WEBVTT 00:00:00.180 --> 00:00:03.557 - The following is a conversation with Andrew Scull, a historian of 00:00:03.640 --> 00:00:07.557 psychiatry and mental health. He has authored many books that I 00:00:07.640 --> 00:00:11.520 highly recommend including Madness in Civilization: 00:00:11.980 --> 00:00:15.817 A Cultural History of Insanity from the Bible to Freud, from 00:00:15.900 --> 00:00:19.770 the Madhouse to Modern Medicine and Desperate Remedies: 00:00:20.140 --> 00:00:23.690 Psychiatry's Turbulent Quest to Cure Mental Illness. 00:00:24.240 --> 00:00:27.917 Andrew Scull has spent decades studying how societies have understood 00:00:28.000 --> 00:00:31.780 madness, how psychiatry rose to authority, and how often 00:00:32.080 --> 00:00:35.580 that authority was used with false confidence and catastrophic 00:00:35.820 --> 00:00:39.437 consequences. In this conversation we'll trace the long arc from the 00:00:39.520 --> 00:00:43.197 asylum era to eugenics, from lobotomy and insulin coma 00:00:43.280 --> 00:00:47.220 therapy to electroconvulsive therapy, psychoanalysis, 00:00:47.560 --> 00:00:51.377 antipsychotics, antidepressants and the modern crisis 00:00:51.460 --> 00:00:55.317 of mental health. It is in part a story about the 00:00:55.400 --> 00:00:59.137 terrifying history of bad ideas in medicine but it is 00:00:59.220 --> 00:01:03.037 also about the fascinating mystery of the human mind and 00:01:03.120 --> 00:01:05.460 about the difficult journey to understand it. 00:01:06.400 --> 00:01:09.897 This is a Lex Fridman podcast. To support it please check out our sponsors in the 00:01:09.980 --> 00:01:13.537 description where you can also find links to contact me, ask 00:01:13.620 --> 00:01:19.380 questions, give feedback and so on. And now dear friends here's Andrew Scull. 00:01:20.700 --> 00:01:25.360 Is it fair to characterize your view on psychiatry and mental illness 00:01:26.180 --> 00:01:30.600 as that there's a crisis in modern psychiatry? We have made some progress- 00:01:30.840 --> 00:01:34.937 - Yes -... over the past century but mostly we still are not good at treating 00:01:35.020 --> 00:01:42.020 mental illness either via the drugs or talk therapy meaning psychopharmacology or 00:01:42.680 --> 00:01:47.980 psychotherapy or as you put it the brain or the mind route. 00:01:48.220 --> 00:01:52.017 So let's start at the end of our story. Let's start at where we 00:01:52.100 --> 00:01:56.540 stand before we go into the rich history that you so eloquently write about. 00:01:56.740 --> 00:02:00.557 - So psychiatry is a profession that tries to 00:02:00.640 --> 00:02:05.060 deal with an enormously complicated thing. The 00:02:06.080 --> 00:02:12.620 human mind, the human emotions, the human ability to attempt to understand the world 00:02:13.700 --> 00:02:18.260 and in particular obviously it focuses on people where 00:02:19.060 --> 00:02:22.900 our common sense approach to the world seems to break down. 00:02:24.140 --> 00:02:28.130 People whose emotional life is filled with turmoil, 00:02:28.840 --> 00:02:32.600 people whose ability to relate to others is badly 00:02:32.700 --> 00:02:36.537 damaged, people who see things in the world that the rest of 00:02:36.620 --> 00:02:40.340 us simply think aren't there. They're illusions, 00:02:40.460 --> 00:02:47.257 they're hallucinations, they're delusions and this is a subject that has 00:02:47.340 --> 00:02:50.440 occupied some very clever minds over the years 00:02:51.460 --> 00:02:58.257 and there's no question that in the course of at least the last three quarters of a 00:02:58.340 --> 00:03:01.077 century there has been some limited 00:03:01.160 --> 00:03:08.160 progress in dealing with the problems that mental illness creates. Some of that is 00:03:09.140 --> 00:03:12.380 confined to the milder forms of mental distress; 00:03:13.320 --> 00:03:16.610 the more serious forms of psychosis and 00:03:16.780 --> 00:03:20.680 breakdown of emotional control those are areas where I think 00:03:21.260 --> 00:03:25.197 again there's been some progress but it's easy to overstate how much 00:03:25.280 --> 00:03:30.774 of that there's been. As we'll see probably later in our conversation today 00:03:30.857 --> 00:03:35.077 the advent of modern psychopharmacology which 00:03:35.160 --> 00:03:38.897 occurred in the early nineteen fifties was a serendipitous 00:03:38.980 --> 00:03:42.840 event. It wasn't planned for. It happened almost by accident 00:03:43.620 --> 00:03:47.577 and it did mark in some ways an advance over some 00:03:47.660 --> 00:03:50.950 of the things that psychiatry had engaged in before that 00:03:51.680 --> 00:03:58.680 and no question for some people that revolution and a parallel revolution 00:03:59.080 --> 00:04:02.000 in the psychotherapeutic realm have 00:04:02.600 --> 00:04:06.480 created some advance for patients and we should not 00:04:06.580 --> 00:04:09.520 minimize that. What we have available to us 00:04:10.440 --> 00:04:14.390 are symptomatic treatments not cures. We don't have 00:04:14.500 --> 00:04:18.377 a psychiatric penicillin for any of the conditions we're 00:04:18.460 --> 00:04:22.257 gonna be talking about. That doesn't mean we can't do some things that 00:04:22.340 --> 00:04:28.777 help but the help is quite limited and it's important to understand 00:04:28.860 --> 00:04:32.400 both the ways in which we have progressed and the 00:04:32.560 --> 00:04:38.730 limits of that progress and also to understand that when we treat something 00:04:40.360 --> 00:04:44.137 sometimes we create new problems what we call 00:04:44.220 --> 00:04:49.260 iatrogenic problems, things caused by the interventions that we use. 00:04:50.340 --> 00:04:54.240 That's true of some psychotherapeutic interventions and 00:04:54.400 --> 00:04:58.360 most certainly true of the drugs we use to treat mental illness these days. 00:04:58.620 --> 00:05:05.620 So for example in treating PTSD we often get patients to confront 00:05:06.800 --> 00:05:13.800 the episode -- the trauma which provoked their distress and that is 00:05:14.300 --> 00:05:17.800 often a very, very fraught process and for many 00:05:17.900 --> 00:05:22.840 patients it actually makes things worse. For some patients it makes them better. 00:05:23.720 --> 00:05:26.420 So that's a situation where you could see problems 00:05:27.520 --> 00:05:31.320 With both antipsychotics and antidepressants, the two 00:05:31.440 --> 00:05:38.440 main classes of psychotropic drugs that we use, um, they're at best partially 00:05:39.280 --> 00:05:43.017 effective and they don't work for a 00:05:43.100 --> 00:05:46.820 significant fraction of patients who are given them and one of the big 00:05:46.920 --> 00:05:50.600 problems psychiatry faces is that 00:05:51.480 --> 00:05:55.220 psychiatrists don't know in advance who's going to respond well 00:05:55.520 --> 00:05:58.040 to the drugs, who's going to respond badly, 00:05:59.320 --> 00:06:03.197 for which group of patients in the middle the side effects and 00:06:03.280 --> 00:06:07.140 the main effects, if that's what we want to call them, the therapeutic effect 00:06:07.780 --> 00:06:11.960 are finely balanced and making those judgment calls about what to do 00:06:12.860 --> 00:06:15.977 are very, very difficult. Now in terms of the 00:06:16.060 --> 00:06:21.610 crisis psychiatry faces at the moment as I see it there are 00:06:23.060 --> 00:06:28.820 a number of strands that point to this. Psychiatry's diagnostic system, 00:06:29.700 --> 00:06:33.487 that is still used -- I mean, the fundamental basis of, 00:06:33.570 --> 00:06:40.557 of psychiatric diagnosis today was really first formulated in 1980 with the third 00:06:40.640 --> 00:06:45.740 edition of The Diagnostic and Statistical Manual of a profession -- - DSM-III 00:06:45.940 --> 00:06:52.940 -... DSM-III and then there's been DSM-III-R, DSM-IV, DSM-IV-TR, and now DSM 00:06:53.340 --> 00:06:56.900 5. Finally not with a Roman numeral but with 00:06:57.320 --> 00:07:01.257 with an Arabic numeral. So they thought with DSM 00:07:01.340 --> 00:07:04.777 5 when they needed to modify it it would be like a piece of 00:07:04.860 --> 00:07:08.810 software. You have Windows 10, Windows 11, and 00:07:08.940 --> 00:07:12.540 so on right? Now that diagnostic system 00:07:13.040 --> 00:07:16.637 came into being because psychiatrists had a very hard time 00:07:16.720 --> 00:07:20.637 agreeing with one another about what was wrong with somebody, and that 00:07:20.720 --> 00:07:24.617 became embarrassingly clear in -- first in the professional 00:07:24.700 --> 00:07:28.557 literature which outsiders didn't read and then via a 00:07:28.640 --> 00:07:32.317 very famous study that's a scientific fraud by David 00:07:32.400 --> 00:07:36.137 Rosenhan called On Being Sane in Insane Places where he 00:07:36.220 --> 00:07:39.240 claimed to have sent in pseudo patients to the hospital 00:07:40.080 --> 00:07:43.997 and they all were diagnosed as schizo. All but one of them diagnosed as 00:07:44.080 --> 00:07:47.897 schizophrenic the other as somebody with bipolar disorder and they 00:07:47.980 --> 00:07:51.690 were fake patients. So almost in a panic after 00:07:51.780 --> 00:07:55.520 that study appeared in Science and because 00:07:55.740 --> 00:07:58.697 there was an abundant professional literature from the 00:07:58.780 --> 00:08:04.460 1960s showing the same thing that diagnosis was a very erratic process. 00:08:05.320 --> 00:08:09.880 The DSM-III task force led by Robert Spitzer who was then at Columbia 00:08:10.680 --> 00:08:14.497 was explicitly set up to try to create a sort of tick the 00:08:14.580 --> 00:08:18.197 boxes approach to deciding which box a 00:08:18.280 --> 00:08:22.137 patient belonged in. Were you schizophrenic? Were you this type of 00:08:22.220 --> 00:08:24.870 schizophrenic or that type of schizophrenic? Were you 00:08:25.520 --> 00:08:30.360 manic depressive or bipolar? Did you have various forms of depression? 00:08:32.000 --> 00:08:39.000 And to construct those boxes what they relied upon was a list of symptoms and if 00:08:39.920 --> 00:08:43.360 you had more than a certain number If you had more than 00:08:43.660 --> 00:08:48.440 six of ten Six or ten or more symptoms of a certain sort 00:08:49.460 --> 00:08:53.217 you could be diagnosed with major depression for example. So that 00:08:53.300 --> 00:08:58.657 system came into being. It was partially embedded 00:08:58.740 --> 00:09:02.337 because it appealed to drug companies who were developing 00:09:02.420 --> 00:09:05.100 drugs to treat these various disorders. 00:09:06.020 --> 00:09:10.360 It appealed to insurance companies 'cause it gave them a stable base to look at. 00:09:11.360 --> 00:09:17.260 It appealed to, as diagnosis always does to patients and their families who are 00:09:18.460 --> 00:09:25.250 scrambling to deal with these enormous upsets in the mental life of either 00:09:25.380 --> 00:09:27.830 themselves or a family member. 00:09:28.760 --> 00:09:32.220 So provided some sense of certainty around diagnosis. 00:09:33.040 --> 00:09:36.890 But that was always based simply on symptoms in the way an eighteenth 00:09:36.980 --> 00:09:40.450 century doctor might diagnose dropsy or diagnose, 00:09:41.240 --> 00:09:45.060 Some other kind of disor--- Fever for example well 00:09:46.060 --> 00:09:50.017 fever and other diseases they talked about in the eighteenth 00:09:50.100 --> 00:09:54.560 century are really a constellation of very different things under one label. 00:09:55.500 --> 00:09:59.417 And I think that's what is turning out to be true of the 00:09:59.500 --> 00:10:02.900 DSM labels. But that approach 00:10:03.400 --> 00:10:07.260 was really all that psychiatry could come up with if it 00:10:07.380 --> 00:10:11.300 wanted to make sure whether you were in Walla Walla or New York or 00:10:11.720 --> 00:10:15.637 San Francisco or Atlanta you reached the same conclusion faced 00:10:15.720 --> 00:10:20.340 by the same patient. That you had a reliable diagnostic system. 00:10:21.280 --> 00:10:24.877 That didn't mean necessarily it was a valid diagnostic system if you 00:10:24.960 --> 00:10:28.157 understand the distinction between validity and 00:10:28.240 --> 00:10:32.117 reliability. Reliability means you and I faced with the 00:10:32.200 --> 00:10:35.917 same sets of facts reach the same conclusion but 00:10:36.000 --> 00:10:39.737 that conclusion may or may not reflect the 00:10:39.820 --> 00:10:43.757 underlying reality of things right? So you had this 00:10:43.840 --> 00:10:47.377 diagnostic system and it went through various 00:10:47.460 --> 00:10:51.437 iterations each time it went through an iteration the number 00:10:51.520 --> 00:10:58.520 of possible psychiatric disorders you could get grew and grew and grew and it 00:10:59.360 --> 00:11:03.137 became difficult to believe in some of those categories shall 00:11:03.220 --> 00:11:06.480 we say. That they were really illnesses rather 00:11:07.120 --> 00:11:11.860 th-than some sorta social construct. But beyond that um, 00:11:13.000 --> 00:11:18.840 psychiatrists wanted to be more like other medical doctors to root 00:11:20.340 --> 00:11:23.780 their diagnoses in an understanding of the underlying 00:11:24.060 --> 00:11:27.720 pathology of the disorder. What was it that caused 00:11:27.820 --> 00:11:31.797 people to become schizophrenic? The sense was 00:11:31.880 --> 00:11:35.837 if we could grasp that we'd have a better handle on how to attack it How 00:11:35.920 --> 00:11:42.920 To treat it. And when uh, DSM-5 was mooted the fifth edition in the early 2000s 00:11:46.080 --> 00:11:49.877 NIMH then under the leadership of Steven Hyman who's at 00:11:49.960 --> 00:11:53.840 Harvard now and succeeded by Thomas Insel 00:11:54.280 --> 00:11:58.117 who ruled NIMH for about thirteen years. The 00:11:58.200 --> 00:12:01.997 two of them had pushed psychiatry and psychiatric 00:12:02.080 --> 00:12:04.930 research in a very particular direction. 00:12:06.240 --> 00:12:11.240 On the one hand, towards understanding the genetics of mental illness, 00:12:12.080 --> 00:12:18.657 and on the other, to looking at what the new discipline of neuroscience could 00:12:18.740 --> 00:12:22.617 contribute to understanding things. Both of them were heavily invested 00:12:22.700 --> 00:12:28.000 in the idea that mental illness was brain disease. 00:12:28.120 --> 00:12:31.937 And if it was brain disease, then the question was what was making the 00:12:32.020 --> 00:12:35.620 mechanism here go awry? What was 00:12:35.820 --> 00:12:39.637 causing people's emotions or their cognitive skills or 00:12:39.720 --> 00:12:44.000 their sense of the world to become so disordered? 00:12:44.920 --> 00:12:48.797 And they invested a lot of money in that approach. When Insel stepped 00:12:48.880 --> 00:12:51.860 down, he gave an interview actually to somebody at MIT 00:12:52.700 --> 00:12:56.260 and he's repeated it since in a book he wrote about his experiences 00:12:56.940 --> 00:13:00.280 where he said, "Well, you know, as I look back on my 13 years, 00:13:01.060 --> 00:13:03.570 I funded an enormous amount of scientific... 00:13:03.654 --> 00:13:05.540 really cool scientific research. 00:13:06.340 --> 00:13:10.117 I funded geneticists and I funded neuroscientists and 00:13:10.200 --> 00:13:12.750 we-- they did a lot of really interesting science." 00:13:14.160 --> 00:13:17.840 And after spending 20 billion dollars, the lot of the 00:13:17.940 --> 00:13:22.357 mentally ill has improved not one bit right?" 00:13:22.440 --> 00:13:25.357 Which was a pretty devastating statement, I thought. 00:13:25.440 --> 00:13:27.677 - And NIMH is National Institute of Mental Health. 