformed into the sex

1903
02:20:48,430 --> 02:20:52,187
drive- ... And sexual
experiences and the repression of

1904
02:20:52,270 --> 02:20:56,530
sexuality and the modification
of sexuality as people grow.

1905
02:20:57,530 --> 02:21:01,300
Um, all of that enters the picture.
It's one of the things that

1906
02:21:01,400 --> 02:21:05,377
ends up dividing Freud and Jung,
Jung somewhat because

1907
02:21:05,460 --> 02:21:10,170
Jung downplays that sexual
side of things after the break.

1908
02:21:11,250 --> 02:21:18,250
Um, but so Freud develops a very
complicated theory of mind initially

1909
02:21:19,100 --> 02:21:22,400
reflecting his training as a neurologist.

1910
02:21:23,300 --> 02:21:26,650
He tries to write an essay which
survives called Project for a

1911
02:21:26,740 --> 02:21:30,477
Scientific Psychology,
and the scientific psychology is gonna

1912
02:21:30,560 --> 02:21:33,780
tie psychology back into neurology.

1913
02:21:34,740 --> 02:21:37,970
But he abandons that,
and once he's abandoned that,

1914
02:21:38,600 --> 02:21:42,400
he goes on to develop increased...
an increasingly elaborate theory. He

1915
02:21:42,500 --> 02:21:46,397
writes The Interpretation of Dreams,
for example, because he

1916
02:21:46,480 --> 02:21:53,480
begins to regard dreams as an arena where
these hidden memories, these suppressed-

1917
02:21:53,860 --> 02:22:00,760
... things reemerge in disguised
form in your dream life. And so

1918
02:22:00,980 --> 02:22:06,000
that book marks an important
step forward. He becomes

1919
02:22:06,100 --> 02:22:11,290
interested in things like slips of the
tongue, so-called Freudian mistakes.

1920
02:22:11,380 --> 02:22:14,980
As seeing those as revealing
what really is hidden from you.

1921
02:22:15,700 --> 02:22:20,980
And so there's this very elaborate
dissection of things that relies upon

1922
02:22:21,900 --> 02:22:25,920
long extended talk therapy.

1923
02:22:26,300 --> 02:22:30,280
- Of course underlying it he's building a

1924
02:22:30,420 --> 02:22:34,167
model of how this whole
mind thing works. There's-

1925
02:22:34,250 --> 02:22:37,897
... three interacting parts of the
personality. First the id, which is the

1926
02:22:37,980 --> 02:22:41,637
primitive entirely unconscious
driven by pleasure principle seeking

1927
02:22:41,720 --> 02:22:45,100
immediate gratification or basic
drives such as sex and aggression.

1928
02:22:45,620 --> 02:22:49,360
There's the ego, which
is the rational mediator

1929
02:22:49,520 --> 02:22:53,137
operating under reality principle
balancing the id's demands with

1930
02:22:53,220 --> 02:22:56,680
external reality.
And finally, the super ego,

1931
02:22:57,180 --> 02:23:00,957
which is the internalized moral
standards and ideals producing

1932
02:23:01,040 --> 02:23:06,617
guilt or pride and striving
for perfection. So that's the structure.

1933
02:23:06,700 --> 02:23:10,570
- Yeah. That is broadly speaking
the structure that Freud ends up with,

1934
02:23:11,280 --> 02:23:14,977
and the conflicts
between these entities and

1935
02:23:15,060 --> 02:23:19,940
the ways they interact are
obviously the thing that

1936
02:23:21,400 --> 02:23:25,300
creates your mental universe,
your way of being in the world and

1937
02:23:25,580 --> 02:23:29,700
in many cases creates pathology, which

1938
02:23:30,640 --> 02:23:34,920
through the process
of psychoanalysis you can transform

1939
02:23:36,080 --> 02:23:39,900
grotesque unhappiness into ordinary
unhappiness or something like that.

1940
02:23:40,500 --> 02:23:45,000
You know? So- - Yeah, sure - Yes,
you get that. And initially,

1941
02:23:45,580 --> 02:23:50,052
Jung gets one of the heirs to the
International Harvester fortune as

1942
02:23:50,135 --> 02:23:51,140
a patient, and,

1943
02:23:52,000 --> 02:23:57,157
um, the McCormick family are
as rich as the Rockefellers

1944
02:23:57,240 --> 02:24:02,410
and the Carnegies and the, you know,
the Vanderbilts of that world.

1945
02:24:02,940 --> 02:24:06,870
This guy is a US senator
who ends up committing

1946
02:24:06,980 --> 02:24:10,160
suicide in nineteen twenty-five
after a lot of treatment from,

1947
02:24:11,140 --> 02:24:14,957
from Jung when he fails to win
reelection to the US Senate. He

1948
02:24:15,040 --> 02:24:18,640
kills himself in Washington
in the interregnum. But he also gets

1949
02:24:19,020 --> 02:24:22,470
another one of that brood.
One of the Rockefeller daughters,

1950
02:24:22,800 --> 02:24:26,080
Edith Rockefeller marries a McCormick.

1951
02:24:26,200 --> 02:24:30,097
And she has a lot of psychological
issues, and she tries

1952
02:24:30,180 --> 02:24:32,300
to get Jung to move to Chicago

1953
02:24:33,140 --> 02:24:37,100
promising him she'll set him
up in a mansion with lots of her

1954
02:24:37,220 --> 02:24:40,840
friends as his patients,
and Jung has no interest.

1955
02:24:41,820 --> 02:24:46,060
So then she finally persuades him to come

1956
02:24:47,300 --> 02:24:50,837
to New York and accompany
her on the liner across to

1957
02:24:50,920 --> 02:24:54,720
Zurich to be treated.
She's agoraphobic, and

1958
02:24:54,820 --> 02:24:58,600
so she has a hard time being out,
out of her little cocoon.

1959
02:24:59,380 --> 02:25:03,200
So she's treated there as an example
of how peculiar she was. I

1960
02:25:03,360 --> 02:25:09,060
mentioned the agoraphobia. So she occupies
a huge array of suites with all her

1961
02:25:09,160 --> 02:25:13,057
servants and so on in Zurich.
And she takes a

1962
02:25:13,140 --> 02:25:16,997
train journey, it's stopping
train, and her chauffeur

1963
02:25:17,080 --> 02:25:20,897
follows the train in the Rolls Royce in
case she has to jump out of the train at

1964
02:25:20,980 --> 02:25:24,717
a station 'cause she can't bear
it anymore. And she becomes a

1965
02:25:24,800 --> 02:25:28,640
Jungian analyst, but she's
very wealthy and she writes

1966
02:25:28,760 --> 02:25:32,417
big checks to Jung which is the
important thing. And then Jung

1967
02:25:32,500 --> 02:25:35,780
attracts Paul Mellon and his wife Mary.

1968
02:25:36,560 --> 02:25:40,020
And so Jung's works are
published by Princeton

1969
02:25:40,120 --> 02:25:43,780
University Press with a subvention
from that Mellon Foundation.

1970
02:25:44,500 --> 02:25:48,177
So it's a long-running thing.
Freud doesn't get

1971
02:25:48,260 --> 02:25:51,360
patients quite that rich.
He gets some rich Americans.

1972
02:25:51,820 --> 02:25:55,597
- We should say that Freud
became-- Freud's ideas became quite

1973
02:25:55,680 --> 02:25:59,900
popular among the intellectual and artist
class in the nineteen twenties in America.

1974
02:26:00,070 --> 02:26:03,390
- And another thing happened.
World War I saw

1975
02:26:04,540 --> 02:26:08,400
the breakdown of many soldiers
from something that came

1976
02:26:08,500 --> 02:26:14,577
to be labeled as shell shock. The label
shell shock intimates its, the first

1977
02:26:14,660 --> 02:26:18,597
theories about its origin,
which was that shells bursting near

1978
02:26:18,680 --> 02:26:22,317
you and bombs bursting near
you shook up your body and your

1979
02:26:22,400 --> 02:26:26,097
brain and created some
physical damage that then

1980
02:26:26,180 --> 02:26:30,670
accounted for the symptoms of shell shock:
your mutism, your blindism, your

1981
02:26:31,540 --> 02:26:34,960
constant shaking,
your nightmares, all of that.

1982
02:26:35,100 --> 02:26:38,747
But it became increasingly apparent that

1983
02:26:38,830 --> 02:26:43,900
shell shock was actually
a psychological thing. The trauma of war

1984
02:26:44,720 --> 02:26:49,200
in significant number of cases
brought about mental breakdowns.

1985
02:26:50,180 --> 02:26:54,097
And in thinking about that,
Freud's ideas about the

1986
02:26:54,180 --> 02:26:58,057
unconscious mind and trauma
and its connection

1987
02:26:58,140 --> 02:27:01,957
to symptomatology
acquired a new significance

1988
02:27:02,040 --> 02:27:05,537
for a lot of people in that period.
And then after the war,

1989
02:27:05,620 --> 02:27:12,620
you're absolutely right among a certain
smart section of society, those

1990
02:27:13,660 --> 02:27:16,160
ideas developed a considerable purchase.

1991
02:27:16,760 --> 02:27:20,360
Psychiatrists who were
mostly stuck in the asylums

1992
02:27:21,160 --> 02:27:24,917
dealing with psychotic patients
wanted nothing to do with these

1993
02:27:25,000 --> 02:27:28,160
ideas and this talk therapy.
The mainstream

1994
02:27:29,160 --> 02:27:32,980
psychotherapy which was mostly
in a clinical setting

1995
02:27:33,160 --> 02:27:39,540
Yeah, Freud's ideas were not popular.
No. The only partial exception to that was

1996
02:27:40,320 --> 02:27:44,260
The mental hospital
in Washington DC--the only federal

1997
02:27:44,360 --> 02:27:48,260
mental hospital, St. Elizabeths.
William Alanson White,

1998
02:27:48,360 --> 02:27:52,940
who was then the superintendent, was
somewhat sympathetic to Freud's ideas and

1999
02:27:54,080 --> 02:27:58,017
tried a bit, but you're
talking about thousands

2000
02:27:58,100 --> 02:28:01,917
of patients and the idea of talk
therapy for them is obviously out of

2001
02:28:02,000 --> 02:28:09,000
reach, plus they are much more severely
disturbed, so it does happen. Novelists,

2002
02:28:12,020 --> 02:28:15,040
painters, artists, playwrights,

2003
02:28:16,160 --> 02:28:20,940
uh and the audience for those
elite forms of culture

2004
02:28:21,800 --> 02:28:28,611
do tend to embrace Freudian ideas. Sex
sells in the theater and on the movies.

2005
02:28:28,695 --> 02:28:33,771
Um, obviously. But beyond that,
part of Freud's appeal to everybody,

2006
02:28:33,854 --> 02:28:38,960
it was something he lamented
at one point. He said, "You know,

2007
02:28:39,660 --> 02:28:44,640
my case histories read like short
stories. Like works of fiction.

2008
02:28:46,100 --> 02:28:50,520
And in that sense, people think they
lack the stamp of serious science.

2009
02:28:51,380 --> 02:28:55,040
But I'm driven to that because
that's how I unpack what's going on."

2010
02:28:55,500 --> 02:28:59,440
Well, psychoanalysis is telling stories.
It's getting people to recover

2011
02:28:59,600 --> 02:29:02,740
stories, recover memories,
to rebuild, right?

2012
02:29:04,060 --> 02:29:11,060
Um, and its elements of psychological
conflict and hidden motives and so forth

2013
02:29:12,220 --> 02:29:15,817
naturally very appealing to people writing

2014
02:29:15,900 --> 02:29:21,880
novels. People writing plays.
People doing screenplays." And

2015
02:29:22,700 --> 02:29:25,840
for artists of the modern sort

2016
02:29:26,660 --> 02:29:33,660
the idea that we can extract things
from the subconscious Surrealism and the

2017
02:29:34,040 --> 02:29:37,797
like, for example, are clearly
very heavily influenced by

2018
02:29:37,880 --> 02:29:41,487
Freudian ideas But it's
important to know circa

2019
02:29:41,570 --> 02:29:46,920
1930 there are probably three hundred
psychoanalysts in North America.

2020
02:29:48,840 --> 02:29:53,720
if they each Classical psychoanalysis
involving five hours a week

2021
02:29:55,900 --> 02:29:59,740
They can't treat that many
patients A few thousand

2022
02:30:00,280 --> 02:30:03,770
when there are hundreds of thousands
in the hospitals Right Mm-hmm So

2023
02:30:04,140 --> 02:30:11,140
what changes that Hitler
starts killing off Jews

2024
02:30:12,340 --> 02:30:15,777
and killing off
psychoanalysts The ones who can

2025
02:30:15,860 --> 02:30:20,580
escape some of them go to England
and some come to America

2026
02:30:21,460 --> 02:30:25,257
the most famous escapee
is Freud himself and his daughter

2027
02:30:25,340 --> 02:30:28,897
Anna Who Princess Bonaparte who's one of

2028
02:30:28,980 --> 02:30:32,210
Freud's great supporters
bribes the Nazis to get him

2029
02:30:32,300 --> 02:30:36,260
out And he travels by train
to London Very sick with

2030
02:30:36,840 --> 02:30:39,560
cancer of the jaw As he
has been since the mid-'20s

2031
02:30:40,440 --> 02:30:44,357
So he sets up shop in London
and Anna succeeds him really

2032
02:30:44,440 --> 02:30:48,177
as one of the central figures
in British psychoanalysis But other

2033
02:30:48,260 --> 02:30:53,920
analysts come here to America So
the numbers of analysts probably by

2034
02:30:54,820 --> 02:30:58,777
1940 America's not yet
in the war have a bit more than

2035
02:30:58,860 --> 02:31:02,417
doubled And more
importantly psychoanalytic

2036
02:31:02,500 --> 02:31:06,200
training has become much more
organized here The institutes

2037
02:31:06,540 --> 02:31:10,380
outside the universities
control psych... And

2038
02:31:10,500 --> 02:31:14,270
universities are not yet the knowledge
factories they become after the

2039
02:31:14,360 --> 02:31:17,517
war mm-hmm And that's
a crucial mistake that

2040
02:31:17,600 --> 02:31:22,380
psychoanalysis makes It's great because
it controls its training completely

2041
02:31:23,260 --> 02:31:27,000
The bad thing is when the center
of gravity moves to the university

2042
02:31:27,960 --> 02:31:34,457
it's not there and either resists being
incorporated or the university resists

2043
02:31:34,540 --> 02:31:38,477
incorporating it So I think that's
a structural weakness for that

2044
02:31:38,560 --> 02:31:45,560
But what really transforms
things is World War II Five

2045
02:31:47,840 --> 02:31:54,840
fifty minute hours famously They
last fifty minutes 'cause then there's

2046
02:31:55,780 --> 02:32:01,758
ten ten minutes for four analysts
to recover before the next patient arrives

2047
02:32:01,842 --> 02:32:02,675
Yes You

2048
02:32:03,100 --> 02:32:10,100
are free associating on the couch

2049
02:32:12,200 --> 02:32:16,860
and gradually being coaxed
to see as material emerges

2050
02:32:17,680 --> 02:32:19,280
what you're hiding from yourself

2051
02:32:20,040 --> 02:32:23,867
I mean initially they tried This is in
their early early days That they tried

2052
02:32:23,950 --> 02:32:27,897
hypnosis yes But they've You know
this is where Freud took the big leap and

2053
02:32:27,980 --> 02:32:31,960
expanded free association
Right So I mentioned

2054
02:32:32,060 --> 02:32:36,850
Freud training under Charcot Charcot
hypnotized his hysterical patients

2055
02:32:37,980 --> 02:32:41,877
We now know a lot of that was
fakery Not I don't think he

2056
02:32:41,960 --> 02:32:45,637
was conscious of the fakery
but the patients were on

2057
02:32:45,720 --> 02:32:49,497
display over and over again and they
worked their routines up very well and

2058
02:32:49,580 --> 02:32:56,580
they deceived him and they deceived
the audience But Freud came back from

2059
02:32:57,220 --> 02:33:02,760
Paris bringing with him the idea
that hypnosis was the way forward

2060
02:33:04,040 --> 02:33:07,680
But after the break with
Breuer Breuer had a general

2061
02:33:07,780 --> 02:33:11,385
medical practice and lost interest
in hysteria and didn't want anything to do

2062
02:33:11,468 --> 02:33:15,180
with the revisions
of Freud's work on hysteria

2063
02:33:16,220 --> 02:33:22,440
After that happened Freud who was a very
clumsy hypnotist by his own account

2064
02:33:24,440 --> 02:33:28,237
began to develop this alternative
of free association

2065
02:33:28,320 --> 02:33:32,277
and getting people to speak
whatever came into their head

2066
02:33:32,360 --> 02:33:36,077
without a censor.
That was the important thing, that the

2067
02:33:36,160 --> 02:33:39,660
half-murdered memories were being
hidden from you and your-- uh,

2068
02:33:40,460 --> 02:33:43,907
the constellation of psychological
forces in your unconscious was

2069
02:33:43,990 --> 02:33:49,677
squashing them down but they were
reemerging as other kinds of symptoms

2070
02:33:49,760 --> 02:33:53,517
- So how well does
psychoanalysis work? How

2071
02:33:53,600 --> 02:33:58,340
much do we understand? We've talked about
all these approaches that didn't work.

2072
02:33:59,120 --> 02:34:00,820
How well did it work at that time?

2073
02:34:01,020 --> 02:34:04,877
- You know, one of the things after
World War II when psychoanalysis

2074
02:34:04,960 --> 02:34:08,950
was making great strides in America
and the Rockefeller Foundation was

2075
02:34:09,040 --> 02:34:12,577
still heavily involved
in promoting psychiatry and

2076
02:34:12,660 --> 02:34:16,160
developing what it hoped
would be new tools in it

2077
02:34:16,980 --> 02:34:20,600
The then heads of the institute-- Of the

2078
02:34:20,880 --> 02:34:24,340
funding program,
Alan Gregg and Robert Morison,

2079
02:34:24,680 --> 02:34:28,207
especially Morrison,
kept pressing the analysts:

2080
02:34:28,290 --> 02:34:31,140
"Provide us proof that what you do works."

2081
02:34:31,960 --> 02:34:35,677
And the analyst kept resisting
and resisting and resisting, saying

2082
02:34:35,760 --> 02:34:39,677
"It's much more complicated than that.
There's no easy measure because

2083
02:34:39,760 --> 02:34:44,280
what we're doing is reconstructing entire
personalities, entire ways of being."

2084
02:34:45,780 --> 02:34:49,057
Sense People sense themselves,
their ways of being in the world.

2085
02:34:49,140 --> 02:34:52,250
"And we don't have easy
ways to measure that."

2086
02:34:52,500 --> 02:34:56,297
- To contrast that with
the 80% promises over and

2087
02:34:56,380 --> 02:34:57,617
over and over and over. Yes, yes, yes.

2088
02:34:57,700 --> 02:35:01,700
- And it's a long and complicated pro...
That was very important. Because

2089
02:35:04,540 --> 02:35:10,417
another kind of psychotherapeutics
is emerging in, in the aftermath, during

2090
02:35:10,500 --> 02:35:14,440
and in the aftermath
of the war as a rival for both

2091
02:35:15,140 --> 02:35:19,120
psychiatry and for psychoanalysis.
Initially

2092
02:35:19,220 --> 02:35:23,057
not terribly successful,
but as time goes on,

2093
02:35:23,140 --> 02:35:26,588
a more and more important
part of the story.

2094
02:35:26,671 --> 02:35:29,560
So to focus on the war for a minute,

2095
02:35:29,680 --> 02:35:33,357
Um, America's psychiatrists
went to the military

2096
02:35:33,440 --> 02:35:37,317
brass and to the politicians
before America entered the

2097
02:35:37,400 --> 02:35:41,220
war, and it had some advance warning
because America didn't enter till

2098
02:35:41,320 --> 02:35:45,137
Pearl Harbor, but the European war
had been going on. And they said,

2099
02:35:45,220 --> 02:35:48,737
"Look, if we have to fight, we're gonna
have the same problem we had in the

2100
02:35:48,820 --> 02:35:52,607
First World War. We're gonna
train these soldiers, gonna equip

2101
02:35:52,690 --> 02:35:56,197
them, we're gonna put them
in the battlefield and the

2102
02:35:56,280 --> 02:36:00,180
psychologically vulnerable
among them are gonna break down."

2103
02:36:00,740 --> 02:36:07,740
"They'll be shell shock all over again,
so we should screen all recruits to make

2104
02:36:08,720 --> 02:36:12,880
sure they're not psychologically
weak and susceptible."

2105
02:36:14,820 --> 02:36:18,720
And they screen out 1 3/4 million people

2106
02:36:20,100 --> 02:36:23,977
and say, "These men are not fit.
So now we won't have the

2107
02:36:24,060 --> 02:36:27,000
problems we had in World War I." Except

2108
02:36:28,150 --> 02:36:35,060
it quickly turns out that those
problems reemerge. Industrial warfare

2109
02:36:37,080 --> 02:36:41,710
exposes people to seeing
things and doing things

2110
02:36:42,480 --> 02:36:45,920
that all of us in normal
life would recoil from.

2111
02:36:47,200 --> 02:36:51,780
And when we're forced to do
them as soldiers, many of us--

2112
02:36:52,840 --> 02:36:58,054
Can't speak from experience, but from
talking to people who've gone through all

2113
02:36:58,138 --> 02:36:58,971
this--

2114
02:36:59,640 --> 02:37:03,517
Uh, many of them find the experiences and

2115
02:37:03,600 --> 02:37:07,537
the memories those create intolerable.
And they emerge in symptoms

2116
02:37:07,620 --> 02:37:08,620
and they break down.

2117
02:37:09,460 --> 02:37:13,277
So it became a huge problem
for the American Army, as it did for all

2118
02:37:13,360 --> 02:37:16,790
the armies. Actually,
the Nazis just shot people.

2119
02:37:18,660 --> 02:37:22,340
Broke down, bang, you're dead.
We're not dealing with you.

2120
02:37:23,340 --> 02:37:30,340
But, um, obviously the Allies, that was
not the response. Um, and they quickly had

2121
02:37:30,860 --> 02:37:36,960
to try to treat these troops,
maybe get them back into the fighting

2122
02:37:38,660 --> 02:37:42,397
lines, maybe get them
into support positions.

2123
02:37:42,480 --> 02:37:46,220
Something to cope with the problem,
which was both, um,

2124
02:37:47,000 --> 02:37:50,520
created extraordinary morale
problems among the troops

2125
02:37:50,800 --> 02:37:54,717
and it invited malingering,
claiming you had these

2126
02:37:54,800 --> 02:38:00,120
conditions when you didn't. It obviously
cost a lot of the fighting force.

2127
02:38:00,960 --> 02:38:04,750
In combat conditions, as much
as 25% of the soldiers broke

2128
02:38:04,840 --> 02:38:07,060
down. So it was a big, big problem.

2129
02:38:09,280 --> 02:38:15,100
Before the war, there were about 2,000
psychiatrists in North America, in the US.

2130
02:38:16,920 --> 02:38:20,677
At the end of the war, there were
more than 2,000 psychiatrists in the US

2131
02:38:20,760 --> 02:38:25,900
military. Okay, so you had
to train people in a hurry, um,

2132
02:38:26,960 --> 02:38:30,520
and even still,
it was hard to get enough people

2133
02:38:30,620 --> 02:38:34,597
trained. And it turned
out that the head of the

2134
02:38:34,680 --> 02:38:38,657
US military, not the first,
but the first one died, the second

2135
02:38:38,740 --> 02:38:42,377
one uh was a man named
William Menninger from the

2136
02:38:42,460 --> 02:38:46,060
Menninger Clinic in Kansas,
where he and his brother

2137
02:38:46,620 --> 02:38:49,820
ran a psychoanalytic treatment facility.

2138
02:38:51,020 --> 02:38:54,820
So Bill Menninger became
the head of Army psychiatry.

2139
02:38:55,560 --> 02:38:59,417
He concluded that the best
treatment for these soldiers breaking

2140
02:38:59,500 --> 02:39:03,217
down was psychotherapeutic
in nature. The origin of their

2141
02:39:03,300 --> 02:39:09,200
condition was trauma, uh,
and so in a watered-down way, Freud's

2142
02:39:09,300 --> 02:39:12,917
ideas, those were the ones
that the people that recruited

2143
02:39:13,000 --> 02:39:19,460
quickly and retrained as psychiatrists
absorbed. So they formed after the war

2144
02:39:20,300 --> 02:39:22,640
a fairly coherent group of people,

2145
02:39:23,620 --> 02:39:27,557
separate from the psychiatrists
in the state hospitals who were still

2146
02:39:27,640 --> 02:39:29,350
very biologically oriented.

2147
02:39:31,980 --> 02:39:36,008
Another group emerged during the war
precisely because you couldn't produce

2148
02:39:36,091 --> 02:39:36,924
enough

2149
02:39:37,500 --> 02:39:43,080
psychotherapists who were MDs quickly
enough. Psychologists were drafted in

2150
02:39:43,900 --> 02:39:49,480
and asked to treat.
So what the psychologists discovered was,

2151
02:39:49,820 --> 02:39:54,327
"Hey, we could do this stuff too, and we
really like it." "It's interesting-"

2152
02:39:54,410 --> 02:40:00,420
"...it's challenging. We should do that."
So after the war, similar kind of problem.