00:13:27.760 --> 00:13:31.410 - National Institute of Mental Health, yes. I shouldn't resort to jargon. 00:13:32.720 --> 00:13:36.537 But the National Institute of Mental Health had been founded in the late 00:13:36.620 --> 00:13:42.394 1940s with the goal of improving, doing basic research training people in 00:13:42.478 --> 00:13:47.520 the field advancing the care of the mentally ill and producing obviously 00:13:47.920 --> 00:13:54.390 cures and advances. Uh, and its mission has varied widely 00:13:54.480 --> 00:13:58.060 over the years since but starting in the 00:13:58.500 --> 00:14:02.320 in the-- in the 1990s—the period when the first George Bush 00:14:02.700 --> 00:14:06.220 declared the decade of the brain—uh, NIMH 00:14:06.400 --> 00:14:10.217 increasingly focused on the idea that mental illness was purely a 00:14:10.300 --> 00:14:13.817 brain disease and there's something to that and there's also some 00:14:13.900 --> 00:14:15.897 mistake in thinking about it that way. 00:14:15.980 --> 00:14:19.537 - This is, by the way, as we will talk about this distinction 00:14:19.620 --> 00:14:24.017 between seeing mental health, the maladies of the human mind, 00:14:24.100 --> 00:14:28.040 as a problem of the brain, like neurobiology, neuroscience, versus 00:14:28.440 --> 00:14:34.020 the problem of the mind, which is more in the cognitive, psychotherapy, these more, 00:14:34.920 --> 00:14:38.657 less amenable to scientific rigor. So I think what's 00:14:38.740 --> 00:14:42.277 appealing about studying the brain and neurobiology, neurosciences, there's 00:14:42.360 --> 00:14:45.520 data. Yes. It's more rigorous. You can do science. 00:14:45.780 --> 00:14:50.440 - It’s the kind of thing that really appealed to medical school deans because 00:14:51.380 --> 00:14:57.817 once NIH and the drug companies too were funding basic research on 00:14:57.900 --> 00:15:04.900 neurobiology and basic research on genetics, the money flooded in. Um, and 00:15:05.200 --> 00:15:09.040 psychiatry, which had been something of an orphan, became much more popular, 00:15:09.320 --> 00:15:11.932 - and we should say that this is something you write a lot about. 00:15:12.016 --> 00:15:13.217 There are all these factors to 00:15:13.300 --> 00:15:19.747 consider. So there's cultural elements, political, public policy elements. Then at 00:15:19.830 --> 00:15:24.960 a certain point, drug companies, insurance companies come in, of course. 00:15:25.880 --> 00:15:29.480 all human beings around somebody who's 00:15:29.600 --> 00:15:34.638 suffering with a mental health issue, so family factors, that's connected, 00:15:34.722 --> 00:15:35.760 cultural stuff. 00:15:35.960 --> 00:15:41.846 - it's a very complicated area and oversimplification is a real problem I 00:15:41.929 --> 00:15:42.763 think. 00:15:43.140 --> 00:15:49.917 Uh, and I think even that dichotomy you just drew between, um, the 00:15:50.000 --> 00:15:54.530 brain and the social or psychological, some mix of those things, 00:15:55.400 --> 00:15:57.470 I think in some ways that's a category mistake, 00:15:57.553 --> 00:15:59.503 that's a mistaken way of looking at the 00:15:59.760 --> 00:16:06.760 world, because the brain you have today, you're not born with. Human 00:16:07.520 --> 00:16:11.147 brains are remarkably plastic things. They develop in response to the 00:16:11.230 --> 00:16:18.230 environment. Social, psychological are embedded in our brains. 00:16:18.900 --> 00:16:25.900 Rigid separation, saying one or the other—no. Abundant evidence from 00:16:26.440 --> 00:16:32.399 epidemiology that social factors play an important role in the development 00:16:32.482 --> 00:16:39.037 of illness. - Nevertheless, history of psychotherapy, for example, subfields... 00:16:39.120 --> 00:16:46.120 human mind is complicated, all these factors. To say anything 00:16:46.480 --> 00:16:50.954 helpful, you have to simplify. Freud famously simplified a lot towards 00:16:51.037 --> 00:16:52.990 a particular view of the human 00:16:53.080 --> 00:17:00.080 mind. That simplification, actually, we'll talk about if it's correct 00:17:01.000 --> 00:17:04.560 in a deeper sense, was productive. 00:17:04.800 --> 00:17:11.148 - Yes. In fact, whenever you're trying to deal with a very complicated set 00:17:11.231 --> 00:17:12.100 of issues, 00:17:12.760 --> 00:17:16.657 you have to simplify. You have to make heuristic 00:17:16.740 --> 00:17:20.280 decisions about what you're going to neglect and what you're gonna 00:17:20.400 --> 00:17:23.867 emphasize. But what I'm trying to say, well, 00:17:23.950 --> 00:17:27.500 you asked me about the crisis in psychiatry, 00:17:28.420 --> 00:17:33.650 and the simplest way for me to encapsulate the issue and the 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 00:17:40.360 --> 00:17:46.180 Eisenberg, who had a very long career at Harvard, and Eisenberg 00:17:46.960 --> 00:17:50.020 said towards the end of his career, he said, "When I entered 00:17:50.120 --> 00:17:56.980 psychiatry, it was brainless psychiatry, leaving it mindless psychiatry." Yeah, 00:17:57.360 --> 00:18:03.480 sums up the way the field to a large degree has moved. 00:18:04.140 --> 00:18:09.563 In the process, insights are lost, though in other ways, 00:18:09.647 --> 00:18:12.400 things are being gained. Um, 00:18:13.480 --> 00:18:17.860 Freudians tended to neglect the biological, to suggest the brain 00:18:18.680 --> 00:18:22.477 as a biological organism was not something we needed to 00:18:22.560 --> 00:18:26.457 worry about. We worried at the level of a 00:18:26.540 --> 00:18:32.770 psychological model of how our minds work. And all too often, 00:18:34.120 --> 00:18:38.040 not exclusively because some of the psychiatrists I'm friends with 00:18:38.800 --> 00:18:45.540 are very sophisticated men and women and do grasp that you can't move in these 00:18:47.060 --> 00:18:50.540 bipolar directions. You've got to meet somewhere in the middle. 00:18:51.220 --> 00:18:57.840 But that sort of got lost, I think, in all the enthusiasm for 00:18:58.700 --> 00:19:02.617 neuroscience. I mean, when antipsychotic drugs were discovered 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 00:19:09.640 --> 00:19:13.480 that they helped us spawn as people began to say, "Well, 00:19:13.580 --> 00:19:15.780 why did these drugs work? What did they do?" 00:19:17.080 --> 00:19:20.437 Was to begin to understand that the brain wasn't just a set of 00:19:20.520 --> 00:19:24.137 electrical signals, as had been thought in the first half of the 20th 00:19:24.220 --> 00:19:28.097 century and before. But rather there was this very 00:19:28.180 --> 00:19:32.077 interesting chemical soup running around in our brains with 00:19:32.160 --> 00:19:35.780 neurotransmitters that help the brain work the way it did 00:19:35.940 --> 00:19:39.020 and perhaps explained why it went awry. 00:19:40.080 --> 00:19:43.897 So it was one of the many factors that gave rise to neuroscience. The 00:19:43.980 --> 00:19:47.877 first neuroscience conventions were in the 1970s, and they attracted a 00:19:47.960 --> 00:19:51.337 few hundred people. Now it's tens of thousands of 00:19:51.420 --> 00:19:55.317 neuroscientists. It's a huge enterprise. So 00:19:55.400 --> 00:19:59.260 diagnosis has come under threat. The categories that 00:19:59.380 --> 00:20:02.997 we have all become familiar with, that we're told are real 00:20:03.080 --> 00:20:07.540 diseases like bipolar disorder, schizophrenia, major depression, 00:20:08.940 --> 00:20:12.597 are beginning to falter, and we're beginning to 00:20:12.680 --> 00:20:16.277 worry about whether those diagnoses are real 00:20:16.360 --> 00:20:19.940 ways of thinking about the world and may in fact mislead us. 00:20:20.120 --> 00:20:23.417 Because if we think there's something called schizophrenia or the 00:20:23.500 --> 00:20:27.277 schizophrenias, as the inventor of that term put it, if we think 00:20:27.360 --> 00:20:31.177 there's something like that and we try to research where it 00:20:31.260 --> 00:20:37.577 comes from, but that's not really what's going on, obviously we're probably 00:20:37.660 --> 00:20:41.417 gonna not make the progress we could be making if we had a better 00:20:41.500 --> 00:20:43.737 diagnostic system. And that's what 00:20:43.820 --> 00:20:47.657 DSM-V thought it was gonna be able to do and discovered 00:20:47.740 --> 00:20:51.420 it couldn't. So it stayed basically with the symptomatic approach. 00:20:51.620 --> 00:20:53.467 - If we can just really brief - 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 00:20:57.400 --> 00:21:04.400 here, looking it up on Perplexity, DSM One in 1952 was a 32 page pamphlet- 00:21:04.970 --> 00:21:09.720 with 106 diagnoses heavily influenced by psychodynamic concepts- 00:21:10.240 --> 00:21:14.080 and etiology using broad, often vague categories like reactions. 00:21:14.490 --> 00:21:21.417 DSM Two in 1968 expanded to 185 diagnoses still psychodynamically 00:21:21.500 --> 00:21:25.397 flavored and reliability poor, but added more attention 00:21:25.480 --> 00:21:29.277 to childhood disorders and later removed homosexuality as a disorder in 00:21:29.360 --> 00:21:33.217 1974 printing. Then to the revolution, as you 00:21:33.300 --> 00:21:37.000 mentioned, the DSM Three in 1980 introduced explicit 00:21:37.100 --> 00:21:43.960 symptom-based diagnostic criteria, a multi axial assessment system, and an officially 00:21:44.220 --> 00:21:49.817 atheoretical stance about causes aiming to improve reliability and research utility. 00:21:49.900 --> 00:21:53.477 And then DSM Three R in 1987 revised criterion 00:21:53.560 --> 00:22:00.560 expanded to around two 97 diagnoses. DSM Four in '94 and DSM Four TR in 00:22:01.460 --> 00:22:05.910 2000 focused on literature driven empirical revisions,- 00:22:06.400 --> 00:22:10.257 added and deleted some disorders increased coordination with 00:22:10.340 --> 00:22:17.317 ICD 10 and goes on. And then finally in 2013 DSM Five came 00:22:17.400 --> 00:22:20.320 out which eliminated the multiaxial system 00:22:21.100 --> 00:22:24.777 integrated most information into a single nonaxial 00:22:24.860 --> 00:22:28.790 diagnostic list than separate notations for psychological and medical 00:22:28.900 --> 00:22:32.717 factors. It reorganized chapters e.g. 00:22:32.800 --> 00:22:36.660 Neurodevelopmental, obsessive-compulsive related, trauma and 00:22:36.820 --> 00:22:40.760 stress related disorders introduce new and refined entities and so 00:22:40.860 --> 00:22:47.740 on. But big picture trajectory conceptually the DSM moved from cause 00:22:47.824 --> 00:22:48.937 focused and 00:22:49.020 --> 00:22:55.060 psychoanalytical to symptom-based, theoretical, and reliability driven 00:22:56.380 --> 00:23:00.260 over time. There has been growth in the number of granularity of categories 00:23:00.420 --> 00:23:04.057 closer alignment with ICD ongoing controversy 00:23:04.140 --> 00:23:07.437 over medicalization, validity, and the balance between 00:23:07.520 --> 00:23:11.337 categorical and dimensional approaches. Yes. It 00:23:11.420 --> 00:23:15.220 feels like that description doesn't necessarily fully get to the 00:23:15.320 --> 00:23:21.860 core of why the DSM five doesn't quite get the full scope of the problem 00:23:22.140 --> 00:23:26.197 - You invest a ton of money. You invest- 00:23:26.280 --> 00:23:30.180 ...$20 billion-- More than $20 billion in a particular approach. 00:23:30.920 --> 00:23:34.500 And at the time you're constructing this, you say, "Finally, 00:23:34.940 --> 00:23:38.377 because of all the work that's being done in genetics, we now have 00:23:38.460 --> 00:23:40.320 decoded the human genome. 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 00:23:48.100 --> 00:23:52.680 understanding of the role of neurotransmission in the brain. 00:23:54.260 --> 00:23:59.320 Surely we're going to be able to recast our diagnostic system 00:24:00.200 --> 00:24:04.140 based on underlying pathology so that we won't be 00:24:04.560 --> 00:24:08.137 worrying about symptoms anymore. We'll be looking at the actual 00:24:08.220 --> 00:24:11.570 underlying pathological changes that have taken place. 00:24:12.480 --> 00:24:16.300 But in the event, it turned out they couldn't do that. By about 00:24:16.480 --> 00:24:20.357 2008, they had thrown up their hands and said, "No, we're going 00:24:20.440 --> 00:24:23.460 to have to continue to refine, 00:24:24.800 --> 00:24:30.660 rely upon the same basic approach that we developed in 1980." And 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 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 00:24:45.940 --> 00:24:49.480 his successor Allen Frances, who'd run DSM-IV, 00:24:50.520 --> 00:24:54.297 they both were fiercely critical about what was going on and said it was 00:24:54.380 --> 00:24:58.130 being done in the dark and it was done in secrecy and it wasn't scientific. 00:24:58.920 --> 00:25:00.690 And when it was about to come out, 00:25:01.720 --> 00:25:04.900 Thomas Insel and Steven Hyman, the two then existing and the 00:25:05.140 --> 00:25:08.797 preceding director of the National Institute of Mental Health, denounced the 00:25:08.880 --> 00:25:11.920 document as unscientific and useless. 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 00:25:16.580 --> 00:25:21.460 diagnostic system is being dissed by leading figures like that, 00:25:22.580 --> 00:25:28.707 What else was a problem? The difficulties with the drug existing 00:25:28.790 --> 00:25:33.500 therapies, particularly, had become more and more manifest. 00:25:33.980 --> 00:25:40.980 To make matters worse, partly because Big Pharma had sometimes behaved, 00:25:42.960 --> 00:25:49.797 shall we say, rather unethically sometimes with these drugs, it had hidden things 00:25:49.880 --> 00:25:55.803 that undercut their claims. It had manufactured studies. 00:25:55.886 --> 00:25:58.460 It had manipulated data. 00:25:59.080 --> 00:26:02.780 And it got caught out, and it paid billions of dollars in damages 00:26:02.880 --> 00:26:06.140 for some of the tricks it had got up to. 00:26:06.500 --> 00:26:10.197 Not just in psychiatry—I mean Vioxx, for example, the 00:26:10.280 --> 00:26:13.820 painkiller, was another huge scandal, and it was a $5 billion 00:26:13.960 --> 00:26:17.817 settlement. But the drug companies had 00:26:17.900 --> 00:26:21.737 suffered some reputational damage. Beyond that, they didn't 00:26:21.820 --> 00:26:25.477 have any real clues. Unfortunately, neuroscience hadn't thrown up new 00:26:25.560 --> 00:26:28.900 targets for different forms of drug development 00:26:29.720 --> 00:26:33.477 And they decided they could make more money with spending their money on 00:26:33.560 --> 00:26:36.490 research on other diseases, not mental illness 00:26:37.740 --> 00:26:41.297 A crisis was you were stuck with a set of drugs that Steve Hyman 00:26:41.380 --> 00:26:44.900 says, "Aren't really any advance on the ones by 00:26:45.020 --> 00:26:48.520 accident we found in the fifties. Mm-hmm. And 00:26:48.960 --> 00:26:52.397 there isn't new research unless it's small startups going 00:26:52.480 --> 00:26:57.140 on to develop new ones, so you have an increasing sense 00:26:57.960 --> 00:27:04.960 Your diagnostic process is falling apart, your drug treatments' limitations are 00:27:06.250 --> 00:27:07.037 becoming 00:27:07.120 --> 00:27:14.057 more manifest and, um, as well for people 00:27:14.140 --> 00:27:18.520 with serious mental illness. Public policy has screwed things up badly. 00:27:19.380 --> 00:27:25.977 So if you, a person with serious mental illness, you will 00:27:26.060 --> 00:27:31.720 die on average fifteen to twenty-five years before the rest of us. That 00:27:32.660 --> 00:27:36.317 gap has been growing rather than diminishing. So, that's not a good 00:27:36.400 --> 00:27:38.897 thing. It's not something I want to 00:27:38.980 --> 00:27:42.830 lay entirely at the door of psychiatry. So don't get me wrong, I think a 00:27:43.000 --> 00:27:49.146 lot of this is public policy that has really abandoned treatment for 00:27:49.229 --> 00:27:54.437 the seriously mentally ill. And you see it on the streets of our cities. You 00:27:54.520 --> 00:27:57.100 see the sidewalk psychotics. You see people who are 00:27:57.220 --> 00:28:04.077 cycling between brief periods of inpatient care, uh, the gutter, or the flop 00:28:04.160 --> 00:28:07.700 house and the jail. You so the three 00:28:07.900 --> 00:28:11.857 largest centers of inpatient psychiatric care, if you can call it 00:28:11.940 --> 00:28:15.577 that in the United States today are the Los Angeles 00:28:15.660 --> 00:28:20.017 County Jail, Cook County Jail in Chicago, and Rikers Island in New 00:28:20.100 --> 00:28:24.731 York, that's shockingly, because by their very nature, of course, 00:28:24.814 --> 00:28:29.580 prisons aren't equipped to deal with serious mental illness 00:28:29.760 --> 00:28:32.840 - Some dark ways to return to the asylum era. 00:28:32.940 --> 00:28:37.776 - Yeah, well, you know, the asylums had acquired a very bad reputation, 00:28:37.859 --> 00:28:42.677 and I've written about some of the reasons why that happened, but when 00:28:42.760 --> 00:28:48.281 asylums were founded, it was a period of enormous optimism that we were going to be 00:28:48.365 --> 00:28:49.577 able to cure these 00:28:49.660 --> 00:28:54.260 people that we would rescue them from attics and from jail cells, 00:28:54.343 --> 00:28:58.780 and through providing a therapeutic environment, coaxing them to 00:28:58.940 --> 00:29:04.273 work, creating a system where they learn to control themselves, 00:29:04.357 --> 00:29:10.148 not necessarily to drive their demons out, but to keep them under some sort of wraps. 00:29:10.231 --> 00:29:14.177 The expectation was when the asylums came along is that they'd not 00:29:14.260 --> 00:29:18.077 only rescue people from horrendous conditions in the prisons and 00:29:18.160 --> 00:29:22.017 the jails, but they'd actively cure them and 00:29:22.100 --> 00:29:28.437 the earliest alienists, as they called themselves then, thought that 00:29:28.520 --> 00:29:33.393 they could cure 60, 70, 80 percent, maybe even more of patients, 00:29:33.477 --> 00:29:35.737 as long as they came in early. 00:29:35.820 --> 00:29:39.357 And really, asylums were built out of that sense. 00:29:39.440 --> 00:29:42.192 of optimism, that sense that we, you know, 00:29:42.275 --> 00:29:45.380 that so much was environmental and so much was 00:29:46.420 --> 00:29:51.784 Not exacerbating the condition by treating people like animals or treating them, 00:29:51.867 --> 00:29:57.498 you know. Beating them and in other ways horrifically maltreating them, 00:29:57.582 --> 00:30:00.297 that would create, um, a sense of 00:30:00.380 --> 00:30:06.020 Cure and really that underlay the construction of the asylums and 00:30:06.120 --> 00:30:12.884 Now having abandoned the asylums, which we did starting a little bit in the 1950s 00:30:12.968 --> 00:30:16.180 but really the late 1960s onwards, uh. 00:30:16.280 --> 00:30:20.381 That was because there was going to be something miraculous called community 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. 00:30:25.340 --> 00:30:31.369 confidence tricks. There were no substitute community facilities 00:30:31.452 --> 00:30:34.920 for dealing with the really serious mentally ill. 00:30:35.420 --> 00:30:38.687 - So now we're in this truly, in, in this crisis- 00:30:38.770 --> 00:30:42.430 ... in this essentially dark ages. And in part 00:30:42.960 --> 00:30:47.227 I think our conversation, our journey through the history of psychiatry- 00:30:47.310 --> 00:30:50.957 ... is an exploration of some 00:30:51.040 --> 00:30:54.997 gigantic mistakes but also an exploration of where lay some 00:30:55.080 --> 00:30:58.917 hope for the future. So we'll talk quite a bit about this. I 00:30:59.000 --> 00:31:02.460 was wondering if you can also just lay out 00:31:02.580 --> 00:31:06.177 what are the big categories of mental illness that we're referring to. You've 00:31:06.260 --> 00:31:10.957 already hinted at them, but like levels of seriousness- 00:31:11.040 --> 00:31:13.097 ... and the categories of illness- 00:31:13.180 --> 00:31:15.760 ... like with psychosis and depression and so on. 00:31:16.220 --> 00:31:23.220 - So going back to the early 20th century was when the German psychiatrist Emil 00:31:23.980 --> 00:31:28.260 Kraepelin working with thousands of records in German asylums 00:31:29.060 --> 00:31:32.597 inductively developed a distinction between two very 00:31:32.680 --> 00:31:35.220 broad categories of mental illness. 00:31:36.200 --> 00:31:39.080 One he called dementia praecox or early dementia, 00:31:40.020 --> 00:31:43.980 and the other he called manic depressive illness which was a more remitting 00:31:44.080 --> 00:31:47.450 illness that sometimes went away entirely, 00:31:47.940 --> 00:31:54.111 other times went back and forth whereas dementia praecox was a one way ticket 00:31:54.194 --> 00:31:55.027 down. 00:31:55.980 --> 00:32:01.440 Now that label was transformed by a Swiss psychiatrist Bleuler 00:32:02.580 --> 00:32:06.380 into the term we use today schizophrenia although 00:32:06.820 --> 00:32:10.697 Bleuler talked about the schizophrenias because he thought 00:32:10.780 --> 00:32:15.970 under that broad label there were a diverse group of things running around. 00:32:16.900 --> 00:32:20.337 And I think that was an important insight that tends to get lost 00:32:20.420 --> 00:32:24.277 sometimes. This was jamming together people 00:32:24.360 --> 00:32:28.217 with very serious psychosis, that is people who'd lost touch 00:32:28.300 --> 00:32:31.180 with we liked-- what we like to think of as reality, 00:32:32.180 --> 00:32:36.900 whose emotional and cognitive lives were in total turmoil, 00:32:37.760 --> 00:32:41.660 Who were -- who lost the ability to connect 00:32:41.760 --> 00:32:44.920 with other human beings. So their social skills 00:32:45.140 --> 00:32:48.797 atrophied, their-- Well, this is something contemporary 00:32:48.880 --> 00:32:52.550 psychiatrists would refer to as the positive and negative symptoms 00:32:52.633 --> 00:32:57.540 of schizophrenia. - But underlying the definition of schizophrenia here is a 00:32:57.660 --> 00:33:01.460 detachment from reality. So you're hearing voices-... you're seeing visions. 00:33:01.640 --> 00:33:05.497 - You're thinking people are plotting against you. You think the 00:33:05.580 --> 00:33:08.097 television is talking directly to you. 00:33:08.180 --> 00:33:11.817 - And because of that it has these consequences of how you're 00:33:11.900 --> 00:33:14.841 connected to the rest of the world and what your emotional life is like, 00:33:14.924 --> 00:33:15.837 all that kind of stuff. 00:33:15.920 --> 00:33:19.320 - Yes. Your emotional life flattens out. Your language capacity 00:33:19.720 --> 00:33:23.380 deteriorates. Your ability to relate to other people 00:33:24.000 --> 00:33:27.767 either vanishes or becomes caught up in the web of 00:33:27.850 --> 00:33:31.320 delusions where you think people around you are plotting 00:33:31.440 --> 00:33:33.697 against you or doing terrible things to you. 00:33:33.780 --> 00:33:37.237 - And is that a different world than the world of bipolar and the world of 00:33:37.320 --> 00:33:42.157 depression? - Yes. The Greeks recognized and the Romans, ancient Greece and 00:33:42.240 --> 00:33:46.540 ancient Rome recognized different forms of insanity as they called it. 00:33:47.460 --> 00:33:48.960 So melancholia 00:33:49.900 --> 00:33:53.677 would have been the term the Greeks and the Romans would have used and it 00:33:53.760 --> 00:34:00.760 survived and was very much around. And I think that is a form of 00:34:01.520 --> 00:34:07.840 depression. What's happened now is major depression has become a catchall category. 00:34:07.960 --> 00:34:14.700 So it embraces both what we might think of as milder forms of emotional distress 00:34:15.780 --> 00:34:19.740 along with what melancholia referred to which was really 00:34:20.800 --> 00:34:24.497 a kind of depression that had psychotic features. This loss of 00:34:24.580 --> 00:34:28.180 contact as it were with everyday reality. 00:34:28.460 --> 00:34:31.190 - Something you would talk about maybe like a clinical depression. 00:34:31.273 --> 00:34:31.997 And by the way, we 00:34:32.080 --> 00:34:36.977 should mention that this field in the 21st century is like a minefield. 00:34:37.060 --> 00:34:43.074 - Yes, very much so. So here's a very strange bit of historical record. 00:34:43.157 --> 00:34:47.757 The other distinction and the distinction we're grappling with so we 00:34:47.840 --> 00:34:51.657 have people who are-- whose depression is of such a scale they're 00:34:51.740 --> 00:34:55.417 threatening to do away with themselves. They've retreated 00:34:55.500 --> 00:34:59.140 into complete almost immobility. They're 00:34:59.280 --> 00:35:02.840 overwhelmed by senses of sadness and loss and 00:35:02.940 --> 00:35:06.897 they're-- If they're religious then they're damned to hell and all those 00:35:06.980 --> 00:35:10.560 kinds of things. So we have this psychosis 00:35:11.180 --> 00:35:14.657 that we've been talking about. We have something also that the 00:35:14.740 --> 00:35:18.677 ancients recognize: dementia; the loss really the loss 00:35:18.760 --> 00:35:24.090 of our mind as it were. But then we also have 00:35:24.920 --> 00:35:31.257 other kinds of disturbance of our mental faculties that generally 00:35:31.340 --> 00:35:35.057 we think of as more minor but I don't want to make light of them 00:35:35.140 --> 00:35:38.847 because often people suffer from these things genuinely 00:35:38.930 --> 00:35:42.797 suffer pretty badly. But those things-- we in 00:35:42.880 --> 00:35:46.500 the 20th and 21st centuries tend to talk about as neuroses 00:35:47.100 --> 00:35:53.617 neurotic diseases, psychotic diseases. In the 19th century neurosis was a 00:35:53.700 --> 00:35:57.600 term that meant things rooted in the brain as you can 00:35:57.700 --> 00:36:01.660 see from the root of the word and psychosis was stuff that 00:36:02.220 --> 00:36:03.770 came from the mind, the psyche. 00:36:04.540 --> 00:36:08.300 And yet sometime in the late 19th century those things crossed over 00:36:09.080 --> 00:36:16.080 and so when we talk in the present we do tend to distinguish between the core, 00:36:17.400 --> 00:36:20.627 really the most severe forms of mental disorder, 00:36:20.710 --> 00:36:24.517 ...which would include things like Alzheimer's disease 00:36:24.600 --> 00:36:28.140 and other forms of dementia, would include 00:36:28.480 --> 00:36:32.357 very serious depression, would include bipolar 00:36:32.440 --> 00:36:36.500 disorder where people oscillate either have extreme mania so they're 00:36:37.300 --> 00:36:41.120 they're not getting any sleep. They're talking at an extraordinary rate 00:36:41.260 --> 00:36:44.697 Their behavior is very hard to tolerate, and they're exhausting 00:36:44.780 --> 00:36:48.697 themselves, and they may even die from exhaustion if it's not controlled. 00:36:48.780 --> 00:36:52.297 And very often that alternates with periods of 00:36:52.380 --> 00:36:59.350 depression. So that was a category that was captured initially as, 00:36:59.860 --> 00:37:03.477 Manic depressive illness and later on evolved into 00:37:03.560 --> 00:37:07.497 bipolar disorder and then separating out depression 00:37:07.580 --> 00:37:11.317 and major depression separately. But then there are a whole bunch of 00:37:11.400 --> 00:37:15.060 other things like, for example, phobias. 00:37:15.560 --> 00:37:19.220 People can't go outside because they find it too frightening. 00:37:19.990 --> 00:37:23.780 Milder phobias: "I can't get in an airplane because it's gonna crash," 00:37:24.510 --> 00:37:28.280 "I can't go to school because it's overwhelming for me." So school phobia 00:37:28.420 --> 00:37:35.040 emerges as a diagnosis. A disorder that at first attracted Freud, hysteria. 00:37:35.520 --> 00:37:38.217 - And now we should say you wrote a book on hysteria. 00:37:38.300 --> 00:37:38.907 - Oh, I did indeed, yes. 00:37:38.990 --> 00:37:42.577 - You mentioned... I mean, hysteria, every classification we're 00:37:42.660 --> 00:37:46.397 talking about has been used and abused by every 00:37:46.480 --> 00:37:49.007 layer of society including institutions- - Yes 00:37:49.090 --> 00:37:55.700 -...including just culturally the word hysteria applied to different races 00:37:55.800 --> 00:37:59.047 disproportionately, to different, um- - Genders particularly, yes, yes 00:37:59.130 --> 00:38:00.337 -...genders disproportionate- 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 00:38:04.320 --> 00:38:09.660 complicated human mind- - Yes -...and everybody is dogmatically creating 00:38:09.780 --> 00:38:15.417 narratives that hold, take hold, and in so doing can lead to some abuses- 00:38:15.500 --> 00:38:17.777 - Yes, they do. Yes, they do -...as you document. 00:38:17.860 --> 00:38:21.560 - If you look back at the asylum era born in this period of intense 00:38:21.740 --> 00:38:25.577 optimism, and then the claims to be able to cure these vast 00:38:25.660 --> 00:38:27.600 numbers of patients were overblown. 00:38:28.660 --> 00:38:32.517 Uh, I do believe the early asylums actually did good work and that some 00:38:32.600 --> 00:38:38.040 patients did very well and recovered as a result of their stays. But what happened, 00:38:39.060 --> 00:38:42.560 they weren't discharging 80% of their patients. They were discharging 00:38:42.760 --> 00:38:48.680 35 or 40% of their patients, and what that meant is every year left behind 00:38:49.540 --> 00:38:53.497 were a batch of chronic patients, and then the next year you repeated it. And over 00:38:53.580 --> 00:38:57.337 time, what that means is the ratio of new 00:38:57.420 --> 00:39:01.090 patients to chronic patients gets worse and worse. 00:39:02.100 --> 00:39:05.717 And more and more the image of the asylum is defined by the 00:39:05.800 --> 00:39:09.397 chronic patient who hasn't recovered and maybe spends years or 00:39:09.480 --> 00:39:16.480 decades there and only leaves in a pine box. So the image of the asylum declined 00:39:18.340 --> 00:39:21.800 drastically. As they became more and more overcrowded, 00:39:21.900 --> 00:39:25.737 conditions in them deteriorated. Patients were often 00:39:25.820 --> 00:39:29.717 abused. Psychiatrists didn't know what to do with them, and they 00:39:29.800 --> 00:39:35.540 faced a problem in the late 19th century. You'd promised 70% or 80% cures, 00:39:36.380 --> 00:39:40.097 but we're not seeing that. In fact, when we calculate cures and the numbers of 00:39:40.180 --> 00:39:44.037 people in the asylum, it's more like 10% or 12%. That's 00:39:44.120 --> 00:39:48.017 the way you could play with statistics 'cause that's all the old patients 00:39:48.100 --> 00:39:55.100 mixed with the new. But still, it looks very bad. How do you explain this doctor? 00:39:56.220 --> 00:40:00.057 You've promised us one thing, and you delivered something quite different. The 00:40:00.140 --> 00:40:04.057 answer came in a way of blaming the victim, in a way 00:40:04.140 --> 00:40:06.980 of saying, "Well, you know, what we didn't understand 00:40:07.780 --> 00:40:11.480 was that mental illness is a fundamentally biological 00:40:11.580 --> 00:40:15.277 condition. These people are evolutionary 00:40:15.360 --> 00:40:18.877 throwbacks." Evolution was generally thought of as a 00:40:18.960 --> 00:40:22.897 progressive onwards and upwards, but these people had fallen back 00:40:22.980 --> 00:40:26.537 into a lesser form of 00:40:26.620 --> 00:40:31.286 existence. They'd lost their essential humanity because their brains were 00:40:31.369 --> 00:40:32.203 defective. 