2153
02:40:01,640 --> 02:40:05,617
Mental illness is a massive problem. The
returning soldiers, it's a big problem,

2154
02:40:05,700 --> 02:40:09,800
but it's also a problem
in the community. Um,

2155
02:40:10,780 --> 02:40:14,657
these guys don't...
The psychiatrists don't go and work in the

2156
02:40:14,740 --> 02:40:20,617
mental hospital. They start
outpatient treatment. And by

2157
02:40:20,700 --> 02:40:26,837
1958, about 80%
of psychiatrists are working in

2158
02:40:26,920 --> 02:40:29,780
outpatient rather than
in the hospitals, right?

2159
02:40:30,580 --> 02:40:34,217
So the psychologists organize
themselves and federal

2160
02:40:34,300 --> 02:40:37,657
money -- Again, "We need you.
We need you. We need more of

2161
02:40:37,740 --> 02:40:41,057
you." So the VA, the Veterans

2162
02:40:41,140 --> 02:40:44,917
Administration, and then
once the National Institute of

2163
02:40:45,000 --> 02:40:48,817
Mental Health is established,
they start providing a lot of money

2164
02:40:48,900 --> 02:40:52,840
for training, and they train not
just psychiatrists, they train

2165
02:40:52,960 --> 02:40:56,860
psychologists. So the question is:
How are the psychologists gonna set

2166
02:40:56,960 --> 02:40:58,290
up clinical training?

2167
02:40:59,120 --> 02:41:03,057
So what the psychologists come
up with, the clinically oriented

2168
02:41:03,140 --> 02:41:10,140
ones, is a training program where would-be
clinical psychologists spend two years

2169
02:41:12,680 --> 02:41:16,500
learning basic scientific psychology

2170
02:41:16,600 --> 02:41:20,557
and research methods, and then
they have two or three years

2171
02:41:20,640 --> 02:41:26,850
of clinical work and an experience.
And that's very clever because

2172
02:41:27,840 --> 02:41:31,777
it means when they start looking
for grants, they know how to

2173
02:41:31,860 --> 02:41:35,677
do that, and the psychoanalysts don't
have a clue how to apply for federal

2174
02:41:35,760 --> 02:41:37,910
grant money, and they
don't get any almost.

2175
02:41:38,700 --> 02:41:42,020
Beyond that, these people begin to work on

2176
02:41:42,300 --> 02:41:46,157
treating symptoms. The psychoanalysts
think to treat a symptom is to

2177
02:41:46,240 --> 02:41:49,620
play Whac-A-Mole.
If you don't deal with the underlying

2178
02:41:49,740 --> 02:41:55,521
problems of the personality,
their interaction between your id ego

2179
02:41:55,605 --> 02:41:56,760
and superego,

2180
02:41:58,380 --> 02:42:01,630
you suppress that symptom,
and another one will pop up over here.

2181
02:42:04,080 --> 02:42:07,977
The clinical psychologists go,
"We're gonna treat the symptoms of what

2182
02:42:08,060 --> 02:42:12,907
are troubling people. We're gonna treat
the symptoms, and we're gonna develop

2183
02:42:12,990 --> 02:42:19,817
techniques that allow people
to cope with those symptoms

2184
02:42:19,900 --> 02:42:25,460
and eliminate them." And how are we
gonna do that? We're going to do it

2185
02:42:26,000 --> 02:42:31,860
primarily through what initially
is cognitive behavioral therapy and

2186
02:42:31,960 --> 02:42:37,060
later interpersonal therapy and some
other variants emerge. But basically, what

2187
02:42:37,900 --> 02:42:43,672
they try to do with those techniques
is develop things that work relatively

2188
02:42:43,755 --> 02:42:44,589
quickly,

2189
02:42:45,260 --> 02:42:51,180
work specifically on one set
of problems or small subset of problems,

2190
02:42:52,020 --> 02:42:55,857
and try to get those
under control. And how does

2191
02:42:55,940 --> 02:42:59,120
it work? You've developed
really bad habits.

2192
02:43:00,440 --> 02:43:04,400
You... The way you react
to being socially snubbed

2193
02:43:04,500 --> 02:43:10,350
or being ignored or the way you
deal with your coworkers or the

2194
02:43:11,750 --> 02:43:14,740
trouble you're having
with your disruptive child

2195
02:43:16,460 --> 02:43:19,720
will help you see the patterns
that you've fallen into

2196
02:43:20,440 --> 02:43:24,257
and will give you exercises
that will work to give

2197
02:43:24,340 --> 02:43:28,237
you a better way of coping with those
things that don't produce these

2198
02:43:28,320 --> 02:43:32,017
symptoms. I'm oversimplifying
obviously, but basically that's the

2199
02:43:32,100 --> 02:43:33,540
fundamental thrust of this.

2200
02:43:33,940 --> 02:43:38,610
- And one of the other contrasting things
about CBT, Cognitive Behavioral Therapy,

2201
02:43:39,460 --> 02:43:45,920
is that it doesn't have necessarily that
heavy requirement of five hours a week.

2202
02:43:46,060 --> 02:43:51,377
- Exactly. So these therapies could
be packaged. They could be reproduced.

2203
02:43:51,460 --> 02:43:54,360
They could be tested
to see whether they worked,

2204
02:43:55,380 --> 02:43:59,297
so they had an evidentiary foundation. The
psychoanalyst would say, "It's gonna take

2205
02:43:59,380 --> 02:44:03,337
us years, and it's hard to measure."
These guys went, "Well, we'll

2206
02:44:03,420 --> 02:44:07,210
measure what happens when
we treat people this way?"

2207
02:44:07,460 --> 02:44:08,293
- Psychologists.

2208
02:44:08,400 --> 02:44:12,377
- Uh, yeah. The symptoms are what matter,
not the underlie-- you know, the

2209
02:44:12,460 --> 02:44:17,150
underlying more complex thing that
psychoanalysts claimed to be treating.

2210
02:44:18,200 --> 02:44:24,360
And so it's shorter. It's reproducible

2211
02:44:25,540 --> 02:44:29,357
whereas psychoanalytic-- You know, every
patient is a new patient, a new-- with a

2212
02:44:29,440 --> 02:44:35,780
new set of complicated things going on.
Here we are. We're gonna do this.

2213
02:44:35,980 --> 02:44:40,580
- And the key figures here are Albert
Bandura, Albert Ellis, Aaron Beck.

2214
02:44:40,760 --> 02:44:44,880
- Yes. Um, Bandura
and some other psychologists

2215
02:44:45,700 --> 02:44:51,577
launching this movement, and then
later on Aaron Beck, who went by

2216
02:44:51,660 --> 02:44:58,527
Tim Beck who just recently died at...
I think he was ninety-nine. Extraordinary.

2217
02:44:58,610 --> 02:44:59,737
- No, no, I think he crossed 100.

2218
02:44:59,820 --> 02:45:01,940
- Maybe 100. Yeah. Maybe 100.

2219
02:45:02,120 --> 02:45:06,017
- There's videos of him talking at that
age and he's still, he's still killing

2220
02:45:06,100 --> 02:45:10,440
it, so wise. - Aaron Beck is a
remarkable figure because he was

2221
02:45:10,540 --> 02:45:17,260
also one of the first in the 1960s
to look at psychiatric diagnosis

2222
02:45:18,160 --> 02:45:22,017
and show how unreliable
it was, how-- how difficult

2223
02:45:22,100 --> 02:45:25,020
it was to get psychiatrists
to agree on what was wrong.

2224
02:45:25,220 --> 02:45:26,817
- So he was a psychoanalyst, right?

2225
02:45:26,900 --> 02:45:30,157
- He had been trained
as a psychoanalyst, became

2226
02:45:30,240 --> 02:45:33,900
disillusioned with it, and so there
were two strands, two important

2227
02:45:34,020 --> 02:45:37,420
strands that stemmed from his work.
First, this...

2228
02:45:38,120 --> 02:45:41,320
He was one of the ones
within the community itself

2229
02:45:41,920 --> 02:45:45,717
who said to his fellow
psychiatrists, "You know, we're

2230
02:45:45,800 --> 02:45:48,793
not very good at this
diagnosis business--" "...

2231
02:45:48,877 --> 02:45:51,120
and maybe we need to work on that."

2232
02:45:51,400 --> 02:45:55,500
Okay? And that was very important
for the movement towards DSM-III.

2233
02:45:57,160 --> 02:45:58,940
The other side of the coin was

2234
02:45:59,920 --> 02:46:03,970
he broke with the idea that treating
symptoms was a waste of time,

2235
02:46:05,280 --> 02:46:08,997
and joined with the
psychologists who already

2236
02:46:09,080 --> 02:46:15,367
embarked on that journey to say,
"How can we develop techniques to overcome

2237
02:46:15,450 --> 02:46:21,800
these self-destructive ways in which
people are responding? How can we help

2238
02:46:22,840 --> 02:46:27,877
with their ability to interact?"
So interpersonal

2239
02:46:27,960 --> 02:46:31,800
therapy is, you know, much more
concerned with the way in which

2240
02:46:32,220 --> 02:46:35,997
if your relations with other
people break down, that

2241
02:46:36,080 --> 02:46:39,397
damages your emotional stability. If you

2242
02:46:39,480 --> 02:46:42,957
repair those relationships,
that helps your emotional

2243
02:46:43,040 --> 02:46:50,040
stability come back. So all of this
develops, and Americans are unusual. The--

2244
02:46:52,580 --> 02:46:56,320
Most of the rest of the world has
what we call socialized medicine.

2245
02:46:57,600 --> 02:47:01,200
Um, America doesn't have that,
so we're used to paying for medical care.

2246
02:47:01,880 --> 02:47:08,680
And so Americans were more willing, I
think, to pay for clinical psychologists,

2247
02:47:09,480 --> 02:47:14,700
and they attacked some of the problems
of everyday living, the more

2248
02:47:15,560 --> 02:47:20,070
uh, I was gonna say minor, but these
are often quite distressing things. But

2249
02:47:20,920 --> 02:47:24,777
those were-- those were the things
they were most successful at doing. If I

2250
02:47:24,860 --> 02:47:28,720
look at the literature on CBT,
for example, and its

2251
02:47:28,820 --> 02:47:32,460
uses in cases of schizophrenia,
the evidence is pretty

2252
02:47:32,580 --> 02:47:39,580
poor that it works. And even the evidence
for the milder conditions is a bit more

2253
02:47:40,240 --> 02:47:43,940
ambiguous than we like...
That they like to pretend.

2254
02:47:44,590 --> 02:47:48,057
The Cochrane Reviews, which
are a systematic attempt to

2255
02:47:48,140 --> 02:47:51,340
assess how strong
the evidence for particular

2256
02:47:52,120 --> 02:47:55,957
approaches to disease
of all sorts are, say

2257
02:47:56,040 --> 02:47:59,850
that at best, the evidence
for CBT is of low and

2258
02:47:59,980 --> 02:48:03,580
medium confidence, you know?
But I think, again,

2259
02:48:04,320 --> 02:48:07,417
there are patients
for whom this helps, and

2260
02:48:07,500 --> 02:48:14,500
indeed, for the milder forms
of depression, I think CBT works better

2261
02:48:15,560 --> 02:48:19,317
than the drugs without some
of the side effects that the, the

2262
02:48:19,400 --> 02:48:22,880
drugs have. And indeed, NICE, which is the

2263
02:48:23,020 --> 02:48:26,300
British organization that
passes on what treatments

2264
02:48:26,500 --> 02:48:30,277
the National Health Service
will support and which

2265
02:48:30,360 --> 02:48:36,340
ones are, are sufficiently evidence-based
has come to that same conclusion.

2266
02:48:36,480 --> 02:48:38,930
- So I think one thing to just say
about cognitive behavioral therapy,

2267
02:48:39,013 --> 02:48:39,847
I mean, it's--

2268
02:48:40,760 --> 02:48:47,760
It has some elements of kind of surface
level intuitive kind of things like--

2269
02:48:50,500 --> 02:48:54,217
... being aware of and adjusting
your thought patterns, being

2270
02:48:54,300 --> 02:48:57,867
aware of triggers that get you--
down a negative spiral-- - Exactly

2271
02:48:57,950 --> 02:48:59,850
-... and then basic behavior changes,

2272
02:49:00,680 --> 02:49:05,620
habit changes that lead to a healthier
life. So I think, I think this kinda,

2273
02:49:07,020 --> 02:49:10,677
you know, getting your life
together kind of process-

2274
02:49:10,760 --> 02:49:14,557
... is intuitive that that would
have a positive effect on some

2275
02:49:14,640 --> 02:49:18,390
percent of the population. But as you
get more serious and serious into the

2276
02:49:18,560 --> 02:49:24,180
land of mental disorders, it starts
to be a little bit less conclusive.

2277
02:49:24,580 --> 02:49:28,380
- Yes. I think that's an accurate
statement of what-- the way

2278
02:49:28,520 --> 02:49:32,477
I read the literature.
And it's not a cure-all, but

2279
02:49:32,560 --> 02:49:36,240
for some patients, this really
does seem to improve things

2280
02:49:36,680 --> 02:49:40,457
quite a lot.
And it does make sense that you

2281
02:49:40,540 --> 02:49:45,880
have developed poor ways of responding
to signals from the outside world,

2282
02:49:46,780 --> 02:49:51,837
and they've become habitual, and they've
-- habits, as we know, are very

2283
02:49:51,920 --> 02:49:52,900
hard to break.

2284
02:49:53,800 --> 02:49:57,320
You know, there's a lot of homework,
there's a lot of exercises you have to do

2285
02:49:57,403 --> 02:50:02,540
to try to reconfigure the ways
you deal with the world.

2286
02:50:03,760 --> 02:50:07,437
And it's not for everybody, and it doesn't
work for everybody, but there's some

2287
02:50:07,520 --> 02:50:13,820
set, subset of people for whom
this seems to have positive effects.

2288
02:50:14,440 --> 02:50:19,140
- So this, this is the lay of the land.
We talked about some of the darkness.

2289
02:50:20,060 --> 02:50:23,857
Lobotomies and so on.
There is some talk therapy ideas of

2290
02:50:23,940 --> 02:50:27,840
psychoanalysis, and then there is,
from the clinical psychology

2291
02:50:27,960 --> 02:50:34,960
side, cognitive behavioral therapy. Then
starts to emerge the psychopharmacology-

2292
02:50:36,220 --> 02:50:39,460
...that challenges this whole
shebang of talk therapy,

2293
02:50:39,700 --> 02:50:46,660
period. And can you talk about the
accidental origins of psychopharmacology-

2294
02:50:47,000 --> 02:50:48,800
...that challenges this whole thing?

2295
02:50:49,140 --> 02:50:52,700
- Hardly anybody had conceived
of the idea that drugs could be

2296
02:50:52,840 --> 02:50:54,580
used to treat mental illness.

2297
02:50:55,400 --> 02:50:59,080
Drugs had been used in the mental
hospitals back in the 19th and

2298
02:50:59,220 --> 02:51:03,097
20th centuries, but they were
usually things that were used

2299
02:51:03,180 --> 02:51:06,737
to control patients,
to calm them down. Opiates, for

2300
02:51:06,820 --> 02:51:10,700
example various hypnotics
that would put people

2301
02:51:10,800 --> 02:51:16,246
to sleep when they were
extremely agitated, and so forth.

2302
02:51:16,329 --> 02:51:18,517
Sometimes marijuana was

2303
02:51:18,600 --> 02:51:22,517
experimented with, as was alcohol
in the 19th century interestingly

2304
02:51:22,600 --> 02:51:26,633
enough-...
given the revival of psychedelics.

2305
02:51:26,716 --> 02:51:33,630
But the idea that a drug might be used
to actually attack the underlying problem,

2306
02:51:35,060 --> 02:51:41,690
it emerged by accident in the following
kind of way. The drug industry in general

2307
02:51:43,250 --> 02:51:44,083
Had emerged

2308
02:51:44,870 --> 02:51:48,467
mostly in Germany, where I'd mentioned
the most advanced medicine was being

2309
02:51:48,550 --> 02:51:52,407
practiced in the late
19th century. From the

2310
02:51:52,490 --> 02:51:57,444
chemical industry from, for example,
refining coal tar into different

2311
02:51:57,527 --> 02:51:58,360
substances,

2312
02:51:59,510 --> 02:52:04,090
that's where we got aspirin. That's
where we got a whole bunch of drugs.

2313
02:52:05,090 --> 02:52:08,847
And gradually, the drug companies
become more organized. They

2314
02:52:08,930 --> 02:52:13,839
differentiate themselves from all
the quack remedies that are around.

2315
02:52:13,922 --> 02:52:14,790
And the war,

2316
02:52:15,810 --> 02:52:19,527
I think greatly accelerates--
Again World War II

2317
02:52:19,610 --> 02:52:23,567
greatly accelerates things,
not least because we discover a

2318
02:52:23,650 --> 02:52:27,127
real magic bullet called
penicillin and then the other

2319
02:52:27,210 --> 02:52:30,620
antibiotics that we
subsequently come across.

2320
02:52:31,510 --> 02:52:35,307
Penicillin had been observed
by Alexander Fleming in

2321
02:52:35,390 --> 02:52:39,267
his, famously, in his
lab in some Petri tube

2322
02:52:39,350 --> 02:52:43,227
Petri dishes where bacteria
had been killed. Later was one

2323
02:52:43,310 --> 02:52:46,927
of the co-winners of the Nobel Prize
and made a lot of capital out of that

2324
02:52:47,010 --> 02:52:50,300
discovery. It was really Howard
Florey and his team at Oxford

2325
02:52:50,950 --> 02:52:56,110
who developed the therapeutic
potential of penicillin.

2326
02:52:57,650 --> 02:53:01,270
And actually, Florey flew
some of it in his jacket

2327
02:53:01,390 --> 02:53:08,290
across the Atlantic to America, and it was
Americans that solved the critical thing.

2328
02:53:09,290 --> 02:53:12,687
It took Florey and his team weeks to

2329
02:53:12,770 --> 02:53:16,674
develop enough penicillin
to treat a single mouse.

2330
02:53:16,758 --> 02:53:19,150
What America learned how to do

2331
02:53:19,990 --> 02:53:23,927
was mass produce penicillin. And that

2332
02:53:24,010 --> 02:53:27,270
was critical because it
was vital to the war effort

2333
02:53:27,710 --> 02:53:31,647
obviously. And after the war, it was vital

2334
02:53:31,730 --> 02:53:36,150
to the civilian population because
it was such an important breakthrough.

2335
02:53:37,270 --> 02:53:44,087
So drugs, drug companies
grew fatter on that. They

2336
02:53:44,170 --> 02:53:48,870
embarked on research to try to find new
substances they could use to treat things.

2337
02:53:49,850 --> 02:53:53,490
Um, and a French company
named Rhône-Poulenc

2338
02:53:55,670 --> 02:53:59,547
came across a chemical that had
actually been synthesized back in the

2339
02:53:59,630 --> 02:54:03,040
1880s in Germany. It was an antihistamine,

2340
02:54:03,210 --> 02:54:07,007
chlorpromazine. They didn't know
what to do with it, but other

2341
02:54:07,090 --> 02:54:10,140
kinds of antihistamines in the
war had been used effectively,

2342
02:54:11,210 --> 02:54:15,310
and they thought "Well, let's look and see
if we can find a market for this drug."

2343
02:54:15,710 --> 02:54:19,607
And so they...
The interesting thing to remember in

2344
02:54:19,690 --> 02:54:23,597
those days is that investigating
the property of new drugs was

2345
02:54:23,680 --> 02:54:27,487
a Wild West phenomenon.
There were no controls. You could

2346
02:54:27,570 --> 02:54:31,357
do whatever you wanted,
and you handed stuff out and said,

2347
02:54:31,440 --> 02:54:35,287
"Why don't you try this and see
if it works?" Right? So Rhône-

2348
02:54:35,370 --> 02:54:39,210
Poulenc did that.
They thought this might work as an

2349
02:54:39,350 --> 02:54:42,987
antiemetic. If you have
a child who's prone to car

2350
02:54:43,070 --> 02:54:45,350
sickness, you give
them an antiemetic drug.

2351
02:54:46,270 --> 02:54:49,827
So that was one possibility.
Another possibility, it might work for

2352
02:54:49,910 --> 02:54:53,787
eczema so that people didn't scratch
themselves. Well, there were a

2353
02:54:53,870 --> 02:54:57,787
number of possibilities and somebody
said, "Well maybe it will work as

2354
02:54:57,870 --> 02:55:01,787
an anesthetic potentiator,"
meaning if you gave

2355
02:55:01,870 --> 02:55:05,767
some of these you need to use
less anesthetic or would act like a

2356
02:55:05,850 --> 02:55:09,807
catalyst because it tended
to make you sleepy. If you

2357
02:55:09,890 --> 02:55:13,687
read the leaflets on Dramamine,
one of the cautions is 'it'll

2358
02:55:13,770 --> 02:55:16,750
make you sleepy, don't drive,' right? So

2359
02:55:17,670 --> 02:55:21,690
why don't we give it to some surgeons
and see if they can find a use for it?

2360
02:55:22,070 --> 02:55:28,207
Literally it's like that. And one
of the people who gets that drug is a

2361
02:55:28,290 --> 02:55:32,230
lieutenant in the French
Navy, Henri Laborit,

2362
02:55:33,490 --> 02:55:37,407
and he tries it as an anesthetic
potentiator and he also gives it to some

2363
02:55:37,490 --> 02:55:43,150
of the patients who are awaiting surgery.
Normally when you're awaiting surgery,

2364
02:55:43,690 --> 02:55:48,447
you're a little bit anxious.
These patients stop being anxious.

2365
02:55:48,530 --> 02:55:52,367
Um, this was the era
of lobotomies and he wrote to

2366
02:55:52,450 --> 02:55:56,107
one of his relatives who worked in one of
the Paris mental hospitals. He said, "This

2367
02:55:56,190 --> 02:55:59,917
like, this works like a chemical
lobotomy. These people don't care

2368
02:56:00,000 --> 02:56:02,747
anymore about their surgery." - And that's
supposed to be a good thing, right?

2369
02:56:02,830 --> 02:56:07,710
- Well, lobotomy hadn't become the nasty
word it would become in a few years.

2370
02:56:08,670 --> 02:56:12,467
So one of his colleagues
contacts Delay and Deniker, who

2371
02:56:12,550 --> 02:56:16,337
work at Saint-Anne's which is the biggest
mental hospital in Paris and says,

2372
02:56:16,420 --> 02:56:19,430
"Hey guys this might work on your

2373
02:56:19,910 --> 02:56:23,510
psychiatric patients.
You should give it a try." And they do.

2374
02:56:24,390 --> 02:56:27,885
When it doesn't work, they give larger
dose and when it doesn't work they give

2375
02:56:27,969 --> 02:56:32,110
a large dose and sure enough patients

2376
02:56:32,210 --> 02:56:35,907
stopped acting out.
They stopped smashing furniture. They

2377
02:56:35,990 --> 02:56:42,730
become-- They're still sorta conscious
but they're less mobile and they're

2378
02:56:43,730 --> 02:56:49,090
much calmer.
And this is why in the early stages

2379
02:56:49,190 --> 02:56:52,907
Chlorpromazine which
becomes known as Largactil or

2380
02:56:52,990 --> 02:56:55,910
Mighty Drug in Europe and Thorazine here,

2381
02:56:56,730 --> 02:56:59,797
it becomes known as a major
tranquilizer because it has this

2382
02:56:59,880 --> 02:57:03,547
tranquilizing effect.
The hospitals see it as a boon

2383
02:57:03,630 --> 02:57:07,430
because it'll help control the patients.
They're not yet thinking of it

2384
02:57:07,530 --> 02:57:11,387
as more than that. So that's
the accidental way it, way it's

2385
02:57:11,470 --> 02:57:15,860
discovered. It comes
to North America via Quebec,

2386
02:57:16,230 --> 02:57:19,147
where there's
a psychiatrist up there Heinz

2387
02:57:19,230 --> 02:57:23,047
Lehmann who actually works in the
Protestant Hospital. Québec in those

2388
02:57:23,130 --> 02:57:28,150
days is dominated by its Anglo
speaking elite who oppressed

2389
02:57:29,800 --> 02:57:32,470
the French Canadians pretty mightily

2390
02:57:33,410 --> 02:57:37,570
But because of the French connection,
he gets amounts of the drug.

2391
02:57:50,810 --> 02:57:57,070
Rhône-Poulenc has had to sell
the rights to an American company.

2392
02:57:58,430 --> 02:58:01,927
In those days, American physicians
don't trust European science or

2393
02:58:02,010 --> 02:58:06,847
European medicine-- especially
European medicine. So

2394
02:58:06,930 --> 02:58:10,407
Rhône-Poulenc sells the rights.
The first two drug companies it

2395
02:58:10,490 --> 02:58:14,287
approaches say, "No thank you. This
doesn't look very interesting to us. I

2396
02:58:14,370 --> 02:58:18,187
don't think there's much of a market."
And then SmithKline & French buys it

2397
02:58:18,270 --> 02:58:25,270
up and within two years, two million
people are taking this drug. It's a

2398
02:58:25,790 --> 02:58:29,667
bonanza for them right?
Not an accident 'cause

2399
02:58:29,750 --> 02:58:33,587
they put their best salesman
on the job of selling this

2400
02:58:33,670 --> 02:58:37,447
and they realize the hospital
psychiatrists mostly aren't

2401
02:58:37,530 --> 02:58:41,270
interested. They haven't yet
gotten to this idea of a chemical

2402
02:58:41,490 --> 02:58:44,807
cure or a chemical treatment. - So
it's the companies that wake up to this?