00:40:32.820 --> 00:40:38.140 So what emerged then was the idea of degeneration, the idea that 00:40:39.000 --> 00:40:42.477 these patients were degenerates. They were people with an inferior 00:40:42.560 --> 00:40:46.357 biology. You couldn't release them because they breed like rabbits. They didn't 00:40:46.440 --> 00:40:50.680 have any self-control because of their diminished humanity. 00:40:50.980 --> 00:40:52.500 - This is the narrative. 00:40:52.900 --> 00:40:56.777 - This is the narrative. And so what it did was provide a 00:40:56.860 --> 00:41:00.717 justification for locking up people in asylums that wasn't therapeutic 00:41:00.800 --> 00:41:02.877 at all. It was just keeping them out of the way. 00:41:02.960 --> 00:41:06.147 - And then it led to the justification of sterilization- - Exactly. 00:41:06.230 --> 00:41:07.127 -...based on the same argument. 00:41:07.210 --> 00:41:10.707 - So maybe we can release them if we make sure they can't breed. 00:41:10.790 --> 00:41:12.457 - This is the beginning of the darkness. 00:41:12.540 --> 00:41:16.397 - It is the beginning of the darkness. My own state was 00:41:16.480 --> 00:41:20.197 one of the pioneers in this process, and it 00:41:20.280 --> 00:41:24.020 continued to sterilize mental patients up until about 1960. 00:41:24.620 --> 00:41:31.620 - By the 1960s, over 60,000 sterilizations have been performed in the US with 00:41:32.380 --> 00:41:36.477 California performing a disproportionately high number. 00:41:36.560 --> 00:41:39.757 - That's correct. But even more serious 00:41:39.840 --> 00:41:43.790 consequences could flow from these set of issues. 00:41:44.420 --> 00:41:51.205 When you start talking, one British psychiatrist said that if his patients 00:41:51.289 --> 00:41:55.520 that were coming into the asylum had been puppies, 00:41:57.040 --> 00:42:00.937 we'd have tied them up in a sack because they were some horrible mongrel, not 00:42:01.020 --> 00:42:03.749 a purebred dog, tied them up in a sack with some lead weights, 00:42:03.833 --> 00:42:05.877 and thrown them in a pond and drowned them. 00:42:05.960 --> 00:42:06.793 - Man. 00:42:06.920 --> 00:42:10.440 - That kind of language is very, very dangerous. 00:42:11.160 --> 00:42:14.517 And what happened, California's law surrounding 00:42:14.600 --> 00:42:18.417 sterilization was advocated for in the West. By that I 00:42:18.500 --> 00:42:22.550 mean North America and Britain and much of Europe. 00:42:23.420 --> 00:42:27.337 There were enough checks and balances in a democratic system that even 00:42:27.420 --> 00:42:30.760 though there were enthusiasts, the eugenicists who said, 00:42:31.210 --> 00:42:34.360 "Best get rid of these people, put them to death," 00:42:35.100 --> 00:42:40.450 that never really, that never really acquired mass support. 00:42:41.290 --> 00:42:44.750 But what happened in Germany once Nazi-- the Nazis came to 00:42:44.850 --> 00:42:48.630 power is they seized on these notions and that the idea 00:42:48.730 --> 00:42:52.460 that the mentally ill were, as they put it, useless eaters, 00:42:52.550 --> 00:42:56.467 people consuming resources but never gonna get better, just a burden on 00:42:56.550 --> 00:43:00.387 the state. Their lives weren't worth living because after all, they had this 00:43:00.470 --> 00:43:03.687 serious mental illness. So first you 00:43:03.770 --> 00:43:07.487 sterilize, and then you go, "But we're still supporting all these 00:43:07.570 --> 00:43:11.330 people." And so Hitler starts something called the T4 program 00:43:11.430 --> 00:43:17.150 after the street name of the house where this was concocted, Tiergartenstraße 4. 00:43:18.330 --> 00:43:24.670 And the mentally ill were the first people to suffer from the Final Solution. 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 00:43:29.410 --> 00:43:34.270 quarter million people, that the technology of the gas chamber 00:43:34.354 --> 00:43:39.567 was developed, and the technology of disguising the 00:43:39.650 --> 00:43:46.500 gas chamber as showers was developed. And so patients were taken away 00:43:47.530 --> 00:43:51.327 to a number of psychiatric centers and systematically 00:43:51.410 --> 00:43:55.187 put to death, and they had the crematoriums and the black 00:43:55.270 --> 00:43:59.027 smoke, and local people talked about the buses that were bringing them in as 00:43:59.110 --> 00:44:02.450 killing crates. So they were aware of what was going on. 00:44:02.570 --> 00:44:05.707 - Were they influenced by the narratives that were born in the United States? 00:44:05.790 --> 00:44:07.707 - Yes, absolutely. They- - About this kind of- 00:44:07.790 --> 00:44:10.987 - About that sort of thing, and lacking the check, the checks and 00:44:11.070 --> 00:44:15.650 balances that at least until recently this country had, um, 00:44:16.510 --> 00:44:18.850 it was relatively easy for Hitler 00:44:19.690 --> 00:44:23.507 to do that. And particularly with the war looming, the idea 00:44:23.590 --> 00:44:27.387 that we're gonna support all these useless people, let's kill 00:44:27.470 --> 00:44:33.770 them. And German psychiatry for the most part collaborated with that process. 00:44:34.210 --> 00:44:38.930 - I wonder how many people throughout that whole journey in the psychiatry profession 00:44:39.870 --> 00:44:43.850 sort of were brave enough to speak up like, "Hey, maybe the 00:44:43.950 --> 00:44:46.677 sack of puppies kinda language-" - Oh, yes. Oh, yes. 00:44:46.760 --> 00:44:47.710 -... is a problem?" 00:44:48.310 --> 00:44:52.730 - That's the really nasty direction that that language could lead to. 00:44:53.690 --> 00:44:57.110 And it was symptomatic of the kind of 00:44:57.610 --> 00:45:01.227 stigma that tends to attach itself to mental illness and this 00:45:01.310 --> 00:45:05.140 sense of hopelessness. So but if you're a healing profession, 00:45:05.630 --> 00:45:09.090 if, if you enter psychiatry thinking, 00:45:09.610 --> 00:45:13.560 "I'm gonna do this to help people, to cure people, to make their lives better," 00:45:15.290 --> 00:45:19.940 to just become a glorified boarding housekeeper keeping them under lock 00:45:20.023 --> 00:45:20.857 and key 00:45:21.090 --> 00:45:24.750 or in the alternative to collaborate in this, in the sorts of 00:45:25.130 --> 00:45:28.247 awfulness that the Nazis perpetrated, that's 00:45:28.330 --> 00:45:32.127 something from which decent human beings 00:45:32.210 --> 00:45:37.590 tend to recoil and decent psychiatrists tended to recoil. And so 00:45:38.650 --> 00:45:41.847 still thinking as they did by the end of the 19th 00:45:41.930 --> 00:45:47.850 century that mental illness was predominantly a biological problem, 00:45:49.630 --> 00:45:53.487 some of them began to say, "Well, maybe biology as well as being the 00:45:53.570 --> 00:45:57.550 problem could provide the solution. Maybe we should look for 00:45:57.730 --> 00:46:02.567 ways to intervene in the biological systems of these people and make them 00:46:02.651 --> 00:46:03.484 better." 00:46:04.030 --> 00:46:08.647 The same logic that applies I would say in the present- 00:46:08.730 --> 00:46:10.567 ... for, for many working in the field. 00:46:10.650 --> 00:46:14.027 - But in a cruder form. - But in a very different form, exactly. 00:46:14.110 --> 00:46:17.967 - Yeah. If, if we can just speak about the Nazis a bit more, you 00:46:18.050 --> 00:46:21.787 highlight that America financially supported the German psychiatric 00:46:21.870 --> 00:46:25.747 researchers with deep Nazi ties like Ernst Rudin who was 00:46:25.830 --> 00:46:29.610 the key architect of Hitler's mass sterilization and extermination 00:46:29.710 --> 00:46:33.627 laws. So it seems like the Nazis borrowed 00:46:33.710 --> 00:46:37.007 the American narratives of the psychiatrist that these are lesser 00:46:37.090 --> 00:46:42.330 biological beings and then this financial support and the ties continued. 00:46:42.450 --> 00:46:46.227 - Yeah. So one of the organizations that 00:46:46.310 --> 00:46:50.854 recognized that mental illness was an acute social problem, 00:46:50.938 --> 00:46:52.820 very costly to the state 00:46:54.750 --> 00:46:59.530 inflicting all kinds of suffering on people was The Rockefeller Foundation. 00:47:00.510 --> 00:47:03.987 What we don't realize today is that the 00:47:04.070 --> 00:47:07.950 involvement of the federal government in medical research 00:47:08.090 --> 00:47:11.817 and indeed scientific research is a World War II 00:47:11.900 --> 00:47:15.787 and post-war development partly the Cold War and Sputnik and 00:47:15.870 --> 00:47:21.000 all of that. But that's when big science and big medicine got funded- 00:47:21.130 --> 00:47:24.250 ... in extravagant ways. Before the war, 00:47:25.170 --> 00:47:29.007 science was an orphan. It didn't get money from the government much and 00:47:29.090 --> 00:47:36.090 medicine even more so. So to the extent medical training was reformed, 00:47:36.995 --> 00:47:42.630 that was the product of investment by The Rockefeller Foundation enormously wealthy 00:47:42.830 --> 00:47:47.420 by the standards of the time. And come about 1930, 00:47:48.790 --> 00:47:52.607 The Rockefeller Foundation decided it needed 00:47:52.690 --> 00:47:59.250 to concentrate its resources and pick priorities for the money it was investing. 00:48:00.410 --> 00:48:03.790 And it may seem a rather strange thing within the 00:48:04.090 --> 00:48:07.590 whole range of medical areas that it could choose, 00:48:08.230 --> 00:48:12.107 it chose psychiatry as the one that it was going to invest in. And 00:48:12.190 --> 00:48:15.210 I think it did so in part for 00:48:16.590 --> 00:48:20.670 precisely because scientific research in psychiatry was so backward, 00:48:22.310 --> 00:48:26.647 partly because it was such a pressing public problem. 00:48:26.730 --> 00:48:30.527 And partly, and this was less public but nonetheless I 00:48:30.610 --> 00:48:34.447 think played an important role, several of the trustees of The 00:48:34.530 --> 00:48:38.187 Rockefeller Foundation had direct experience of mental 00:48:38.270 --> 00:48:41.167 illness in their families. Wives who'd been 00:48:41.250 --> 00:48:44.947 institutionalized as schizophrenic. In one case, a 00:48:45.030 --> 00:48:47.950 wife who murdered the children and killed herself 00:48:48.710 --> 00:48:52.110 leaving her husband as a major actor in The 00:48:52.310 --> 00:48:55.867 Rockefeller Foundation bereft and of course inclined 00:48:55.950 --> 00:49:01.920 then to support research in this area. And Rockefeller spread its money very widely, 00:49:02.760 --> 00:49:06.477 Precisely 'cause it didn't know where to spend most of 00:49:06.560 --> 00:49:10.080 its money. So it did some support of 00:49:10.300 --> 00:49:14.060 Psychotherapeutics. It supported a number of the then 00:49:14.160 --> 00:49:17.600 extant therapeutic experiments going on, 00:49:18.360 --> 00:49:22.257 and it supported work in genetics. And one of the geneticists it 00:49:22.340 --> 00:49:26.137 supported, Ernst Rüdin in Germany, who was the leading 00:49:26.220 --> 00:49:29.510 German researcher in genetics and mental disorder. 00:49:30.320 --> 00:49:34.120 And Rüdin, because he's absorbed the lessons from California 00:49:34.400 --> 00:49:38.240 about sterilization, became a very enthusiastic proponent of that, 00:49:38.980 --> 00:49:42.230 and then a supporter of murdering mental patients. 00:49:42.700 --> 00:49:46.239 - And we should say, I mean, we'll probably talk about the complicated nature 00:49:46.322 --> 00:49:50.347 of science- ...that it sometimes can be captured by certain ideologies and- 00:49:50.430 --> 00:49:54.150 ...in so doing do a lot of damage to humanity. But 00:49:54.360 --> 00:49:58.137 ultimately, the beacon of hope for the future of humanity lays in the 00:49:58.220 --> 00:50:02.150 scientific method, as flawed as it is. So everything we're talking about, 00:50:02.600 --> 00:50:07.500 we get to see how you F up- 00:50:09.740 --> 00:50:14.397 In a major dark disturbing ways throughout the 20th century- 00:50:14.480 --> 00:50:17.797 ...on the-- in the psychiatric profession. But that 00:50:17.880 --> 00:50:21.497 should be instructive lessons of how we proceed forward to do 00:50:21.580 --> 00:50:23.100 better and better and better. 00:50:24.120 --> 00:50:30.928 - We can discuss a series of therapeutic experiments on people who were shut up 00:50:31.011 --> 00:50:35.217 in a double sense. They were locked away, and their voices were not heeded 00:50:35.300 --> 00:50:39.117 because it was the product of their madness. And so what we see in 00:50:39.200 --> 00:50:42.697 the first five decades really of the 20th 00:50:42.780 --> 00:50:46.717 century is people with a variety of motivations 00:50:46.800 --> 00:50:50.100 including the desire to improve the lot of the mentally ill 00:50:50.580 --> 00:50:54.800 engaging in uncontrolled experiments that had terrible results. 00:50:55.680 --> 00:50:59.540 And the science behind it was shaky but nonetheless 00:50:59.800 --> 00:51:03.260 it existed. It wasn't just plucked out of the sky. 00:51:04.350 --> 00:51:08.257 And yes, it eventually those things break down. I mean, the clearest case 00:51:08.340 --> 00:51:12.157 of that because it's the most extreme of these at least in the 00:51:12.240 --> 00:51:15.780 public imagination is lobotomy. The 00:51:15.880 --> 00:51:19.800 idea that you are going to solve psychotic breakdowns in people 00:51:20.600 --> 00:51:23.940 by excising part of their brain 00:51:24.660 --> 00:51:28.380 initially by drilling holes in the skull and injecting alcohol 00:51:28.480 --> 00:51:32.097 or using what looks like a butter knife to break connections 00:51:32.180 --> 00:51:36.057 between the brain. And then later when that process 00:51:36.140 --> 00:51:40.010 seems to be too slow, the Henry Ford of lobotomy-- 00:51:40.320 --> 00:51:44.157 his daughter said Walter Freeman aspired to be the Henry Ford of lobotomy, the 00:51:44.240 --> 00:51:47.650 one who could mechanize the production of it and get it done 00:51:47.800 --> 00:51:51.377 fast. He invented the ice pick lobotomy where you 00:51:51.460 --> 00:51:54.850 used an ice pick in the orbit of the eye 00:51:55.660 --> 00:51:59.540 having rendered somebody unconscious after two or three electric shocks 00:52:00.460 --> 00:52:04.320 and you banged it through the bone and wiggled it about and 00:52:04.440 --> 00:52:08.460 severed -- I mean, it's just hard to even describe. 00:52:08.720 --> 00:52:12.340 - So this is from the 1930s to the 1970s? 00:52:12.680 --> 00:52:16.600 - Yes. Freeman starts his work in 1936 00:52:16.780 --> 00:52:20.757 borrowing from the work of the preceding year of Portuguese 00:52:20.840 --> 00:52:24.777 neurologist named Egas Moniz. And Moniz wins the Nobel 00:52:24.860 --> 00:52:28.240 Prize in medicine in 1949 for lobotomy. 00:52:28.780 --> 00:52:32.717 So it's important to see that. That was 14 years 00:52:32.800 --> 00:52:36.717 of experience and yet that won a Nobel Prize. I'm 00:52:36.800 --> 00:52:38.750 sure that's one they'd like to retract. 