2403
02:58:44,890 --> 02:58:47,690
- The companies wake up,
they sell it to the

2404
02:58:48,150 --> 02:58:51,510
politicians. They go to the
state legislatures. They have

2405
02:58:52,490 --> 02:58:56,950
moving pictures of an agitated
patient who turns calm, you know.

2406
02:58:57,170 --> 02:59:00,530
- So this is already
the mechanism of big pharma?

2407
02:59:00,750 --> 02:59:04,647
- Yeah. So it's starting to be big
pharma. It transforms Smith Kline

2408
02:59:04,730 --> 02:59:08,607
& French from a small operator into
a big company, and then of course once

2409
02:59:08,690 --> 02:59:12,547
that's successful, it turns
out that chlorpromazine can

2410
02:59:12,630 --> 02:59:16,447
be easily tweaked as a molecule, and so

2411
02:59:16,530 --> 02:59:20,367
copycat drugs emerge on the scene.
So this happens in

2412
02:59:20,450 --> 02:59:25,070
America in 1954.
The following year in 1955

2413
02:59:25,910 --> 02:59:31,550
we get the so-called minor tranquilizers
being invented and brought to market.

2414
02:59:31,990 --> 02:59:36,730
- This is Miltown. - Yeah, this is
Miltown heavily promoted by the first

2415
02:59:37,570 --> 02:59:41,250
major television star
of the mid-'50s Milton Berle,

2416
02:59:41,890 --> 02:59:47,090
who calls himself Uncle Miltown
and promotes the drug heavily on his show.

2417
02:59:47,430 --> 02:59:50,730
- So these are mostly like
tranquilizer type of effects?

2418
02:59:51,050 --> 02:59:54,370
- Those work really-- They're
muscle relaxant types of things and

2419
02:59:55,010 --> 02:59:58,707
later on in the '60s we
get Valium and Librium

2420
02:59:58,790 --> 03:00:02,547
coming on adding to or
replacing those, those first

2421
03:00:02,630 --> 03:00:05,627
generation drugs.
So you have major tranquilizers, minor

2422
03:00:05,710 --> 03:00:08,430
tranquilizers. Minor tranquilizers

2423
03:00:08,550 --> 03:00:13,510
and guess what? The Freudians don't want
really anything to do with these drugs.

2424
03:00:13,730 --> 03:00:17,830
- Right. Of course. - Uh, the hospital
psychiatrist wants to wake up to the

2425
03:00:18,590 --> 03:00:25,240
usefulness of Thorazine and its
analogues do start using the drugs a lot,

2426
03:00:26,130 --> 03:00:30,110
And that's really important,
and in the early '60s,

2427
03:00:31,370 --> 03:00:34,887
they changed their name.
Instead of being major tranquilizers, they

2428
03:00:34,970 --> 03:00:36,730
become antipsychotics.

2429
03:00:37,550 --> 03:00:42,170
- Right. - So that suggests they
actually attack the underlying psychosis.

2430
03:00:42,350 --> 03:00:45,067
- Is there any evidence of that for them?

2431
03:00:45,150 --> 03:00:50,510
- They do change the forms of psychosis
in important ways, some good

2432
03:00:51,330 --> 03:00:58,330
and some they fail to attack. So, um,
they reduce the agitation, they reduce

2433
03:01:02,810 --> 03:01:06,767
the delusions and the hallucinations,
the things psychiatrists call the positive

2434
03:01:06,850 --> 03:01:10,710
symptoms of schizophrenia
those, those they help

2435
03:01:10,810 --> 03:01:14,707
with for not every patient
but for a significant

2436
03:01:14,790 --> 03:01:17,627
number of patients, and they're
very -- That's very important.

2437
03:01:17,710 --> 03:01:19,167
- Why are they called the positive?

2438
03:01:19,250 --> 03:01:22,630
- The positive symptoms
activate things. They activate

2439
03:01:22,750 --> 03:01:26,690
the hallucinations and the delusions.
Those are changing,

2440
03:01:26,790 --> 03:01:30,540
and they're visible usually because
if somebody's deluded or hallucinating,

2441
03:01:31,150 --> 03:01:36,747
you know about it pretty quickly... right?
The negative symptoms are things like

2442
03:01:36,830 --> 03:01:41,990
apathy, loss of ability to interact
with people, poverty of language,

2443
03:01:42,650 --> 03:01:46,890
lack of initiative.
All of those things are devastating.

2444
03:01:47,250 --> 03:01:51,660
- Just to state out loud and clear
that both positive and negative affects

2445
03:01:51,743 --> 03:01:52,577
so-called

2446
03:01:53,190 --> 03:01:56,950
by psychologists of schizophrenia are
both devastating and both negative.

2447
03:01:57,270 --> 03:02:00,170
- Yes, yes. Uh, I think that's right.

2448
03:02:00,270 --> 03:02:02,127
- In the common parlance
of what negative means.

2449
03:02:02,210 --> 03:02:06,110
- It's a very strange choice of language,
but it's been there for a long time,

2450
03:02:06,510 --> 03:02:10,639
so it's embedded. Now,
to the extent antipsychotics work,

2451
03:02:10,722 --> 03:02:13,270
they work on the positive symptoms.

2452
03:02:14,450 --> 03:02:18,307
They either dull them down so you're
still hallucinating a bit and you're still

2453
03:02:18,390 --> 03:02:21,570
delusional, but it's
not-- it's very much less,

2454
03:02:22,290 --> 03:02:28,210
and you are you're somewhat pacified.
You're less overtly disturbed.

2455
03:02:29,610 --> 03:02:33,850
But the negative side of things,
not so much or not at all.

2456
03:02:35,890 --> 03:02:42,287
Then on top of that, the drugs work
for some people and they don't work for

2457
03:02:42,370 --> 03:02:47,186
others, and a significant number
of psychotic patients that are non-drug

2458
03:02:47,270 --> 03:02:48,103
responders

2459
03:02:49,590 --> 03:02:53,417
just as a significant number of people
with depression are not responsive to

2460
03:02:53,500 --> 03:02:59,380
antidepressants. Moreover,
initially the enthusiasm for these drugs

2461
03:03:00,270 --> 03:03:06,130
everybody neglects the fact that
they have serious side effects or

2462
03:03:07,250 --> 03:03:13,207
many of them argue the side
effects are an essential part of the

2463
03:03:13,290 --> 03:03:17,127
treatment and you just have to put up
with it. So what are we talking about

2464
03:03:17,210 --> 03:03:20,850
when I say there are nasty side effects?

2465
03:03:21,930 --> 03:03:25,630
Well among others, you may
become incurably restless.

2466
03:03:26,520 --> 03:03:30,407
So you're constantly in motion,
you're moving around, you're never, never

2467
03:03:30,490 --> 03:03:32,700
still. If you're
in the presence of somebody

2468
03:03:33,710 --> 03:03:37,647
like that, it becomes unbearable
after a fairly short while, and

2469
03:03:37,730 --> 03:03:40,950
it's unbearable often to the
person who can't control it.

2470
03:03:42,570 --> 03:03:46,030
Other patients develop
Parkinson's disease symptoms.

2471
03:03:47,270 --> 03:03:51,227
Is an awful affliction
which unfortunately affects a

2472
03:03:51,310 --> 03:03:54,770
significant number of people each
year, and we don't have-- We have

2473
03:03:55,310 --> 03:03:58,950
through L-DOPA a means to delay its impact

2474
03:03:59,310 --> 03:04:03,490
but eventually that loses its efficacy
and unfortunately we don't have a cure

2475
03:04:04,920 --> 03:04:08,817
So you have those. And then
perhaps the nastiest is what's

2476
03:04:08,900 --> 03:04:10,400
called tardive dyskinesia.

2477
03:04:11,640 --> 03:04:14,990
Tardive because it's late developing,
it doesn't happen right away,

2478
03:04:15,840 --> 03:04:19,477
and dyskinesia because what
involves is jerky uncontrolled

2479
03:04:19,560 --> 03:04:22,760
movements of the body and particularly
of the facial muscles. So

2480
03:04:23,520 --> 03:04:27,037
your tongue will protrude,
you'll make strange noises, you'll

2481
03:04:27,120 --> 03:04:30,977
twitch, you'll stagger about walking. If

2482
03:04:31,060 --> 03:04:35,420
somebody like that is walking down
the street towards you, you will think

2483
03:04:36,500 --> 03:04:40,257
there's a mentally ill person and you'll
cross to the other side of the street. And

2484
03:04:40,340 --> 03:04:44,177
yes, they probably are a mentally
ill person but what you're seeing

2485
03:04:44,260 --> 03:04:47,560
is the iatrogenic effects
of the drugs they're on.

2486
03:04:47,660 --> 03:04:51,410
Okay? So that problem was ignored for

2487
03:04:51,500 --> 03:04:55,460
about 20 years. A paper appeared
in Science by George Crane,

2488
03:04:55,900 --> 03:04:59,570
a Maryland psychiatrist, in which he said,

2489
03:05:00,050 --> 03:05:03,900
"We as a profession have been
ignoring this terrible problem."

2490
03:05:05,120 --> 03:05:09,240
Yes, the drugs do some good,
but they're also creating a lot of harm,

2491
03:05:10,080 --> 03:05:15,140
and we need to focus more on that.
And it took a few years, but by the '80s,

2492
03:05:16,220 --> 03:05:19,578
I think the American Psychiatric
Association was very worried by

2493
03:05:19,661 --> 03:05:20,494
that problem.

2494
03:05:21,900 --> 03:05:25,929
And um, the drug companies
were kind of worried about it,

2495
03:05:26,012 --> 03:05:27,917
but didn't have any obvious

2496
03:05:28,000 --> 03:05:35,000
solution till towards the end of the '80s
something happened. Nineteen fifty-seven

2497
03:05:35,840 --> 03:05:39,520
when the people were developing
copycat versions of Thorazine,

2498
03:05:40,280 --> 03:05:44,217
clozapine was developed by a small
company which was subsequently bought

2499
03:05:44,300 --> 03:05:49,777
up by a bigger company and introduced
in Europe. It never came to America

2500
03:05:49,860 --> 03:05:56,680
because of two things. First, it tended
not to produce tardive dyskinesia,

2501
03:05:57,620 --> 03:06:01,577
and at that time many in the profession
thought if you didn't get those symptoms

2502
03:06:01,660 --> 03:06:05,500
you weren't attacking the problem.
Bizarre, right?

2503
03:06:05,600 --> 03:06:10,610
Secondly in a significant
number of patients

2504
03:06:11,460 --> 03:06:14,860
it destroyed the patient's
white blood cells and they died.

2505
03:06:15,360 --> 03:06:19,297
Okay? Not a good outcome.
So it was quickly withdrawn

2506
03:06:19,380 --> 03:06:24,600
from the market, and it never made it
to this side of the Atlantic. However,

2507
03:06:25,580 --> 03:06:32,580
as this tardive dyskinesia problem became
more acute, there was an attempt to revive

2508
03:06:34,020 --> 03:06:41,020
clozapine, and it turns out
it tends to work better in

2509
03:06:41,600 --> 03:06:45,100
treatment-resistant cases,
meaning cases that don't respond to the

2510
03:06:46,020 --> 03:06:49,160
other antipsychotics that we have.

2511
03:06:49,900 --> 03:06:54,960
And it could be revived but at
the cost of weekly blood checks

2512
03:06:56,160 --> 03:06:59,657
'cause you had to be very
careful if your white blood

2513
03:06:59,740 --> 03:07:03,280
cells count started to drop,
you had to stop.

2514
03:07:03,580 --> 03:07:07,770
Right? So it came
to market in the late '80s,

2515
03:07:10,460 --> 03:07:16,720
and very quickly other drug companies
tried to find other compounds

2516
03:07:18,300 --> 03:07:21,917
actually chemically not related
to it, but that's hardly the

2517
03:07:22,000 --> 03:07:27,680
point. The whole class of drugs became
known as second generation antipsychotics.

2518
03:07:28,040 --> 03:07:32,447
- So Clozapine, Risperdal--
- Yes, those kinds of ones.

2519
03:07:32,530 --> 03:07:33,667
- Zyprexa. - Zyprexa among others.

2520
03:07:33,750 --> 03:07:38,330
- Zyprexa. - Yes. And so there were
a number of these, and they have actually

2521
03:07:38,700 --> 03:07:40,620
-- Because they are chemically quite

2522
03:07:41,520 --> 03:07:45,567
different from each other, but they're
classed together in the public mind and -

2523
03:07:45,650 --> 03:07:47,050
...in the professional mind.

2524
03:07:47,580 --> 03:07:51,337
They tend to have different side
effect profiles and slightly different

2525
03:07:51,420 --> 03:07:56,100
modes of action and differing
levels of efficacy, I think.

2526
03:07:56,260 --> 03:07:57,860
- Of course, there's not a real,

2527
03:07:58,120 --> 03:08:02,860
at that time or even now, a real science
of like when you have a human come to you,

2528
03:08:03,760 --> 03:08:06,960
what is the actual protocol of how
you figure out which to give?

2529
03:08:07,100 --> 03:08:10,960
- Right. So in 2005 most of the-- I should

2530
03:08:11,080 --> 03:08:14,957
say, once the Drugs Revolution
came along, increasingly

2531
03:08:15,040 --> 03:08:18,917
the studies were funded by the drug
companies who owned the data and

2532
03:08:19,000 --> 03:08:20,357
controlled the data-- - Right

2533
03:08:20,440 --> 03:08:24,397
-...and only released what they chose
to release, what was helpful for them and

2534
03:08:24,480 --> 03:08:27,820
not what wasn't. - And they
were heavily marketing stuff.

2535
03:08:28,060 --> 03:08:34,440
- Oh yeah, very heavily mar-- And then,
to get FDA approval of efficacy and safety

2536
03:08:34,524 --> 03:08:36,920
you needed two trials.

2537
03:08:37,760 --> 03:08:41,730
You might have conducted 15 trials
and 13 of them had been failures,

2538
03:08:41,840 --> 03:08:45,717
but if you had two that worked,
that was enough. That's what you

2539
03:08:45,800 --> 03:08:52,480
needed. That was the gold standard. So
2005, National Institutes of Mental Health

2540
03:08:52,820 --> 03:08:56,060
funds this drug study,
not an industry study,

2541
03:08:57,280 --> 03:09:01,117
and what it wants to look at,
the first generation drugs are

2542
03:09:01,200 --> 03:09:04,737
now out of patent and they're cheap.
The second generation are

2543
03:09:04,820 --> 03:09:10,500
patented and are quite expensive,
ten times as expensive in some cases.

2544
03:09:11,420 --> 03:09:15,257
So we do something called
the CATIE Study, and it's

2545
03:09:15,340 --> 03:09:18,690
published in the New England Journal
of Medicine. And there are two

2546
03:09:19,020 --> 03:09:22,257
interesting findings.
So you have one first generation

2547
03:09:22,340 --> 03:09:26,157
antipsychotic, one of those
very early drugs, and you

2548
03:09:26,240 --> 03:09:30,360
have four more recent drugs
that you're looking at.

2549
03:09:31,460 --> 03:09:37,277
And you ask a number of questions.
Are the new drugs more

2550
03:09:37,360 --> 03:09:40,980
efficacious than the old drug? No.

2551
03:09:41,820 --> 03:09:47,580
Hmm. Were patients willing
to tolerate these drugs? And that was a

2552
03:09:47,940 --> 03:09:54,220
finding that I thought was much
underreported at the time. Between 67% and

2553
03:09:54,360 --> 03:09:57,610
82% of the patients, depending
on which drug they were on,

2554
03:09:58,100 --> 03:10:01,725
dropped out of the trial because either
the drug wasn't working or they couldn't

2555
03:10:01,808 --> 03:10:05,777
stand the side effects.
So that tells you, these are our

2556
03:10:05,860 --> 03:10:09,710
best drugs, you know, there
are real complications here.

2557
03:10:10,340 --> 03:10:16,280
And then as we delve further into it,
do they have nasty side effects? Well,

2558
03:10:17,340 --> 03:10:24,340
less tardive dyskinesia somewhat, but a
whole new set of side effects. If you take

2559
03:10:27,580 --> 03:10:32,760
these pills, you will gain,
in most cases, a lot of weight,

2560
03:10:35,200 --> 03:10:38,957
10, 20, 30, 40 pounds, 50 pounds. What

2561
03:10:39,040 --> 03:10:43,030
does that do? That gives
you metabolic syndrome;

2562
03:10:43,160 --> 03:10:47,280
it gives you diabetes;
it gives you heart trouble. So

2563
03:10:48,460 --> 03:10:53,300
important to state when
we're looking at this 'cause

2564
03:10:54,680 --> 03:11:00,360
there is no-- There is no free lunch
with medicine. If you take an aspirin,

2565
03:11:01,820 --> 03:11:05,537
it may cause your stomach
to bleed, sometimes enough

2566
03:11:05,620 --> 03:11:09,840
to really put you in serious jeopardy.
Most of the time it's fine.

2567
03:11:10,900 --> 03:11:17,197
Um, everything... Every drug that's
brought to market has the main

2568
03:11:17,280 --> 03:11:21,460
effect we're looking for and
some side effects which may be

2569
03:11:23,140 --> 03:11:27,860
minimal for most people but for some
people maybe worse than that.

2570
03:11:27,943 --> 03:11:29,180
So we've got to--

2571
03:11:30,680 --> 03:11:33,430
It's one of these cost-benefit
analyses, right? You--

2572
03:11:33,520 --> 03:11:35,320
You're getting some relief from your

2573
03:11:36,380 --> 03:11:40,317
psychiatric symptoms,
but you're courting these other

2574
03:11:40,400 --> 03:11:44,037
dangers that may or may not
arise, and going in, we don't

2575
03:11:44,120 --> 03:11:49,837
know where you're gonna fall.
We don't know; trial and error.

2576
03:11:49,920 --> 03:11:53,317
- You mean every individual that walks
into the picture, they don't know where on

2577
03:11:53,400 --> 03:11:54,550
distribution they fall?

2578
03:11:54,680 --> 03:11:59,660
- Right. And we have no biological
markers at the moment that would tell us.

2579
03:12:00,640 --> 03:12:04,920
One or two of my friends in the,
um, psychiatric genetics industry,

2580
03:12:05,760 --> 03:12:09,410
uh, if that's the right term for it,
but, you know, in that research area

2581
03:12:09,760 --> 03:12:13,320
are saying, "Well, we haven't
done very well to find the genetic

2582
03:12:13,580 --> 03:12:16,920
roots of mental illness," but maybe we can

2583
03:12:17,800 --> 03:12:21,650
learn to distinguish which patients are
gonna respond well to drugs and which

2584
03:12:21,820 --> 03:12:26,280
will, which shouldn't be given them
because they're not going to. Um,

2585
03:12:27,140 --> 03:12:31,060
that's a promissory note. It's not
something that they actually can do now.

2586
03:12:31,180 --> 03:12:33,236
It's just we hope we'll
be able to do this,

2587
03:12:33,320 --> 03:12:35,370
and I hope they're able to do it too. But

2588
03:12:36,300 --> 03:12:40,057
You know, you can't have an enormous
amount of confidence in that. Maybe

2589
03:12:40,140 --> 03:12:43,840
it'll happen, or maybe some
other mechanism will emerge that

2590
03:12:43,940 --> 03:12:47,717
allows us to see who the responders
and nonresponders are.

2591
03:12:47,800 --> 03:12:51,637
Who's gonna suffer the worst side effects
if they're put on these medications? And

2592
03:12:51,720 --> 03:12:58,380
The side effects do vary, so, um,
though a lot of what I've described is

2593
03:12:58,500 --> 03:13:00,200
common to this class of drugs.

2594
03:13:00,440 --> 03:13:02,504
- And sometimes it's hard
to describe the side effect.

2595
03:13:02,587 --> 03:13:03,777
You're talking about the human

2596
03:13:03,860 --> 03:13:07,177
mind. Yeah, yeah. So describing
the side effects, it's not like ble-

2597
03:13:07,260 --> 03:13:11,217
bleeding or like
diarrhea or- - Well, yeah.

2598
03:13:11,300 --> 03:13:15,360
- Weight gain, that's describable,
but like the effect on your personality...

2599
03:13:15,820 --> 03:13:20,297
- Yep, that's much harder,
much harder. People, you know,

2600
03:13:20,380 --> 03:13:25,990
some of the patients who drop
out drop out because they find

2601
03:13:26,260 --> 03:13:30,137
the richness of their mental life
is completely gone, and they don't want

2602
03:13:30,220 --> 03:13:35,297
to tolerate that. They'd sooner tolerate
some hallucinations. That's a hard one.

2603
03:13:35,380 --> 03:13:38,557
- So there's a that picture,
the SSRIs that also came to be

2604
03:13:38,640 --> 03:13:41,600
Prozac, Zoloft, Paxil during
that time. Yes, Paxil, all of

2605
03:13:41,700 --> 03:13:45,420
that. Well again, they're the second
generation of antidepressants.

2606
03:13:45,800 --> 03:13:49,417
Mm-hmm. So that's a complicated story.
Again, it's an

2607
03:13:49,500 --> 03:13:52,640
accident. They're at treating
patients with advanced

2608
03:13:52,740 --> 03:13:57,609
tuberculosis in the 1950s. Now, that's
a very unpleasant thing that's also gonna

2609
03:13:57,692 --> 03:14:00,437
kill you, so tuberculosis, very

2610
03:14:00,520 --> 03:14:04,700
advanced cases. You're coughing your lungs
up. You're depressed as all get out.

2611
03:14:05,740 --> 03:14:09,600
And here we have two new
drugs, Iprsoltanto we can

2612
03:14:09,700 --> 03:14:15,057
use that maybe will treat the condition
when you give it to the patients, and

2613
03:14:15,140 --> 03:14:22,140
these depressed tuberculosis patients
start acting happy, dancing about. Their

2614
03:14:22,240 --> 03:14:28,970
mood changes. Bingo! We've got something
that maybe we can use over here to

2615
03:14:29,100 --> 03:14:34,837
treat depression. However,
the drug companies in circa

2616
03:14:34,920 --> 03:14:41,817
1960 think of depression as a small market
because what they're talking about is the

2617
03:14:41,900 --> 03:14:45,857
kind of melancholic psychotic
depressions that leads people

2618
03:14:45,940 --> 03:14:50,144
into the mental hospital.
And that's not an insignificant group,

2619
03:14:50,227 --> 03:14:51,500
but it's not a huge

2620
03:14:51,620 --> 03:14:57,487
group. So it's really much later
on that things begin to change. Right now,

2621
03:14:57,571 --> 03:14:58,840
it's fair to say

2622
03:14:59,540 --> 03:15:04,057
Depression is the common cold
of psychiatry. It's, you know,

2623
03:15:04,140 --> 03:15:05,980
it's abundant there, the

2624
03:15:06,140 --> 03:15:11,157
depressive diagnosis, probably the most
commonly given among psychiatrists,

2625
03:15:11,240 --> 03:15:11,917
so part of

2626
03:15:12,000 --> 03:15:15,777
that is a deeper understanding of the
human mind, and a big part of that is

2627
03:15:15,860 --> 03:15:19,300
probably the drug companies
convincing the world.

2628
03:15:19,820 --> 03:15:23,157
- Well, it's transforming, yes.
So, there were big disputes for

2629
03:15:23,240 --> 03:15:28,960
example, when DSM-5 was being
contemplated about whether grief,

2630
03:15:29,900 --> 03:15:33,867
bereavement would count
as a mental disorder,

2631
03:15:33,950 --> 03:15:37,460
as count as a form of depression if you

2632
03:15:39,300 --> 03:15:44,600
lose a parent, if you lose,
even worse, a child, um

2633
03:15:45,300 --> 03:15:49,620
It's a deeply-- how can I put it?
Deeply upsetting, yes.

2634
03:16:13,760 --> 03:16:19,140
Some psychiatrists say yes and some no,
but it's an example of what happens

2635
03:16:20,180 --> 03:16:23,720
in psychiatry, repeatedly,
what I would call diagnostic creep,

2636
03:16:24,060 --> 03:16:27,917
which is a term, actually,
an Australian named Nick Haslam came

2637
03:16:28,000 --> 03:16:31,697
up with. But it's a phenomenon
I described before that. You

2638
03:16:31,780 --> 03:16:34,500
start with a core of unambiguous

2639
03:16:34,940 --> 03:16:38,677
deviations from the norm
that are so serious that any

2640
03:16:38,760 --> 03:16:42,340
competent member of the culture
knows that's that. But

2641
03:16:43,020 --> 03:16:46,737
then it-- you begin to say, "Well,
there's this penumbra," you see, and

2642
03:16:46,820 --> 03:16:53,087
just outside that core, there are people
who are also disturbed, not perhaps as

2643
03:16:53,170 --> 03:16:56,997
sufficiently disturbed that you
actually recognize it, but it's

2644
03:16:57,080 --> 03:17:02,943
happening. And so that has tended
to happen over and over again.