00:52:38.870 --> 00:52:42.520 - So he popularized Walter Freeman, the ice pick. 00:52:42.770 --> 00:52:46.197 - And his particular specialty after the war became this ice pick 00:52:46.280 --> 00:52:50.177 lobotomy because there were over half million patients in 00:52:50.260 --> 00:52:54.237 America's mental hospitals. Freeman was convinced this operation was 00:52:54.320 --> 00:53:00.490 a cure all. And so he traveled around in a camper truck 00:53:01.300 --> 00:53:04.357 which he called the Lobotomobile and he would descend in the 00:53:04.440 --> 00:53:09.965 summer on state hospitals and he would teach them how to do this ice pick 00:53:10.049 --> 00:53:14.440 lobotomy. - This is by the way an image of the tool. 00:53:15.300 --> 00:53:17.452 - Yes, those are the tools he used. Originally, 00:53:17.535 --> 00:53:20.240 he used an actual ice pick and then he developed this- 00:53:20.480 --> 00:53:23.197 - This is what he developed. This is the state-of-the-art technology. 00:53:23.280 --> 00:53:25.777 - This is the state of the art with a hammer or a mallet. 00:53:25.860 --> 00:53:32.400 - Oh no! - Yes, I'm sorry. It's very distressing. I, I don't know- 00:53:32.680 --> 00:53:36.057 - You having to write about this by the way-- - Well, it's really- - Is a lot 00:53:36.140 --> 00:53:39.477 -...very, very, very, very difficult. I came across, for 00:53:39.560 --> 00:53:43.237 example, picture of a woman, naked woman 00:53:43.320 --> 00:53:46.617 being dragged away by attendants to be lobotomized and she's 00:53:46.700 --> 00:53:53.277 resisting with all her might and to no avail. You have a picture there of 00:53:53.360 --> 00:53:57.680 Walter Freeman lobotomizing a patient in Washington State. 00:53:58.520 --> 00:54:03.363 Freeman was ambidextrous and when he taught neurology, 00:54:03.446 --> 00:54:05.937 he would draw simultaneously 00:54:06.020 --> 00:54:09.817 with his left and right hand and he could do it perfectly. 00:54:09.900 --> 00:54:13.737 When he was performing lobotomy, when his right hand got tired, he switched to 00:54:13.820 --> 00:54:19.140 his left hand and he sometimes would do 20 or 30 lobotomies in an afternoon. 00:54:20.080 --> 00:54:23.700 And he boasted, he said, "You know I could teach any damn 00:54:23.800 --> 00:54:27.340 fool to perform a lobotomy in twenty minutes even a psychiatrist." 00:54:27.840 --> 00:54:33.612 Because Freeman was a neurologist and he had a lot of contempt for psychiatrists. 00:54:33.695 --> 00:54:34.529 So 00:54:34.740 --> 00:54:40.520 So this was a very ugly episode. How did it die away? It really took 00:54:41.400 --> 00:54:47.737 generational change. Some of these lobotomists continued to operate into the 00:54:47.820 --> 00:54:49.790 sixties even to the early seventies, 00:54:50.700 --> 00:54:53.620 but the younger generation who became acquainted 00:54:53.760 --> 00:54:57.457 with the really worst failures of that 00:54:57.540 --> 00:55:02.180 regime; the people on the back wards who were incontinent, who were 00:55:03.340 --> 00:55:07.210 basically zombies had lost all mental power. 00:55:07.930 --> 00:55:11.090 They rebelled against this and by then they had 00:55:11.930 --> 00:55:15.640 a different treatment in the form of antipsychotic drugs- 00:55:16.070 --> 00:55:19.320 ... which looked much more like what regular medicine was doing, 00:55:20.310 --> 00:55:22.787 And didn't have these horrible overtones. And of 00:55:22.870 --> 00:55:29.870 course in the popular mind I think the, probably the most famous, 00:55:31.670 --> 00:55:37.907 instance of telling the public about some of these interventions was the 00:55:37.990 --> 00:55:41.230 film of Ken Kesey's novel One Flew Over the Cuckoo's Nest 00:55:41.890 --> 00:55:45.027 where you see Jack Nicholson giving I think the performance of a 00:55:45.110 --> 00:55:51.810 lifetime who is given ECT, electroconvulsive therapy, 00:55:52.670 --> 00:55:56.550 at--in a very dramatic rendition of what that was not, not really 00:55:57.770 --> 00:56:01.747 what was going on by, by the 1970s 00:56:01.830 --> 00:56:05.687 with ECT but nonetheless certainly what had been going on back in the 00:56:05.770 --> 00:56:10.810 past. And then finally when ECT doesn't smash him to bits 00:56:11.770 --> 00:56:15.607 they lobotomize him and, and the film ends obviously with him being 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. 00:56:22.210 --> 00:56:25.210 So that fixed in the public mind 00:56:26.230 --> 00:56:30.030 some of the images of these things. It is one of the things that gave 00:56:31.210 --> 00:56:35.150 Electroconvulsive therapy such a bad name. 00:56:35.470 --> 00:56:38.867 - So we will actually not to fast forward too quickly,- 00:56:38.950 --> 00:56:41.660 -... let's talk about uh, the full journey 00:56:42.470 --> 00:56:45.785 of everything we've been talking about. So we mentioned the asylum era that began 00:56:45.868 --> 00:56:50.338 in the mid nineteenth century going into twentieth and we talked about 00:56:50.422 --> 00:56:53.090 the narratives- - And we talked about sterilization 00:56:53.210 --> 00:56:58.610 - Sterilization. And let's look at the insulin shock therapy of uh, nineteen 00:56:58.730 --> 00:57:02.567 thirty three to the nineteen sixties where you were putting patients 00:57:02.650 --> 00:57:06.690 in deep hypoglycemic comas using large doses of insulin. 00:57:07.070 --> 00:57:10.847 - Yeah. So as I mentioned for psychiatrists who 00:57:10.930 --> 00:57:14.687 went into the field and were ambitious but who also wanted to 00:57:14.770 --> 00:57:18.437 think of themselves as therapeutic agents- 00:57:18.520 --> 00:57:22.430 ....uh, to just sit there passively and contain the patients 00:57:22.530 --> 00:57:28.230 was very unattractive. And so they looked around for ways in which perhaps 00:57:29.210 --> 00:57:31.670 biological interventions could be used 00:57:32.470 --> 00:57:37.050 to ameliorate this condition that they still saw in largely biological terms. 00:57:38.290 --> 00:57:45.290 Now in some ways one of the crucial early ways in which this thinking went 00:57:47.370 --> 00:57:51.350 and which affected a large number of patients was this: 00:57:52.030 --> 00:57:55.907 one of the few diagnostic triumphs of psychiatry in the early nineteenth 00:57:55.990 --> 00:57:58.370 century as the profession began to emerge 00:57:59.370 --> 00:58:03.267 Was that it began to distinguish a group of patients who were deemed 00:58:03.350 --> 00:58:07.010 to be suffering from something called general paralysis of the insane. 00:58:08.350 --> 00:58:13.880 That encapsulates two things about what was going on. First of all, 00:58:14.750 --> 00:58:18.870 paralysis; the gradual loss of motor control, 00:58:19.690 --> 00:58:24.810 ability to walk, ability to swallow, ability to, to talk. 00:58:26.710 --> 00:58:30.200 So those are primarily what we'd think of these days as neurological 00:58:30.590 --> 00:58:34.310 issues. But those were accompanied by bizarre 00:58:35.170 --> 00:58:38.807 psychiatric symptomatology. These were people who thought they were 00:58:38.890 --> 00:58:44.607 Napoleon or Jesus Christ or the richest and sexiest man in the world- 00:58:44.690 --> 00:58:48.627 ...or Mary the mother of God. They were primarily men 00:58:48.710 --> 00:58:50.460 but there were also female victims. 00:58:51.750 --> 00:58:55.330 At the turn of the twentieth century as many as twenty 00:58:55.450 --> 00:58:58.810 five percent of the people being admitted to asylums 00:58:59.330 --> 00:59:03.210 were suffering from General Paralysis of the Insane or GPI for short. 00:59:04.830 --> 00:59:08.407 There have been a lot of suspicions about this being connected somehow to 00:59:08.490 --> 00:59:13.310 sex and to moral dissolution and so forth 00:59:14.130 --> 00:59:19.607 but what evolved in the early twentieth century was the 00:59:19.690 --> 00:59:25.667 discovery of the actual origins of this 00:59:25.750 --> 00:59:29.327 disorder. So I've said psychiatry has been looking for the 00:59:29.410 --> 00:59:32.407 underlying pathology that lies behind mental 00:59:32.490 --> 00:59:36.890 diseases. This was one that at Rockefeller Institute 00:59:37.870 --> 00:59:44.870 they discovered that the organism that causes syphilis was residing in the brains 00:59:45.687 --> 00:59:49.527 of the people who were suffering from GPI. This was in 00:59:49.610 --> 00:59:53.310 fact tertiary stage of syphilis. Syphilis is a 00:59:53.570 --> 00:59:57.337 still a real public health problem. It was like AIDS in the late nineteenth 00:59:57.420 --> 00:59:58.770 century. It was everywhere. 00:59:59.850 --> 01:00:03.850 And when you first contract syphilis in the primary phase you have pain 01:00:05.050 --> 01:00:08.330 but then it goes underground and you think it's gone 01:00:09.390 --> 01:00:14.707 and it lurks the way chicken pox virus lurks and can 01:00:14.790 --> 01:00:20.742 surface years later right? It lurks, it lurks and it's insidiously damaging 01:00:20.826 --> 01:00:21.527 sometimes 01:00:21.610 --> 01:00:28.610 it attacks the heart and people drop dead of a heart attack in their forties ohh 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 01:00:35.170 --> 01:00:38.720 Or it attacks the central nervous system the spinal column in the brain 01:00:39.130 --> 01:00:42.447 and then you get the paralysis - Mm-hmm...and then you get also the 01:00:42.530 --> 01:00:49.157 psychiatric symptomatology. So when that was discovered that sort of suggested 01:00:49.240 --> 01:00:51.970 that mental illness might have an infectious origin. 01:00:52.830 --> 01:00:56.627 Tertiary syphilis GPI went on to win for 01:00:56.710 --> 01:01:00.630 somebody who developed a treatment for it a Nobel Prize one of only 01:01:00.770 --> 01:01:04.430 two awarded for psychiatric innovations. One was a lobotomy 01:01:04.930 --> 01:01:08.490 the other was giving people malaria to cure their syphilis. 01:01:08.650 --> 01:01:15.190 - In case people didn't hear that- Giving people malaria- 01:01:15.330 --> 01:01:17.880 .. In order to cure syphilis 01:01:18.200 --> 01:01:25.200 - So there was an Austrian doctor, Wagner Jauregg, who had long thought that 01:01:26.200 --> 01:01:29.977 fever could be used to cure mental illness. And he tried rat 01:01:30.060 --> 01:01:33.617 bite fever. He tried giving people typhoid vaccine that creates a 01:01:33.700 --> 01:01:37.480 fever to no avail. And towards the end of World War I, 01:01:38.040 --> 01:01:41.917 the Italians were fighting in World War I on the side of the 01:01:42.000 --> 01:01:44.050 British and the Americans and the French. 01:01:44.620 --> 01:01:48.040 They captured an Italian soldier who had malaria. 01:01:48.440 --> 01:01:51.260 Malaria was endemic in those years in Italy. 01:01:51.920 --> 01:01:55.357 And they brought him to him, and he extracted the malarial blood and 01:01:55.440 --> 01:01:59.300 injected it into a series of patients with GPI, with 01:01:59.430 --> 01:02:02.500 general paralysis of the insane, and claimed it cured them. 01:02:03.760 --> 01:02:07.360 We know from later on when he fessed up that 01:02:07.520 --> 01:02:11.277 those claims were wildly exaggerated, but they were widely 01:02:11.360 --> 01:02:14.600 accepted, and malarial treatment 01:02:14.720 --> 01:02:19.800 spread to Britain, it spread to Germany, it spread to the United States. 01:02:21.010 --> 01:02:26.327 Sometimes it was vials of malarial blood, but very often mental 01:02:26.410 --> 01:02:29.690 hospitals had actual colonies of malarial mosquitoes. 01:02:30.390 --> 01:02:33.590 So imagine you're a mental patient, and you're put in a straitjacket, 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, 01:02:38.400 --> 01:02:40.907 and they bite you, and then you develop malaria. 01:02:40.990 --> 01:02:42.737 - And he got a Nobel Prize for this? 01:02:42.820 --> 01:02:46.357 - Yes, in 1937, he got a Nobel Prize. 'Cause this was a 01:02:46.440 --> 01:02:53.440 condition that was invariably fatal. And the claim was that somehow 01:02:53.600 --> 01:02:57.330 the malarial fever worked. Now, there are two possible 01:02:57.420 --> 01:03:01.057 ways. Von Jauregg thought it stimulated the 01:03:01.140 --> 01:03:04.920 immune system to attack whatever it was, was causing the insanity. 01:03:05.310 --> 01:03:08.817 But the other possibility was the following: When 01:03:08.900 --> 01:03:12.420 you have the malarial parasite in a test 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 01:03:20.220 --> 01:03:23.557 potentially was you were sort of burning the parasites out of the brain with 01:03:23.640 --> 01:03:29.637 this agent. And because people were pretty unsophisticated about 01:03:29.720 --> 01:03:35.370 statistics and because the idea of a controlled trial had not yet come to pass, 01:03:36.320 --> 01:03:42.657 this treatment was used extensively for a couple of decades. What 01:03:42.740 --> 01:03:45.980 caused it to stop, and you talk about the progress of science, 01:03:46.960 --> 01:03:51.290 was the discovery of penicillin, which was a real magic bullet. 01:03:51.580 --> 01:03:55.457 So once you had penicillin, you weren't gonna continue treating people 01:03:55.540 --> 01:03:59.257 with malaria, so it died away. But it was the first 01:03:59.340 --> 01:04:03.177 such treatment, and here's the other way this feeds into the 01:04:03.260 --> 01:04:06.977 narrative of these desperate remedies that develop in this 01:04:07.060 --> 01:04:10.700 period between the mid-'teens and, say, 1950. 01:04:12.220 --> 01:04:17.340 The discovery of the syphilitic origins of general paralysis of the insane 01:04:18.300 --> 01:04:21.720 occurred at a time when medicine had undergone a 01:04:21.920 --> 01:04:25.697 undergone a profound transformation. In the late 19th 01:04:25.780 --> 01:04:30.280 century, the work of Louis Pasteur, who was a chemist, not an MD, 01:04:31.080 --> 01:04:35.850 and the work of Robert Koch in Germany had uncovered 01:04:36.680 --> 01:04:43.680 the origins of a variety of diseases and suggested that bacteria were the reason 01:04:44.796 --> 01:04:50.997 why people sickened. And that led, of course, to a whole series of public 01:04:51.080 --> 01:04:57.097 health triumphs, because initially it didn't lead to antibiotics. But for a lot 01:04:57.180 --> 01:05:04.180 of these diseases, even viral diseases like rabies, you could develop a vaccine. 01:05:05.200 --> 01:05:10.340 And the vaccines were phenomenally effective. And so 01:05:11.200 --> 01:05:16.100 that was one way in which the new germ theory of disease 01:05:16.320 --> 01:05:20.990 transformed medicine and tied it into the laboratory and into science in a new way. 01:05:22.140 --> 01:05:26.040 And the other was the adaptation of Pasteur's theories 01:05:26.230 --> 01:05:33.230 by a British surgeon named Lister, who previously when pus developed 01:05:33.840 --> 01:05:37.230 post-surgery, people had thought that was a good sign. 01:05:38.980 --> 01:05:42.520 Lister said, "No, I don't think so. This is actually these 01:05:42.640 --> 01:05:45.940 nasty germs causing this, and so we're gonna do 01:05:46.080 --> 01:05:49.937 antiseptic surgery." So he sprayed carbolic acid 01:05:50.020 --> 01:05:52.880 on the wounds to try to kill the microbes. 01:05:54.060 --> 01:05:57.937 Most of his colleagues thought he was nuts. Thought he was just-- This 01:05:58.020 --> 01:06:01.414 is ridiculous, these microorganisms. You couldn't even see them, you know? 01:06:01.497 --> 01:06:07.327 Well, you could with a... But Lister prevailed. And eventually we moved from 01:06:07.410 --> 01:06:11.297 antiseptic surgery to aseptic surgery, which is what we have now, 01:06:11.380 --> 01:06:15.017 where you try to have a sterilized set of 01:06:15.100 --> 01:06:18.990 instruments in a sterilized environment, so you don't infect things, right? 01:06:19.280 --> 01:06:23.617 - By the way, these are definitive examples of progress in medicine. 01:06:23.700 --> 01:06:25.717 - Absolutely. - Penicillin-- - Yes. 01:06:25.800 --> 01:06:30.147 -...uh, you know, making sure there's no germs in during surgery. 01:06:30.230 --> 01:06:30.817 - Associated with wounds, yes. 01:06:30.900 --> 01:06:34.820 - So these are all just refreshingly clear examples of progress. 01:06:35.240 --> 01:06:39.057 The reason I say it's refreshingly clear that there's progress, there's not a 01:06:39.140 --> 01:06:44.307 refreshingly clear progress in the history of psychiatry. Maybe, maybe a few hints. 01:06:44.390 --> 01:06:46.420 - Some bits, yes. There haven't been 01:06:47.460 --> 01:06:50.840 the dramatic breakthroughs that I think everybody in the field 01:06:51.460 --> 01:06:55.177 would hope for. And there's some debate about 01:06:55.260 --> 01:06:59.137 how powerful what we have done is, and I 01:06:59.220 --> 01:07:02.997 think it's reasonable to debate that and to also acknowledge 01:07:03.080 --> 01:07:10.080 that there is important progress, limited as it is. Now you have 25% of the admits 01:07:11.160 --> 01:07:14.840 to a mental hospital actually suffering from an infectious 01:07:14.960 --> 01:07:19.740 disease. Medicine in general has now tied its fortunes to the laboratory. 01:07:20.740 --> 01:07:26.640 The idea that disease is caused by bacteria, we can't yet see viruses. 01:07:28.260 --> 01:07:35.260 It is a very powerful one and that notion that disease is caused by bacterial 01:07:35.500 --> 01:07:39.280 infection acquires great momentum but it 01:07:39.380 --> 01:07:44.720 hasn't touched psychiatry so medicine now has interventions that work 01:07:46.100 --> 01:07:49.360 And sometimes quite dramatically 01:07:50.080 --> 01:07:53.880 um you know the first patient given diphtheria vaccine-- 01:07:54.000 --> 01:07:57.587 Diphtheria causes a leather like membrane to grow over your 01:07:57.670 --> 01:08:01.377 throat and you die choking to death And if you have a 01:08:01.460 --> 01:08:07.060 child and you watch that child die like that You will never be over it 01:08:08.200 --> 01:08:11.360 So when you had something that warded that off 01:08:13.180 --> 01:08:16.957 That improved medicine's image dramatically and 01:08:17.040 --> 01:08:20.990 improved its financial prospects dramatically particularly 01:08:21.200 --> 01:08:27.840 as medical training became reformed and more involved with science 01:08:30.260 --> 01:08:34.600 So that hasn't applied to psychiatry until 01:08:35.060 --> 01:08:38.677 syphilis comes along Now we have the model that an 01:08:38.760 --> 01:08:45.760 infectious agent can cause people's minds to go amok 01:08:46.480 --> 01:08:50.237 So The very person who invents the basic distinction 01:08:50.320 --> 01:08:56.960 between kinds of psychoses we still use today schizophrenia and bipolar disorder 01:08:57.960 --> 01:09:01.900 Emil Kraepelin begins to think "You know there may be something infectious 01:09:02.020 --> 01:09:04.170 about the mental illnesses we're treating." 01:09:05.060 --> 01:09:07.300 And one of the people he trains is a young 01:09:08.360 --> 01:09:12.297 psychiatrist from the United States named Henry Cotton Who's also 01:09:12.380 --> 01:09:16.227 been trained by Adolf Meyer who is the leading 01:09:16.310 --> 01:09:19.920 American psychiatrist of the first forty years of the twentieth century 01:09:21.280 --> 01:09:24.360 And when he comes back from Germany having spent a year there 01:09:25.020 --> 01:09:28.737 Meyer secures him a position as head of the New Jersey State Mental 01:09:28.820 --> 01:09:34.720 Hospital at Trenton and Cotton is an ambitious reforming man 01:09:35.260 --> 01:09:38.917 He wants to bring psychiatry back to medicine He also 01:09:39.000 --> 01:09:42.720 wants to chuck out all the old stuff He doesn't want 01:09:43.240 --> 01:09:47.210 chains in his hospital He doesn't want If he can help it straight jackets 01:09:47.600 --> 01:09:54.257 So that goes away But nothing seems to change fundamentally He still isn't 01:09:54.340 --> 01:09:58.097 curing patients And then he comes across this idea of 01:09:58.180 --> 01:10:01.617 focal sepsis The idea that low grade 01:10:01.700 --> 01:10:05.280 infections can lurk in the body and what they do is release 01:10:05.400 --> 01:10:08.720 toxins into the bloodstream and the lymph And hey 01:10:09.180 --> 01:10:13.827 imagine if those toxins get to the brain What's it going to do? 01:10:13.910 --> 01:10:17.700 It's gonna poison the brain and the brain is then gonna act up 01:10:19.080 --> 01:10:23.320 so We don't have antibiotics So what are we gonna do about this 01:10:24.480 --> 01:10:28.430 Well we can perhaps locate the bacterial infection 01:10:29.460 --> 01:10:33.713 and then we can Get rid of it We can engage in what he calls surgical 01:10:33.796 --> 01:10:34.629 bacteriology 01:10:35.760 --> 01:10:39.300 So the first obvious target here is teeth 01:10:40.460 --> 01:10:43.800 Your teeth look close to your brain They're often infected 01:10:44.400 --> 01:10:50.520 That infection often goes untreated for a time... So we pull a lot of teeth 01:10:52.200 --> 01:10:58.180 Patients don't get better Mm Maybe the theory's wrong No Um tonsils 01:10:58.860 --> 01:11:03.700 well they're getting infected so we'll remove them Still don't get better 01:11:05.140 --> 01:11:11.077 Well they're swallowing the bacteria so we remove stomachs and we move spleens 01:11:11.160 --> 01:11:15.057 and we remove colons And we claim to be curing eighty percent 01:11:15.140 --> 01:11:19.017 of our patients And rich patients come from all over America 01:11:19.100 --> 01:11:22.440 to be treated with this novel treatment - Crazy 01:11:22.740 --> 01:11:26.557 - Cotton gives A series of lectures at Princeton There were not 01:11:26.640 --> 01:11:30.120 some lectures which are given by Nobel Prize winners. There's a very 01:11:30.220 --> 01:11:31.260 prestigious series. 01:11:32.500 --> 01:11:36.377 Uh, it's published by Oxford University Press and Princeton University Press. 01:11:36.460 --> 01:11:40.980 The New York Times hails it as a great breakthrough. And in reality, 01:11:41.920 --> 01:11:46.080 45% of the people who get the abdominal surgery die within a year. 01:11:46.360 --> 01:11:47.757 - They're cutting out stomachs. 01:11:47.840 --> 01:11:51.412 - Yep. He's cutting out stomachs. He says--there's this passage in one of his 01:11:51.495 --> 01:11:55.557 papers where he says, "Stomachs are like cement mixers on a construction 01:11:55.640 --> 01:11:59.600 site and could be dispensed with." When you think, oh my God, 01:12:00.820 --> 01:12:04.557 if you were released from Trenton and you had no 01:12:04.640 --> 01:12:09.800 teeth, people immediately knew you were an ex-patient because the word had spread. 01:12:10.860 --> 01:12:17.697 And this goes on for--starting in 1916, Cotton drops dead of a 01:12:17.780 --> 01:12:24.647 heart attack in 1933, but he's succeeded by three people he's trained. They 01:12:24.730 --> 01:12:28.620 drop the abdominal surgery. They use colonic irrigation, but 01:12:29.020 --> 01:12:34.100 but the teeth and the tonsils keep being pulled. I interviewed the dentist 01:12:34.900 --> 01:12:38.717 who had come to the hospital in 1916 and must have pulled several 01:12:38.800 --> 01:12:40.080 hundred thousand teeth. 01:12:41.200 --> 01:12:45.400 In nine-- and he retired in 1960, which was when that finally stopped. 01:12:46.300 --> 01:12:51.700 And he was convinced Cotton should have won the Nobel Prize for this. Oh, well. 01:12:51.980 --> 01:12:55.420 - Can you just give some intuition, put ourselves in that 01:12:55.520 --> 01:12:59.160 mind space? I mean, presumably these are smart 01:12:59.300 --> 01:13:02.757 human beings. Why were they fraudulent in the reporting of how 01:13:02.840 --> 01:13:06.740 effective it is? Why are all the people that are participating, 01:13:07.480 --> 01:13:10.300 both the doctors and general culture-- 01:13:11.040 --> 01:13:13.400 - It's extraordinary. So obviously, 01:13:15.400 --> 01:13:19.317 many of the interventions I'm talking about are very powerful 01:13:19.400 --> 01:13:24.400 interventions conducted by people in white coats and stethoscopes and scalpels. 01:13:24.780 --> 01:13:28.617 - Powerful, by the way, by the amount of impact 01:13:28.700 --> 01:13:31.797 they have on the human body, not powerful in terms of how effective they are. 01:13:31.880 --> 01:13:35.240 - Yes, powerful as well in terms of placebo effect. 01:13:36.140 --> 01:13:40.077 Look, what I am going to do to you, and yes, it's gonna hurt 01:13:40.160 --> 01:13:43.260 and it's very intimate, but it's going to make you better. 01:13:44.390 --> 01:13:47.787 So that's always-- this is a problem that persists in 01:13:47.870 --> 01:13:50.350 contemporary psychiatry, trying to figure out 01:13:51.170 --> 01:13:53.170 how much of the improvement we're seeing 01:13:54.090 --> 01:13:58.007 is the placebo effect and how-- how much of it is the active effect of 01:13:58.090 --> 01:13:59.140 whatever we're doing. 01:13:59.550 --> 01:14:03.947 - But by the way, on that small tangent, let's return to that perhaps often. 01:14:04.030 --> 01:14:08.490 - Yes. - I for one can tell you that for me, for my mind, 01:14:10.030 --> 01:14:14.910 the placebo effect even when you tell me it's placebo will work. 01:14:15.130 --> 01:14:18.920 - Yes! - But now if you have combined an actual gigantic 01:14:19.030 --> 01:14:25.107 operation that is physically, mentally, in every way life changing - 01:14:25.190 --> 01:14:29.127 ... everybody around you in lab coats, all of society's telling 01:14:29.210 --> 01:14:32.810 you this is going to be life changing. I get it. That's like the most 01:14:32.990 --> 01:14:34.410 pure kind of placebo effect. 01:14:34.620 --> 01:14:39.167 - It's placebo effect that comes from both the patient who wants to be better- 01:14:39.250 --> 01:14:42.687 ... and wants to believe this is gonna make them, and from the person 01:14:42.770 --> 01:14:46.110 conducting. And it's easy to deceive yourself, 01:14:46.810 --> 01:14:52.370 to see what you want to see. So anyway, that was one episode. Um, 01:14:53.640 --> 01:14:57.007 we talk about triumphs of medicine so let me talk about one of 01:14:57.090 --> 01:15:01.750 the real triumphs of 20th century medicine 01:15:03.790 --> 01:15:08.470 which is interesting to refer to because it wasn't a cure, 01:15:09.910 --> 01:15:13.410 just like psychiatric drugs aren't a cure for mental illness. 01:15:14.090 --> 01:15:17.710 It was a symptomatic treatment but it transformed lives 01:15:18.350 --> 01:15:22.050 and that was discovery of insulin in the 1920s. 01:15:23.010 --> 01:15:26.550 Previously particularly what we now call type 01:15:26.670 --> 01:15:29.570 one or juvenile diabetes was a death sentence. 01:15:30.670 --> 01:15:34.307 You got it and whatever you did, you tried various quack 01:15:34.390 --> 01:15:38.227 remedies, you tried diet, you tried all sorts of things. The 01:15:38.310 --> 01:15:42.490 inevitable thing was it killed you. And then came insulin. 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 01:15:49.010 --> 01:15:52.790 you can live a relatively normal life and your lifespan is 01:15:52.910 --> 01:15:59.370 greatly expanded. So by any measure you have to say that's dramatic progress. 01:16:00.290 --> 01:16:04.787 But insulin is something our bodies produce we hope 01:16:04.870 --> 01:16:08.657 unless we're really seriously diabetic. Those of us with Type 01:16:08.740 --> 01:16:12.667 Two diabetes, our bodies resist insulin and we have 01:16:12.750 --> 01:16:16.650 to resort to other ways of trying to cope. But 01:16:16.750 --> 01:16:20.730 if you get too much insulin, it makes you unconscious 01:16:21.850 --> 01:16:27.330 and that's how another one of these desperate remedies came along. 01:16:28.710 --> 01:16:32.330 A man named Sakel working in a German clinic 01:16:32.870 --> 01:16:36.707 for drug addicts they were using putting 01:16:36.790 --> 01:16:40.307 people under mild comas to help them through the 01:16:40.390 --> 01:16:44.087 withdrawal symptoms once they got over their addiction. So he was 01:16:44.170 --> 01:16:47.767 familiar with that. And when he moved to Austria, he 01:16:47.850 --> 01:16:51.890 decided he'd try this as a treatment for schizophrenia. 01:16:52.870 --> 01:16:56.687 And so he put people into comas sometimes comas that would 01:16:56.770 --> 01:17:01.770 last hours days um they would be revived by giving them glucose 01:17:02.730 --> 01:17:06.467 usually intravenously sometimes not. Um 01:17:06.550 --> 01:17:10.207 during the time they were in comas they often seized had 01:17:10.290 --> 01:17:14.150 seizures. He saw that as a therapeutic sign. 01:17:14.250 --> 01:17:17.650 And he claimed that this Insulin Coma Treatment 01:17:18.630 --> 01:17:22.507 cured eighty percent of his -- eighty percent tends to come up again and again 01:17:22.590 --> 01:17:25.550 in these treatments as a sort of percentage that you cure. 01:17:26.690 --> 01:17:30.550 And he was invited to New York 01:17:31.130 --> 01:17:34.530 and demonstrated this at the Harlem Valley Mental Hospital. 01:17:35.290 --> 01:17:38.987 It spread. This is in the thirties? This was starting in 01:17:39.070 --> 01:17:42.830 nineteen thirty-three. The visit to America was I believe nineteen thirty- 01:17:43.070 --> 01:17:46.840 six and Sakel ended up settling here. He had a very 01:17:46.950 --> 01:17:50.787 lucrative private practice in New York and when he died he 01:17:50.870 --> 01:17:54.687 left his partner I think an estate of about two million dollars which 01:17:54.770 --> 01:17:58.607 in the early sixties was a very substantial amount 01:17:58.690 --> 01:18:02.327 of money that he'd earned from practice, right? So 01:18:02.410 --> 01:18:06.187 insulin coma therapy was widely adopted. What kept it 01:18:06.270 --> 01:18:10.167 from being a large scale thing was it required an enormous 01:18:10.250 --> 01:18:14.107 amount of nursing and medical attention 'cause people were literally 01:18:14.190 --> 01:18:17.807 hovering on the brink of life and death. They could go into a permanent 01:18:17.890 --> 01:18:21.150 coma, they could just die. Um, so they had 01:18:21.750 --> 01:18:25.527 vital signs had to be monitored. They had to be brought around very 01:18:25.610 --> 01:18:31.847 quickly if need be. And there's some evidence that the treatment killed 01:18:31.930 --> 01:18:35.387 brain cells. And when Sakel was told that, he said, "Yes, that's probably 01:18:35.470 --> 01:18:39.227 true. They're killing the schizophrenic brain cells." That's just 01:18:39.310 --> 01:18:41.727 nonsense, of course. That's just nonsense, but that's 01:18:41.810 --> 01:18:45.427 his rationale. Insulin comas weren't subjected to a 01:18:45.510 --> 01:18:48.407 randomized controlled trial until the nineteen 01:18:48.490 --> 01:18:52.187 fifties. And when they were subjected to a controlled 01:18:52.270 --> 01:18:56.147 trial, they failed it, and so it died out. 01:18:56.230 --> 01:19:00.037 And that's, I guess, scientific progress again in a way, but 01:19:00.120 --> 01:19:02.947 took a long time. One of the people who 01:19:03.030 --> 01:19:08.342 received insulin coma therapy—have you seen the film A Beautiful Mind? Mm-hmm, 01:19:08.426 --> 01:19:08.927 he did. 01:19:09.010 --> 01:19:13.300 Receive insulin coma therapy. Ironically, actually at Trenton State Hospital where 01:19:13.383 --> 01:19:15.337 Cotton had been, so John Nash received 01:19:15.420 --> 01:19:19.430 John Nash got insulin comas, and they were going to lobotomize him, 01:19:20.710 --> 01:19:25.707 and they didn't, but he was at risk of that. We should say 01:19:25.790 --> 01:19:29.230 that this treatment, patients would thrash, moan, 01:19:29.314 --> 01:19:34.839 and convulse before falling into a coma. The treatment required a course of up 01:19:34.922 --> 01:19:40.376 to sixty comas. It turned out to have a mortality rate of one to five percent 01:19:40.460 --> 01:19:44.259 and caused significant brain damage and obesity. Yeah, 01:19:44.343 --> 01:19:48.010 yet was hailed as a miracle cure for schizophrenia. 