2645
03:17:03,026 --> 03:17:08,080
Parents with an autistic child
won't necessarily agree with what I'm

2646
03:17:08,200 --> 03:17:12,420
about to say,
but the chief editor of DSM-IV,

2647
03:17:13,420 --> 03:17:17,197
Allen Frances, is convinced
the huge increase in the number of

2648
03:17:17,280 --> 03:17:21,197
diagnoses of autism is more driven by the

2649
03:17:21,280 --> 03:17:24,720
fact he loosened the criteria
for the diagnosis than it is

2650
03:17:24,840 --> 03:17:29,110
because there are more actual cases.
Autism used to be a fairly

2651
03:17:29,940 --> 03:17:33,737
rare phenomenon, and now sadly it's
a very broad one. And I understand

2652
03:17:33,820 --> 03:17:37,417
why parents react very
negatively to that because the

2653
03:17:37,500 --> 03:17:41,210
diagnosis is the key to all
sorts of social supports and

2654
03:17:41,420 --> 03:17:45,217
educational supports and all the rest,
and they're dealing with a

2655
03:17:45,300 --> 03:17:50,840
child who is extremely difficult.
But there is a real difference between

2656
03:17:51,740 --> 03:17:55,300
the most severe forms
of autism where people lose

2657
03:17:55,440 --> 03:17:59,257
capacity to speak and very
often any ability to

2658
03:17:59,340 --> 03:18:01,640
interact with other people and so forth,

2659
03:18:02,580 --> 03:18:06,520
and the other cases that are
of a still serious but milder sort.

2660
03:18:07,140 --> 03:18:10,250
Diagnostic creep is not driven just by

2661
03:18:10,700 --> 03:18:14,920
psychiatric imperialism, the desire
for more territory, more patients.

2662
03:18:16,260 --> 03:18:20,157
It's driven as well
by patients and people and,

2663
03:18:20,240 --> 03:18:24,040
and they resist it being
pushed back very often.

2664
03:18:24,440 --> 03:18:28,320
So families have formed
organizations like NAMI, but

2665
03:18:28,500 --> 03:18:31,976
those aren't the mentally ill. Those are
the family members of the mentally ill,

2666
03:18:32,060 --> 03:18:32,387
and there

2667
03:18:32,470 --> 03:18:35,980
are differences in the perspectives
and the interests of the family

2668
03:18:36,080 --> 03:18:39,957
members and the patients-...
And that's easy to forget.

2669
03:18:40,040 --> 03:18:42,500
- I think one of the things
you talk about is,

2670
03:18:43,560 --> 03:18:48,100
uh, I mean, the quote you
had was use the word madness.

2671
03:18:48,480 --> 03:18:53,410
But that madness
or mental health maladies,

2672
03:18:54,360 --> 03:18:57,680
if you're suffering from them,
it's a deeply lonely experience.

2673
03:18:58,520 --> 03:19:02,511
And then if you're around
somebody suffering from it,

2674
03:19:02,594 --> 03:19:04,900
it's a very social experience.

2675
03:19:05,780 --> 03:19:09,697
- Yeah. Yeah, this is actually
-- that's a paraphrase of -- I was

2676
03:19:09,780 --> 03:19:13,637
quoting one of my friends and fellow
historians of psychiatry, Michael

2677
03:19:13,720 --> 03:19:17,457
MacDonald. The most solitary
of afflictions for the sufferer and the

2678
03:19:17,540 --> 03:19:21,277
most social of maladies for those
around them. And there's lots of

2679
03:19:21,360 --> 03:19:23,180
ways in which you can see

2680
03:19:24,320 --> 03:19:28,277
that very powerfully, and that's why
I think there are a ton of people who

2681
03:19:28,360 --> 03:19:32,980
suffer in various ways from, from mental
disturbances of one sort and another.

2682
03:19:33,880 --> 03:19:37,737
But the effects aren't confined
to them. They extend out

2683
03:19:37,820 --> 03:19:41,297
to everybody else around
them, and that's really

2684
03:19:41,380 --> 03:19:45,157
powerful. So we had this
first generation there were

2685
03:19:45,240 --> 03:19:47,720
actually two different
kinds of antidepressants,

2686
03:19:48,620 --> 03:19:51,917
MAOIs as they're called in the trade, and

2687
03:19:52,000 --> 03:19:55,677
tricyclics which were called
tricyclics 'cause they had a

2688
03:19:55,760 --> 03:19:59,320
third ring of a certain
element in their molecule.

2689
03:20:00,120 --> 03:20:03,510
Those had as I say, a limited market, but

2690
03:20:03,600 --> 03:20:07,177
also there were
complications associated with

2691
03:20:07,260 --> 03:20:10,600
them that it was easy
to overdose and die. And so

2692
03:20:10,940 --> 03:20:14,837
giving a depressed patient a bunch
of pills that if they took too many

2693
03:20:14,920 --> 03:20:18,717
of them would kill them
was tricky. They also could

2694
03:20:18,800 --> 03:20:24,660
kill you another way because for example,
you couldn't -- certain dietary

2695
03:20:25,480 --> 03:20:28,380
items, cheese, cured meats,

2696
03:20:29,280 --> 03:20:34,640
in combination with them were very,
very health threatening, maybe even fatal.

2697
03:20:36,460 --> 03:20:38,680
Now, in the late '80s,

2698
03:20:40,600 --> 03:20:45,600
the drug companies came across
a new class of antidepressants

2699
03:20:46,400 --> 03:20:50,097
that didn't have those side effects.
As we'll see, they had other side

2700
03:20:50,180 --> 03:20:54,157
effects, but not those.
And the most famous of those

2701
03:20:54,240 --> 03:20:57,900
was Prozac. There were
a class of drugs called

2702
03:20:58,720 --> 03:21:02,437
SSRIs, and again forgive
the acronyms, but what it means is

2703
03:21:02,520 --> 03:21:05,420
selective serotonin reuptake inhibitors.

2704
03:21:06,780 --> 03:21:10,320
Serotonin is something
manufactured in our bodies, actually

2705
03:21:10,780 --> 03:21:14,137
in our digestive system,
and it performs a variety of

2706
03:21:14,220 --> 03:21:19,380
functions in the body. But it's also one
of the neurotransmitters in our brains.

2707
03:21:20,500 --> 03:21:25,380
And the way these drugs worked was by

2708
03:21:27,100 --> 03:21:32,580
slowing the reuptake of serotonin
in the brain, which was

2709
03:21:33,440 --> 03:21:37,117
marketed by the drug companies as the

2710
03:21:37,200 --> 03:21:40,210
solution to depression.
That when you got depressed,

2711
03:21:41,160 --> 03:21:45,037
it was because you didn't have enough
serotonin in your brain, and these pills

2712
03:21:45,120 --> 03:21:51,832
solved that problem. It was like,
well, Tipper Gore, Al Gore's ex-wife,

2713
03:21:51,916 --> 03:21:57,100
was like many politicians' wives,
depressed for reasons I fully understand

2714
03:21:57,600 --> 03:22:01,317
or at least partially understand. And she

2715
03:22:01,400 --> 03:22:05,280
went to her psychiatrist and that
was one of the things she was given,

2716
03:22:05,500 --> 03:22:12,500
and she became one of the big
public advocates for SSRIs which

2717
03:22:12,600 --> 03:22:15,540
still are the most
prescribed antidepressants.

2718
03:22:15,960 --> 03:22:17,997
- Do they work?
And what are the side effects?

2719
03:22:18,080 --> 03:22:21,947
- Yeah. So here's where we get
into slippery territory. Every

2720
03:22:22,030 --> 03:22:26,090
time you do a controlled
study of these antidepressants,

2721
03:22:27,430 --> 03:22:34,030
they beat placebo in a
statistically significant margin,

2722
03:22:35,010 --> 03:22:38,907
but not necessarily in a
clinically significant margin.

2723
03:22:38,990 --> 03:22:42,970
And this is when you see drug
ads, be very careful. This one

2724
03:22:43,070 --> 03:22:45,270
significantly improves X or Y.

2725
03:22:46,490 --> 03:22:49,930
Does that mean clinically or does
it mean statistically? Because

2726
03:22:51,010 --> 03:22:54,547
the fact-- if you -- when
we measure improvement with

2727
03:22:54,630 --> 03:22:57,890
depression, we tend to use
rating scales of various sorts.

2728
03:22:58,830 --> 03:23:05,830
And if you improve on one of the major
scales that's used by one or two points

2729
03:23:07,010 --> 03:23:10,650
on a 60-point scale,
it may be enough to show

2730
03:23:10,810 --> 03:23:14,590
statistical significance. These drugs
look a little better than placebo,

2731
03:23:15,450 --> 03:23:20,330
but doesn't really affect your quality
of life much. And for most patients,

2732
03:23:21,190 --> 03:23:26,330
antidepressants are marginally better

2733
03:23:27,510 --> 03:23:32,510
than placebo, but a lot of the
effect is the placebo effect.

2734
03:23:32,600 --> 03:23:39,430
And they come with very difficult side
effects. A lot of people describe them as

2735
03:23:39,570 --> 03:23:42,410
numbing drugs.
They--...flatten everything out,

2736
03:23:43,230 --> 03:23:46,270
So you can't experience
the highs and lows that normally

2737
03:23:46,590 --> 03:23:50,780
we take as part of human
experience. And then, um,

2738
03:23:51,670 --> 03:23:55,067
the numbing extends elsewhere
in your body. In particular, lots

2739
03:23:55,150 --> 03:24:02,150
of patients find a complete
loss of libido. They...

2740
03:24:03,490 --> 03:24:07,407
They can't get an erection.
They can't climax if they're a

2741
03:24:07,490 --> 03:24:09,720
woman. Their sex life just goes away,

2742
03:24:10,870 --> 03:24:14,450
and sometimes it doesn't come
back after you stop the drugs.

2743
03:24:15,370 --> 03:24:19,340
Next layer of problems, getting
off the drugs for some people turns

2744
03:24:19,430 --> 03:24:26,227
out to be hell on wheels. They get worse
depression than they had before. They

2745
03:24:26,310 --> 03:24:30,930
get a feel-- uh, terrible feelings.
Their brain is sparking something's wrong.

2746
03:24:31,830 --> 03:24:35,767
And so many patients find
themselves trapped on those drugs for

2747
03:24:35,850 --> 03:24:39,430
a long time, and we don't know what
the effects of that are gonna be.

2748
03:24:39,690 --> 03:24:43,527
So it's a very mixed picture,
you know. That's why I

2749
03:24:43,610 --> 03:24:46,460
think groups like NICE
in England are saying,

2750
03:24:47,970 --> 03:24:54,620
"Use CBT as the first line,
not drugs." But again,

2751
03:24:55,930 --> 03:24:59,607
it's also fair to say,
I think what we find and there was a

2752
03:24:59,690 --> 03:25:02,850
recent Lancet study that I think
was revealing on this point.

2753
03:25:04,710 --> 03:25:08,587
It's like this with both antipsychotics
and antidepressants. You have

2754
03:25:08,670 --> 03:25:12,467
a group of people who respond
pretty well, and the side

2755
03:25:12,550 --> 03:25:16,890
effects for them are bearable or even
they don't experience them. That's great.

2756
03:25:18,670 --> 03:25:22,410
You have a group of people, and it's
significant. With depressed patients,

2757
03:25:22,530 --> 03:25:27,870
we're talking 40 or north of forty
percent who aren't responding. Okay?

2758
03:25:29,630 --> 03:25:33,310
So drugs aren't doing anything for them,
and they're running a risk.

2759
03:25:34,570 --> 03:25:38,590
And then in the middle, you have
a group of people who get some positive

2760
03:25:39,550 --> 03:25:46,550
improvement, but they also get side
effects, and that's where, you know, this

2761
03:25:47,270 --> 03:25:50,900
cost-benefit analysis, if we can call
it that, comes into play, and it's

2762
03:25:51,010 --> 03:25:53,830
very difficult.
And the problem is going in,

2763
03:25:54,830 --> 03:25:57,310
you don't know which
group you're gonna fall in.

2764
03:25:57,650 --> 03:26:01,650
And your, and your doctor doesn't know
which group you're gonna fall in. And

2765
03:26:02,990 --> 03:26:08,470
more importantly, one of the things
the Drugs Revolution did was it moved

2766
03:26:09,450 --> 03:26:12,430
the diagnosis and the
prescribing of things

2767
03:26:13,450 --> 03:26:17,287
away from psychiatry
alone, so many of these

2768
03:26:17,370 --> 03:26:21,150
things, particularly antidepressants,
are dispensed by primary

2769
03:26:21,250 --> 03:26:23,310
care docs, not psychiatrists.

2770
03:26:23,890 --> 03:26:28,690
- Let's zoom out. We did say
that there's a real crisis.

2771
03:26:30,050 --> 03:26:33,707
From an individual perspective suffering
from psychosis or suffering from

2772
03:26:33,790 --> 03:26:38,790
depression-... What are
you supposed to do? What

2773
03:26:39,270 --> 03:26:43,450
works, and what is the hope for the
future in the next ten, twenty out?

2774
03:26:43,950 --> 03:26:50,950
- So you probably need to try the drugs
because the suffering is very intense.

2775
03:26:52,310 --> 03:26:55,727
But you need to be aware of things,
and you need a clinician who's

2776
03:26:55,810 --> 03:27:02,810
monitoring very carefully. More generally,
psychiatric research needs to broaden.

2777
03:27:04,310 --> 03:27:09,070
We have spent all our monies on drugs,

2778
03:27:10,090 --> 03:27:13,907
on neuroscience,
and on genetics, but there are

2779
03:27:13,990 --> 03:27:17,370
other things we could do
that would improve the lives

2780
03:27:17,570 --> 03:27:24,487
of families and patients more immediately.
So we need to spend some time on the

2781
03:27:24,570 --> 03:27:28,427
psychosocial dimensions
of mental illness and to allow

2782
03:27:28,510 --> 03:27:35,510
psychiatrists to build careers in those
fields. One of the problems if you're an

2783
03:27:35,610 --> 03:27:40,070
academic psychiatrist, your whole

2784
03:27:40,890 --> 03:27:44,270
future is dependent on you
bringing in grant monies,

2785
03:27:44,950 --> 03:27:48,727
and there aren't grant monies
available to study: Are there better

2786
03:27:48,810 --> 03:27:52,710
ways we could cope with the problem
of homelessness? Are there better

2787
03:27:52,810 --> 03:27:56,687
ways we could ease the problem
for families who are having to cope

2788
03:27:56,770 --> 03:27:59,220
with somebody in their midst
who's hallucinating?

2789
03:28:00,350 --> 03:28:03,190
That sort of thing, I think, would help.

2790
03:28:03,790 --> 03:28:07,727
- What about talk therapy on both
the CBT, cognitive behavioral

2791
03:28:07,810 --> 03:28:11,447
therapy, and psychoanalysis?
We left psychoanalysis in this

2792
03:28:11,530 --> 03:28:14,070
place where society left it behind.

2793
03:28:14,350 --> 03:28:17,310
- I think it's become
a niche product now. Only,

2794
03:28:18,250 --> 03:28:22,167
only the very wealthy can
afford to do it, and some of them

2795
03:28:22,250 --> 03:28:26,500
indeed do make use of it, and some
of them claim that it helps them.

2796
03:28:27,000 --> 03:28:30,837
- Oh, do you think there's future in it?
I will add an extra-- I

2797
03:28:30,920 --> 03:28:37,920
would add an extra bit to that.
Carefully is with the advent and the rapid

2798
03:28:38,220 --> 03:28:41,817
improvement of artificial
intelligence systems-

2799
03:28:41,900 --> 03:28:48,779
...that are able to communicate with
individual humans and learn a lot about

2800
03:28:48,862 --> 03:28:49,695
them,

2801
03:28:50,260 --> 03:28:53,937
and have a conversation about
the deepest secrets that you

2802
03:28:54,020 --> 03:28:57,620
sometimes actually would even be
uncomfortable telling even a therapist.

2803
03:28:58,760 --> 03:29:05,760
That starts to go into the realm
of Freud and Jung and psychoanalysis.

2804
03:29:05,930 --> 03:29:09,420
- Well, yes, and we did see actually COVID

2805
03:29:11,100 --> 03:29:14,837
with the isolation that it produced
and the fact people couldn't go to their

2806
03:29:14,920 --> 03:29:21,400
therapists directly. We did see
the rise of some of this distant

2807
03:29:23,180 --> 03:29:27,037
learning of this, and some
of it may indeed be mechanizable

2808
03:29:27,120 --> 03:29:30,690
in the way you described.
It's very important

2809
03:29:31,560 --> 03:29:35,437
that psychiatrists broaden
their perspective on

2810
03:29:35,520 --> 03:29:39,157
these things, and some
already have. I think

2811
03:29:39,240 --> 03:29:43,910
public policy is in a mess when
it comes to serious mental illness,

2812
03:29:44,820 --> 03:29:49,480
but I'm pessimistic about fixing that
'cause it would cost bunches of money.

2813
03:29:50,320 --> 03:29:53,420
If we were talking about something
where we could cure people,

2814
03:29:53,940 --> 03:29:57,860
transform them from, as they used
to say, tax eaters to taxpayers,

2815
03:29:58,700 --> 03:30:02,497
there'd be incentive to do it.
But the honest answer is right

2816
03:30:02,580 --> 03:30:06,260
now that's not where we are. And so we

2817
03:30:06,600 --> 03:30:12,290
face dilemmas. I think helping people as
much as we can with social supports --And,

2818
03:30:13,980 --> 03:30:17,657
you know, social interaction
is tremendously important to

2819
03:30:17,740 --> 03:30:21,740
people's mental health. If they lack it,
if they're lonely, if they're isolated,

2820
03:30:22,480 --> 03:30:29,417
it does bad things to people. So somehow
providing that kind of support, providing

2821
03:30:29,500 --> 03:30:33,440
some sense of agency
to people who often lack it

2822
03:30:33,560 --> 03:30:37,437
would be very helpful.
Uh, I hope somebody has a

2823
03:30:37,520 --> 03:30:39,870
breakthrough and produces
a better drug because

2824
03:30:40,680 --> 03:30:44,477
unlike some people, I would be
astonished if the major forms

2825
03:30:44,560 --> 03:30:48,140
of mental illness didn't have
a biological component to them.

2826
03:30:48,560 --> 03:30:52,197
I don't think that's ever gonna be
the whole story, but it's going to be an

2827
03:30:52,280 --> 03:30:56,017
important part of the story,
and therefore, you know, the

2828
03:30:56,100 --> 03:30:59,720
fact that major drug companies have
abandoned research in this area,

2829
03:31:00,500 --> 03:31:04,457
they've been bad actors
in many ways, but the drugs have

2830
03:31:04,540 --> 03:31:07,850
had some positive effects,
and the fact that there's no research

2831
03:31:08,480 --> 03:31:15,264
being done by the people with the most
money to develop better treatments

2832
03:31:15,347 --> 03:31:16,181
is well,

2833
03:31:16,300 --> 03:31:20,340
one word for it would be depressing.
You know? That's not what we wanna see.

2834
03:31:20,580 --> 03:31:26,877
- So the path forward is a mix-....of
continued research on drugs, but from a

2835
03:31:26,960 --> 03:31:30,660
patient perspective, extreme
caution in use of those drugs.

2836
03:31:31,180 --> 03:31:34,800
Uh, talk therapy, whether
it's CBT or psychoanalysis,

2837
03:31:35,890 --> 03:31:39,817
further investigation research
on that front. Then the psychosocial

2838
03:31:39,900 --> 03:31:42,007
component of social family-

2839
03:31:42,090 --> 03:31:45,340
.....people around you,
less loneliness, investigating how

2840
03:31:45,940 --> 03:31:51,500
from a cultural social perspective and
from a public policy perspective, can we

2841
03:31:52,320 --> 03:31:55,900
increase the amount of social
connections that people who

2842
03:31:56,040 --> 03:31:58,320
suffer have and all of that together?

2843
03:31:58,840 --> 03:32:02,717
- Yes. And breakthrough with
people who have a very hard time

2844
03:32:02,800 --> 03:32:06,520
making those connections or who've
lost the ability to make them.

2845
03:32:07,480 --> 03:32:08,530
- If we can zoom out,

2846
03:32:09,320 --> 03:32:13,310
looking back at this rich history
of human beings, and we did look at the

2847
03:32:13,400 --> 03:32:17,200
darkness, but I think there's
a very large number of people

2848
03:32:18,200 --> 03:32:22,740
that want to help those who suffer. So,

2849
03:32:23,860 --> 03:32:27,487
looking at the history
of people trying to figure out-

2850
03:32:27,570 --> 03:32:32,570
how to help those who suffer, what gives
you hope about our future? A real hope

2851
03:32:33,720 --> 03:32:37,640
for the future of psychiatry that we
can actually help people who suffer.

2852
03:32:39,640 --> 03:32:46,640
- Well, I think we have a profession
with many very well-meaning people

2853
03:32:50,180 --> 03:32:54,800
who see the suffering on a day-to-day,
face-to-face basis.

2854
03:32:56,120 --> 03:33:02,540
And I like to think that among
them will be people who

2855
03:33:02,640 --> 03:33:06,320
move this thing forward.
And the fact is we

2856
03:33:06,440 --> 03:33:10,060
have moved things forward.
We have tended to dwell a lot on

2857
03:33:10,800 --> 03:33:14,460
some of the very unsavory
aspects of the past,

2858
03:33:15,320 --> 03:33:19,840
and even some of the drawbacks of what
we have available to us in the present.

2859
03:33:20,780 --> 03:33:23,720
But it is important to see at times

2860
03:33:24,980 --> 03:33:28,297
highly motivated people have
been able to do very good

2861
03:33:28,380 --> 03:33:33,810
things to help people with these
conditions. And there is,

2862
03:33:34,740 --> 03:33:39,050
I think, hope in the future
that we will see more of that,

2863
03:33:39,940 --> 03:33:46,940
Than has been the case. And that involves,
in some senses, a shift in the

2864
03:33:47,660 --> 03:33:51,840
mentality of a whole
profession in, in a more

2865
03:33:52,940 --> 03:33:57,420
caring kind of direction or less
technocratic kind of direction, less

2866
03:33:58,460 --> 03:34:05,460
reliance on something as simple as giving
people pills, because that can help,

2867
03:34:07,060 --> 03:34:10,480
but it's clearly not gonna be
the solution to the whole thing.

2868
03:34:11,010 --> 03:34:17,797
We need a system that is aware
of and catering to the,

2869
03:34:17,880 --> 03:34:21,777
suffering that people experience
and finds ways, if they

2870
03:34:21,860 --> 03:34:27,500
can't eliminate it entirely,
to ameliorate it in ways that people will

2871
03:34:28,550 --> 03:34:33,030
sense is actually of help
to them. It's a, it's a

2872
03:34:34,310 --> 03:34:37,570
very difficult area,
this one. It's one that,

2873
03:34:38,270 --> 03:34:44,410
touches some of the most profound
aspects of ourselves as human beings

2874
03:34:45,210 --> 03:34:50,250
and I think as difficult
as this problem is

2875
03:34:51,590 --> 03:34:55,050
it's very important not to be
cynical. Not to give up hope,

2876
03:34:55,210 --> 03:34:59,067
not to deny the possibility of progress,

2877
03:34:59,150 --> 03:35:03,130
because that's always there.
And has happened and

2878
03:35:03,910 --> 03:35:08,010
I hope will happen with increasing
pace in the years ahead of us.

2879
03:35:09,250 --> 03:35:11,250
- And if you're listening to these words

2880
03:35:11,910 --> 03:35:15,841
and you're right now in this moment
of your life where you yourself are

2881
03:35:15,925 --> 03:35:16,758
suffering,

2882
03:35:18,670 --> 03:35:24,390
please know we're with you.
We're in this together. Stay strong.

2883
03:35:25,030 --> 03:35:30,990
There's hope. Legitimately, as one
human to another, I love you. Brother,

2884
03:35:31,110 --> 03:35:33,560
sister, if you're listening
to this, stay strong.

2885
03:35:34,630 --> 03:35:37,930
Andrew, thank you for this incredible
work of history that you do.

2886
03:35:39,110 --> 03:35:42,727
Incredible work of raising
awareness, stepping into a

2887
03:35:42,810 --> 03:35:46,727
difficult topic, and trying
to find the wisdom, the insights

2888
03:35:46,810 --> 03:35:49,810
in it. And thank you for this
incredible conversation today.

2889
03:35:50,510 --> 03:35:52,770
- Lex, thank you for having me, and

2890
03:35:54,010 --> 03:35:57,827
I felt you were remarkably
prepared to push me in various

2891
03:35:57,910 --> 03:36:01,437
directions. So you'd
obviously done a lot of

2892
03:36:01,520 --> 03:36:05,840
preparation to get this in
the right frame. And I hope,

2893
03:36:06,930 --> 03:36:10,770
that people will get something positive

2894
03:36:10,890 --> 03:36:14,807
from this conversation along with some
of the darkness we've inevitably

2895
03:36:14,890 --> 03:36:16,210
had to talk about.

2896
03:36:17,210 --> 03:36:19,808
- Thank you for listening to this
conversation with Andrew Scull.

2897
03:36:19,891 --> 03:36:22,982
To support this podcast, please check
out our sponsors in the description,

2898
03:36:23,066 --> 03:36:25,266
where you can also find
links to contact me,

2899
03:36:25,410 --> 03:36:28,877
ask questions,
give feedback, and so on. And

2900
03:36:28,960 --> 03:36:33,667
now let me leave you with some
words from Friedrich Nietzsche:

2901
03:36:33,750 --> 03:36:35,450
"To live is to suffer,

2902
03:36:36,530 --> 03:36:39,870
To survive is to find
meaning in the suffering."

2903
03:36:41,130 --> 03:36:44,150
Thank you for listening,
and I hope to see you next time.