01:19:48.490 --> 01:19:52.850 Yes, that's right. Performed on John Nash, one of the great 01:19:53.390 --> 01:19:57.970 - minds of the 20th century. - Yes, and Nash clearly did become delusional, 01:19:58.970 --> 01:20:02.770 but that was one of the treatments he was subjected to, 01:20:03.130 --> 01:20:07.510 and well represented, actually, in the film of A Beautiful Mind. 01:20:08.470 --> 01:20:13.290 So I mentioned seizures. Also in Austria-Hungary in this period, 01:20:14.110 --> 01:20:20.567 another psychiatrist decided that you couldn't be both 01:20:20.650 --> 01:20:27.150 schizophrenic and epileptic. That there was somehow an antagonism between the two. 01:20:28.170 --> 01:20:31.147 So if you had epilepsy, you didn't have schizophrenia. If you had 01:20:31.230 --> 01:20:33.450 schizophrenia, you couldn't have epilepsy. 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. 01:20:39.550 --> 01:20:43.487 So then, the logical next step was, "Well, if we could create 01:20:43.570 --> 01:20:48.510 an artificial epileptic seizure, maybe we would drive out the schizophrenia." 01:20:50.430 --> 01:20:53.950 So, what to do? He first tries injecting 01:20:54.070 --> 01:20:57.727 camphor, a natural substance. Natural substances aren't necessarily 01:20:57.810 --> 01:21:01.687 benign substances. That caused abscesses, and it 01:21:01.770 --> 01:21:05.547 wasn't very effective. He sought an alternative, and he settled 01:21:05.630 --> 01:21:09.450 on something that was, um, called Cardiazol 01:21:11.150 --> 01:21:14.350 or Metrazol, depended which side of the Atlantic you were on. 01:21:15.390 --> 01:21:19.007 And injecting that into a patient usually caused a 01:21:19.090 --> 01:21:22.767 seizure, a big seizure like a grand mal seizure, where 01:21:22.850 --> 01:21:27.110 your body arcs back, your legs contract dramatically. 01:21:27.230 --> 01:21:30.510 - You can fracture spines and hips and bones. 01:21:30.950 --> 01:21:34.887 - And you ended up, yes, with fractures of vertebrae, fractures 01:21:34.970 --> 01:21:38.767 of the hip socket. Because when muscles in the 01:21:38.850 --> 01:21:42.627 thigh contract that badly, what happens? The thigh bone 01:21:42.710 --> 01:21:46.530 is driven into the socket at such a rate that it fractures, 01:21:46.910 --> 01:21:50.727 right? So these were among the complications that Metrazol 01:21:50.810 --> 01:21:54.730 produced. More than that, he himself conceded 01:21:55.530 --> 01:21:59.260 that between the injection and the seizure, the 01:21:59.390 --> 01:22:03.990 patient felt as though he were on-- or she was on the brink of death. 01:22:04.790 --> 01:22:07.960 Now imagine, pretend you're a mental patient. 01:22:08.043 --> 01:22:10.787 You're brought in in a straitjacket, a 01:22:10.870 --> 01:22:14.850 man in a white coat with a big hypodermic injects something into you, 01:22:16.330 --> 01:22:18.130 You feel as though you're gonna die. 01:22:18.810 --> 01:22:22.687 And maybe that lingers for two, three, ten minutes, and then 01:22:22.770 --> 01:22:26.350 you seize, with those possible fractures following. 01:22:27.090 --> 01:22:28.007 - Violent seizures. 01:22:28.090 --> 01:22:34.290 - It's violent and hard to witness and is very unpredictable. 01:22:35.170 --> 01:22:39.047 So it's used, but people are not very happy, and that's 01:22:39.130 --> 01:22:45.373 how we get electroconvulsive therapy, electroshock, as it's first called. 01:22:45.457 --> 01:22:46.410 Two Italian 01:22:46.930 --> 01:22:50.480 psychiatrists, Cerletti and Bini, experiment with electricity, and they 01:22:50.650 --> 01:22:52.250 first experiment on dogs. 01:22:53.330 --> 01:22:56.644 And they make a mistake initially. They have an electrode on the head, 01:22:56.728 --> 01:22:57.267 an electrode 01:22:57.350 --> 01:23:01.227 on the anus. The electric current passes through the body, it stops the heart, the 01:23:01.310 --> 01:23:02.143 dogs die. 01:23:03.410 --> 01:23:06.500 So that seems a dead end. And then somebody says to them, "You know, 01:23:06.583 --> 01:23:07.267 you should go to 01:23:07.350 --> 01:23:11.067 the Rome slaughterhouse and see the pigs being slaughtered, 'cause you'll learn 01:23:11.150 --> 01:23:14.947 something very interesting." So they go, and the pigs are dangling by their 01:23:15.030 --> 01:23:20.770 hind legs, and as they come by, two electrodes cross their head. 01:23:21.490 --> 01:23:25.127 Electroshock, they convulse, they're unconscious, their 01:23:25.210 --> 01:23:32.210 throats are slit and pork arrives. So, um, they try that on dogs, and current passing 01:23:35.330 --> 01:23:37.880 through the brain, it turns out, doesn't kill them. 01:23:38.170 --> 01:23:41.567 So they decide to try it out. They pick up a transient 01:23:41.650 --> 01:23:46.590 homeless person at the Rome train station and they bring him in. 01:23:48.250 --> 01:23:52.087 And they try it, and at first they don't use enough current. 01:23:52.170 --> 01:23:56.007 And nothing very much happens. And they're very white- 01:23:56.090 --> 01:23:59.244 faced, they're quite worried off in the corner. We have descriptions of this, 01:23:59.328 --> 01:23:59.747 and they're 01:23:59.830 --> 01:24:03.587 talking, "What should we do?" "Well, we'll up the current." And the patient 01:24:03.670 --> 01:24:08.729 hears that and says, "No, another one, that's deadly." They do it anyway, 01:24:08.812 --> 01:24:10.010 and he convulses. 01:24:10.710 --> 01:24:14.107 Another grand mal seizure, with the same problems of spinal fractures 01:24:14.190 --> 01:24:19.930 and hip fractures and so on. Not universally, obviously, but often enough. 01:24:21.030 --> 01:24:25.270 And he stops breathing. You can imagine the scene. 01:24:27.230 --> 01:24:31.110 And then he spontaneously starts breathing again, and when he comes around, 01:24:32.190 --> 01:24:36.127 he's in contact with reality. They got this miracle cure, 01:24:36.210 --> 01:24:39.110 and it's very easy to administer, cheap, 01:24:40.430 --> 01:24:46.830 doesn't involve injecting things into people's bodies. So that quickly spreads 01:24:47.930 --> 01:24:50.940 across the Atlantic and other parts of Europe. 01:24:52.050 --> 01:24:57.840 And ECT becomes a very widely used intervention. 01:24:59.210 --> 01:25:00.960 Couple of things to say about this. 01:25:02.050 --> 01:25:05.890 It turns out it's not very useful for schizophrenia. 01:25:07.390 --> 01:25:10.907 Remember the connection between seizures and 01:25:10.990 --> 01:25:14.710 seizure and schizophrenia that was originally posited 01:25:15.290 --> 01:25:18.470 posited, but it seems to work in cases of, um, 01:25:18.810 --> 01:25:21.650 depression, suicidal depression particularly. 01:25:22.010 --> 01:25:25.540 - Fast forwarding to the modern day. Mm-hmm. And this is something I 01:25:26.790 --> 01:25:31.840 learned by reading a bunch recently. It seems to be one of the 01:25:32.970 --> 01:25:36.807 few evidence-based, like scientifically backed methods that actually 01:25:36.890 --> 01:25:39.840 worked for clinical depression, for serious depression. 01:25:40.030 --> 01:25:43.827 - Um, yes, if we fast forward, we're looking at in some 01:25:43.910 --> 01:25:47.227 respects a different animal for reasons I'll explain. Okay. 01:25:47.310 --> 01:25:48.700 - This is unmodified ECT. 01:25:49.170 --> 01:25:53.630 - Yeah, so we're talking about unmodified ECT, which rules the roost 01:25:54.930 --> 01:25:58.207 really well into the 1950s, and some places even into the 01:25:58.290 --> 01:26:02.050 1960s. And so it is associated with all the problems of 01:26:02.170 --> 01:26:05.887 fractures that we've talked about. It's also associated with memory 01:26:05.970 --> 01:26:09.727 problems. People often lose memory. There's some 01:26:09.810 --> 01:26:13.727 dispute about how serious that is, but it's pretty widely recognized 01:26:13.810 --> 01:26:17.010 that's one of the prices you're going to pay for that treatment. 01:26:17.330 --> 01:26:22.110 The thing is, for mental hospitals in the '40s and '50s, 01:26:23.110 --> 01:26:26.230 ECT was much more used as a 01:26:26.930 --> 01:26:30.347 device to control people's behavior, than as a therapeutic 01:26:30.430 --> 01:26:37.430 intervention. It was quite punitive, seen as such. Patients didn't want to repeat, 01:26:39.030 --> 01:26:43.870 and so they--...sort of controlled themselves a bit. But yes, 01:26:44.750 --> 01:26:51.750 we don't know why it, quote, "works," but more recent work starting in 01:26:52.810 --> 01:26:56.462 probably the 1990s -- and I'm going to get in trouble with some people for saying 01:26:56.546 --> 01:26:59.790 this because you mentioned patients and 01:27:00.150 --> 01:27:05.330 psychiatrists who swear by ECT. There are others who swear at it. 01:27:05.690 --> 01:27:09.507 Um, partly because of the memory problems I alluded 01:27:09.590 --> 01:27:13.190 to, and partly because of claims that it may cause 01:27:13.630 --> 01:27:17.570 brain damage. Passing an electric current through the brain is possible. 01:27:18.270 --> 01:27:25.250 What changed ECT a bit, quite a bit actually, was giving muscle relaxants 01:27:26.270 --> 01:27:30.207 so that people didn't thrash about, and the fractures were largely a thing of 01:27:30.290 --> 01:27:35.130 the past. When you introduce these muscle relaxers, originally they used curare, 01:27:36.110 --> 01:27:39.727 but then they used other, more modern drugs 01:27:39.810 --> 01:27:43.570 to paralyze the muscles temporarily. The problem is, that would also 01:27:43.710 --> 01:27:47.010 paralyze your breathing muscles, so that's not too good. 01:27:47.910 --> 01:27:51.307 So it became a more complicated procedure because you needed 01:27:51.390 --> 01:27:55.367 anesthesiologists, breathing support, and so forth 01:27:55.450 --> 01:27:59.147 during the procedure. But you did eliminate the 01:27:59.230 --> 01:28:02.687 fractures. It still was a very widely 01:28:02.770 --> 01:28:06.387 disdained practice, I think, particularly when they had drugs 01:28:06.470 --> 01:28:10.367 available. The thinking was that, well, we'd sooner use those, but 01:28:10.450 --> 01:28:14.047 the drugs turn out to be only partially effective, 01:28:14.130 --> 01:28:17.787 and pretty ineffective very often for suicidal cases or in 01:28:17.870 --> 01:28:21.607 cases of extreme melancholia. Now, a couple of 01:28:21.690 --> 01:28:25.167 things to say: Very often, ECT has to be repeated at 01:28:25.250 --> 01:28:28.310 intervals, as a kind of maintenance therapy. 01:28:28.490 --> 01:28:32.127 So it hasn't cured things, but it temporarily 01:28:32.210 --> 01:28:36.060 alleviates the symptoms, and the temporary may be fairly lengthy, but 01:28:36.150 --> 01:28:42.070 nonetheless, very often things will recur. The memory problems can be quite severe. 01:28:43.190 --> 01:28:46.820 The worries about brain damage are, I think, 01:28:47.970 --> 01:28:51.830 certainly things we have to be very cautious about. 01:28:52.650 --> 01:28:55.880 And when we talk about treatment-resistant depression, 01:28:56.850 --> 01:29:00.547 that's an interesting concept to me. What it means is those are the 01:29:00.630 --> 01:29:02.840 patients who don't respond to drugs. 01:29:03.670 --> 01:29:07.587 They may not have a different disease, but the drugs 01:29:07.670 --> 01:29:10.290 don't work for them, hence treatment resistant. 01:29:11.090 --> 01:29:18.090 And the numbers of psychiatrists who are willing to give ECT are rather small, 01:29:19.470 --> 01:29:23.130 and in many states it's hedged around with 01:29:23.270 --> 01:29:27.550 lots of legal restrictions. In California, for example, um, 01:29:28.350 --> 01:29:31.550 ECT now almost can't be given to 01:29:31.670 --> 01:29:38.220 involuntarily confined patients 'cause you have to, you have to volunteer for it. 01:29:38.690 --> 01:29:42.627 So as-- so it's unusual in that most medical procedures 01:29:42.710 --> 01:29:46.467 aren't hedged about by legal constraints like that. And 01:29:46.550 --> 01:29:50.370 there clearly is a very powerful group of people, 01:29:50.910 --> 01:29:54.110 some of them psychiatrists, many of them ex-patients, 01:29:55.190 --> 01:29:59.127 many of them other people who just are suspicious of modern medicine and 01:29:59.210 --> 01:30:06.087 science, who form a group who are very powerfully opposed to ECT. So 01:30:06.170 --> 01:30:12.150 although it's fair to say there are, Trials now that 01:30:13.030 --> 01:30:16.347 seem to provide decent evidence that for some patients 01:30:16.430 --> 01:30:19.907 this works and that those patients are deeply 01:30:19.990 --> 01:30:23.877 distressed before the treatment it's also still 01:30:23.960 --> 01:30:26.607 a controversial treatment, I think it's fair to say. 01:30:26.690 --> 01:30:32.258 - Like basically every single topic, treatment, 01:30:32.341 --> 01:30:36.790 problem subfield of psychiatry today. 01:30:36.910 --> 01:30:41.107 - Yes, yes. - For everything, everything we say today, there will be at least 01:30:41.190 --> 01:30:43.867 one person upset-...and writing a letter. 01:30:43.950 --> 01:30:48.550 - I think lots of people upset. So if we talk about drugs, 01:30:49.770 --> 01:30:52.270 there'll be two kinds of people who will be upset, 01:30:53.490 --> 01:30:57.350 those who think the drugs are more powerful than they 01:30:57.470 --> 01:31:00.997 are or who have been successfully treated by the 01:31:01.080 --> 01:31:04.710 drugs and go, "Well, it worked for me, so, you know, 01:31:05.070 --> 01:31:09.047 stop criticizing it 'cause it really is an effective treatment." And then 01:31:09.130 --> 01:31:12.810 on the other side of the coin, there are those who 01:31:13.450 --> 01:31:17.107 either the drug treatment has been used and it's failed, or they're being 01:31:17.190 --> 01:31:20.130 left with terrible side effects that don't go away, 01:31:21.130 --> 01:31:24.467 or they're part of a general group of people that 01:31:24.550 --> 01:31:31.130 unfortunately is of a growing number these days who are so suspicious 01:31:31.530 --> 01:31:34.670 of medical science and of the drug companies 01:31:35.510 --> 01:31:41.010 that no amount of evidence will sway them. They are convinced that 01:31:43.070 --> 01:31:46.570 you know, the drug treatments are poisonous. 01:31:47.150 --> 01:31:53.930 The Scientologists being a very extreme example of that, who they have a whole 01:31:54.890 --> 01:32:00.690 museum in Los Angeles and the title is Psychiatry Industry of Death. 01:32:01.690 --> 01:32:05.527 And then if you think about all the resistance, for example, that 01:32:05.610 --> 01:32:09.047 has surfaced to vaccination in 01:32:09.130 --> 01:32:12.667 contemporary US and how the trust in vaccination has been 01:32:12.750 --> 01:32:16.110 destroyed for a substantial number of people, 01:32:16.870 --> 01:32:21.030 it's very difficult to convince them that they're mistaken. 01:32:21.130 --> 01:32:24.947 - And not just the trust in vaccination consequence of that is 01:32:25.030 --> 01:32:27.907 a general distrust in science- - A general distrust, exactly. 01:32:27.990 --> 01:32:29.990 -... and distrust in medicine and so on. 01:32:30.150 --> 01:32:37.150 - That's one of my great worries about our contemporary situation, that we're 01:32:37.370 --> 01:32:39.020 only-- we're less than a year in. 01:32:40.050 --> 01:32:43.547 After four years of this, first of all, the degree of 01:32:43.630 --> 01:32:47.567 mistrust will have grown exponentially, and once trust is lost, it's 01:32:47.650 --> 01:32:53.447 very hard to recover. Secondly, the science itself is being 01:32:53.530 --> 01:32:58.827 destroyed. Clinical trials that were midway through were 01:32:58.910 --> 01:33:02.827 aborted, so that knowledge has been lost. You would have 01:33:02.910 --> 01:33:09.850 to start from square one, and that's years of work. Scientists aren't being trained 01:33:11.170 --> 01:33:15.030 because funding has been cut. Scientists 01:33:15.250 --> 01:33:20.070 with successful careers no longer have the funding necessary to do their work, 01:33:21.050 --> 01:33:26.050 and it takes at least six or seven years to train 01:33:27.130 --> 01:33:29.590 a scientist at the beginning of their career. 01:33:30.590 --> 01:33:33.970 And so if you have four years with nobody being trained, 01:33:34.470 --> 01:33:41.327 you're talking about a decade being lost, and what's lost is invisible-- 01:33:41.410 --> 01:33:45.347 ...because it's counterfactuals. We don't know what that science 01:33:45.430 --> 01:33:49.147 will lead to or what that medical treatment might 01:33:49.230 --> 01:33:53.087 lead to, and very many times they fail. That's 01:33:53.170 --> 01:33:57.010 the nature of science. It's the nature of 01:33:57.110 --> 01:34:00.887 medicine and medical research that not every bright 01:34:00.970 --> 01:34:04.830 idea we have is going to eventuate in a breakthrough. 01:34:05.050 --> 01:34:08.930 It would be really simple and wonderful if that opposite were the case. 01:34:09.570 --> 01:34:13.407 But the reality is we have to go down lots of blind alleys, we 01:34:13.490 --> 01:34:16.710 have to try lots of different things, and we have to take 01:34:17.070 --> 01:34:23.403 years to move from the laboratory to practical application. 01:34:23.486 --> 01:34:25.770 And when we eliminate 01:34:26.090 --> 01:34:33.090 a whole segment of that, and when on top of that we diminish people's trust-- 01:34:35.610 --> 01:34:40.850 ...in science, that's a really, I think, a profoundly 01:34:42.230 --> 01:34:45.827 devastating thing that probably given my advanced 01:34:45.910 --> 01:34:49.450 age, I won't live to see the consequences of, but 01:34:49.590 --> 01:34:53.510 my children and grandchildren will. It really 01:34:53.630 --> 01:34:59.610 is something cultural that you've got to build up trust. 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 01:35:03.850 --> 01:35:10.347 very first question you asked me about, is psychiatry in crisis? Well, genetics was 01:35:10.430 --> 01:35:14.150 supposed to provide a clear picture of the origins 01:35:14.250 --> 01:35:17.807 of various mental diseases 'cause they do seem to run in 01:35:17.890 --> 01:35:21.607 families. So the expectation was once we decoded the 01:35:21.690 --> 01:35:25.067 human genome and we could examine bits and pieces of it, that we would very 01:35:25.150 --> 01:35:28.887 quickly find a Mendelian gene or set of 01:35:28.970 --> 01:35:32.350 genes for schizophrenia, let us say. Hasn't happened. 01:35:33.410 --> 01:35:37.367 We now use genome-wide association studies, that is throwing 01:35:37.450 --> 01:35:40.730 everything in the kitchen soup into, into the picture, and then 01:35:41.250 --> 01:35:44.730 without any preconditions and seeing what relates to what. And if we 01:35:44.870 --> 01:35:48.747 use three hundred small variations in 01:35:48.830 --> 01:35:52.690 the genome, we can account for about ten percent of schizophrenia. 01:35:53.650 --> 01:36:00.310 That's not very powerful. Beyond that, what psychiatric genetics has 01:36:00.950 --> 01:36:04.830 tended to throw up is something that undermines the 01:36:04.930 --> 01:36:09.670 distinctions that we've made based on symptomatology. So if you look, 01:36:10.810 --> 01:36:14.130 there is a great deal of overlap in the kinds of genetic 01:36:14.290 --> 01:36:17.947 abnormalities that heighten the susceptibility 01:36:18.030 --> 01:36:23.610 to bipolar disorder or schizophrenia or autism. There's a lot of overlap there. 01:36:24.410 --> 01:36:28.370 What that suggests is these aren't distinctive entities in the way 01:36:28.570 --> 01:36:32.730 that, you know... Schizophrenia, as my friend Robin Murray, 01:36:33.550 --> 01:36:36.827 a British psychiatrist, has to say, "It really seems to be the 01:36:36.910 --> 01:36:40.827 extreme end of psychosis, the most serious." But it's sort 01:36:40.910 --> 01:36:47.007 of on a continuum, you know. And so if psychiatry has to say in ten years, 01:36:47.090 --> 01:36:49.680 as some leading psychiatrists are speculating, 01:36:50.480 --> 01:36:54.147 that there's no such thing as schizophrenia, there's no such thing as 01:36:54.230 --> 01:36:57.907 bipolar disorder, that will tend, I 01:36:57.990 --> 01:37:02.187 suspect, to have pretty bad effects on people's trust- 01:37:02.270 --> 01:37:06.070 ...in psychiatry, and yet that's where the science may lead them. 01:37:06.850 --> 01:37:13.850 So it's a complicated picture, but this issue of, of trust and its absence 01:37:15.150 --> 01:37:20.907 and is, is vital, I think, in looking at not just what 01:37:20.990 --> 01:37:24.380 we're talking about today, but across a whole spectrum of things, 01:37:25.050 --> 01:37:31.690 even outside the medical realm altogether. If you lose trust in institutions, 01:37:32.310 --> 01:37:36.270 trust in science, trust in history. So 01:37:36.430 --> 01:37:40.087 I think more humility and less arrogance, more 01:37:40.170 --> 01:37:47.170 willingness to confess the limits of what we can do, more awareness of the dangers 01:37:48.050 --> 01:37:55.050 of enthusiasm, more skepticism when we're told something is a breakthrough. 01:37:59.190 --> 01:38:05.990 One of the things I worry about is the tendency of science journalism and medical 01:38:06.090 --> 01:38:10.440 journalism to hype things and then 01:38:11.250 --> 01:38:15.790 When the hype turns out to be just that, that undermines trust. 01:38:16.750 --> 01:38:20.850 You know? So be cautious when things come along-... don't be 01:38:21.750 --> 01:38:28.290 so sure that it represents a breakthrough. I'm very worried at the moment. I see, 01:38:29.170 --> 01:38:35.160 Ketamine and psychedelics being propounded as a miracle cure for depression, 01:38:36.010 --> 01:38:39.827 and the evidence for that is enormously weak is the best 01:38:39.910 --> 01:38:43.590 way to put it. And I've seen this movie before too many 01:38:43.710 --> 01:38:49.990 times. You know? I mentioned that 80% cure for Cotton's work, 80% cure 01:38:51.130 --> 01:38:55.570 for insulin coma therapy, 80% cure for the early asylums. 01:38:56.840 --> 01:39:00.260 This is overblown rhetoric, and the reality is 01:39:00.350 --> 01:39:03.720 usually progress comes in small steps. 01:39:03.920 --> 01:39:07.830 Sometimes it comes in big steps. Penicillin, I think 01:39:08.630 --> 01:39:12.990 was a huge step. Uh, I was lucky enough to grow up 01:39:13.950 --> 01:39:17.667 in the era when penicillin and other antibiotics 01:39:17.750 --> 01:39:21.647 became widely available. They hadn't been overused by then. 01:39:21.730 --> 01:39:25.587 And so if I had a strep throat, I had something that got rid of 01:39:25.670 --> 01:39:29.547 it right away. I didn't run the risk of heart valve damage, which 01:39:29.630 --> 01:39:33.490 in previous times would've been the case. So you know, 01:39:33.670 --> 01:39:36.930 once in a while you do have these dramatic shifts, 01:39:37.770 --> 01:39:41.607 and maybe AI will help us in that regard, but 01:39:41.690 --> 01:39:45.870 maybe it won't. It's another potential double-edged sword. 01:39:46.410 --> 01:39:50.107 - I should mention that psychedelics, psilocybin in 01:39:50.190 --> 01:39:52.263 particular, has been demonized for a long time. 01:39:52.346 --> 01:39:54.087 And so there's studies now out of John 01:39:54.170 --> 01:39:59.030 Johns Hopkins-... that are doing serious studies on cases 01:39:59.210 --> 01:40:02.767 where it is effective. I think it's nice to give a 01:40:02.850 --> 01:40:08.547 chance to the different treatments with the rigor of science, but with caution - 01:40:08.630 --> 01:40:12.090 ... and basically ignoring like you're saying, science journalists 01:40:12.570 --> 01:40:16.097 who are basically hyping every new thing 'cause they have to get clicks and all- 01:40:16.180 --> 01:40:17.530 ... this kind of stuff and- 01:40:17.710 --> 01:40:21.727 ... Look at the actual science in the modern day. So the- 01:40:21.810 --> 01:40:25.487 ... in the past, the rigor was not there. In the modern day, there's more. 01:40:25.570 --> 01:40:30.237 - Yes. We can add beyond the realm of science journalists. 01:40:30.320 --> 01:40:32.450 I think Science and Nature 01:40:33.430 --> 01:40:37.347 make choices about what they're gonna foreground, and they too 01:40:37.430 --> 01:40:42.030 have this tendency to look for things that make a big splash. 01:40:42.370 --> 01:40:44.877 - Oh, you mean the, the editors and the-... the major journals. 01:40:44.960 --> 01:40:48.847 - I think the editors, the major journals, that's what they're looking for. As, 01:40:48.930 --> 01:40:49.763 you know, I mean 01:40:50.990 --> 01:40:55.040 negative findings are very important in science. They're, they're the things that 01:40:55.230 --> 01:40:58.967 help us avoid mistakes, but they're not the 01:40:59.050 --> 01:41:01.587 things that are going to get you published in the journal. 01:41:01.670 --> 01:41:05.727 - Right. So it's not just the surface level science journalism. 01:41:05.810 --> 01:41:09.800 It is also the extra journals and the conferences and the publication process. 01:41:10.410 --> 01:41:13.470 - Having lots of scientists working on 01:41:14.350 --> 01:41:17.910 these problems in different sites and different places 01:41:19.490 --> 01:41:22.707 turns out to be very important, I think, as a check on 01:41:22.790 --> 01:41:28.190 enthusiasm, as a check on premature claims that turn out to be unfounded. 01:41:29.210 --> 01:41:33.127 And also because you're often partially right but you're not 01:41:33.210 --> 01:41:37.440 fully right and someone else following the same idea- 01:41:37.530 --> 01:41:42.510 ... is, is perhaps gonna be a little closer to the truth than you were. And so 01:41:43.130 --> 01:41:46.880 it's, it's very helpful to have multi-centered things and not 01:41:47.230 --> 01:41:50.730 everything under one all-knowing-... uh, 01:41:51.050 --> 01:41:54.667 thing. And that's a problem with funding agencies. The 01:41:54.750 --> 01:41:59.090 maverick scientist has a hard time-... very often- 01:41:59.270 --> 01:42:02.547 ... getting a hearing. And we know of lots 01:42:02.630 --> 01:42:06.507 of examples of that in history where after the 01:42:06.590 --> 01:42:10.507 fact we go "oh well yes," we should have supported that line of 01:42:10.590 --> 01:42:15.670 research, but we didn't." - Uh, very well put. Let us return to, 01:42:15.810 --> 01:42:19.707 the origins of ECT and how it was applied. But first, if it's okay, 01:42:19.790 --> 01:42:20.940 a quick bathroom break. 01:42:21.870 --> 01:42:23.829 Quick ten second thank you to our sponsors. 01:42:23.912 --> 01:42:25.627 Check them out in the description. It 01:42:25.710 --> 01:42:28.407 really is the best way to support this podcast. Go to 01:42:28.490 --> 01:42:31.927 lexfridman.com/sponsors. And now dear 01:42:32.010 --> 01:42:38.220 friends back to my conversation with Andrew Scull. Now we're back 01:42:39.070 --> 01:42:42.367 just to talk a little bit more about ECT and One Flew Over the Cuckoo's 01:42:42.450 --> 01:42:46.187 Nest. So what can we say about that, that little cultural 01:42:46.270 --> 01:42:50.030 moment, one of the most famous moments about psychiatry? 01:42:50.430 --> 01:42:54.327 First of all, Ken Kesey wrote this book about his own experience 01:42:54.410 --> 01:42:56.860 in a mental institution. - Yeah, Menlo Park. Yes. 01:42:57.110 --> 01:43:00.490 - How representative is it of the system at the time? 01:43:01.350 --> 01:43:08.190 - Mental hospitals have had a very patchy and complicated history. 01:43:09.090 --> 01:43:11.930 He was working actually in a hospital for veterans. 01:43:12.910 --> 01:43:16.010 Those were largely created after the Second World War 01:43:16.790 --> 01:43:20.550 when there were very many more psychiatric casualties among 01:43:20.690 --> 01:43:27.327 American troops than even the First World War. The interesting thing is we all by 01:43:27.410 --> 01:43:31.247 osmosis know that in the First World War there was something called 01:43:31.330 --> 01:43:34.887 shell shock that afflicted the troops and that the 01:43:34.970 --> 01:43:41.030 military initially resisted recognizing and ultimately were forced to grasp. 01:43:41.850 --> 01:43:45.550 But in World War II, American psychiatric 01:43:45.750 --> 01:43:49.650 casualties among the troops were two to three times as high as in World War I, 01:43:50.610 --> 01:43:54.547 and that's an important part of the history of psychiatry. But the 01:43:54.630 --> 01:43:58.390 upshot of that was that post-war the VA 01:43:58.490 --> 01:44:02.030 was heavily involved in, first of all, paying to train 01:44:02.290 --> 01:44:08.587 psychiatrists and even psychologists, and then had in its mental hospital 01:44:08.670 --> 01:44:14.150 system a considerable involvement with psychiatric disorders. 01:44:15.050 --> 01:44:20.260 Kesey-- Well, the book is different than the film is the first thing to say. 01:44:21.140 --> 01:44:25.740 Obviously, the film is heavily indebted to the book, but it changes various things. 01:44:26.200 --> 01:44:29.280 - Uh, if I may just go into Perplexity, "The book and the 01:44:29.380 --> 01:44:33.120 1975 film tell the same basic story of McMurphy 01:44:33.680 --> 01:44:37.457 challenging an oppressive psychiatric ward, but they differ sharply in 01:44:37.540 --> 01:44:41.360 point of view, tone, and what the story is about. The novel is 01:44:41.460 --> 01:44:45.180 weirder, more political, and more about Chief Bromden's 01:44:45.340 --> 01:44:51.474 inner world and the combine while the film is more naturalistic, character-driven, 01:44:51.557 --> 01:44:53.840 and turns McMurphy into the central hero." 01:44:54.700 --> 01:44:56.260 - Yes, I think that's right. 01:44:56.540 --> 01:45:00.100 - McMurphy is the person that received ECT played by Jack Nicholson. 01:45:00.300 --> 01:45:03.160 - Yes. And you have a nurse figure in Nurse Ratched. 01:45:03.260 --> 01:45:08.020 - Yeah. Yeah. - Louise Fletcher, uh, I think is an equally powerful performance. 01:45:08.120 --> 01:45:11.400 - It's one of the greatest films of all time who happens to be-- 01:45:12.010 --> 01:45:14.387 which is unfortunate for, you know, maybe psychiatry. 01:45:14.470 --> 01:45:18.337 - Psychiatry, yes. It's very interesting. I used to teach, um, a 01:45:18.420 --> 01:45:25.040 class called Madness In The Movies, and, um, I didn't just use... In fact, 01:45:25.180 --> 01:45:32.180 I used relatively few contemporary films and all among all the films from back 01:45:33.040 --> 01:45:36.837 then, the one almost everybody in the class had 01:45:36.920 --> 01:45:43.400 seen was One Flew Over the Cuckoo's Nest. So 18, 19, and 20-year-olds, 01:45:44.280 --> 01:45:48.117 In two thousand and fifteen If I 01:45:48.200 --> 01:45:52.017 showed them Alfred Hitchcock's Spellbound, no chance they'd ever 01:45:52.100 --> 01:45:53.480 seen that, maybe one, 01:45:54.600 --> 01:45:58.377 because they were a class of people interested in film. But everybody had 01:45:58.460 --> 01:46:00.780 seen One Flew Over the Cuckoo's Nest. 01:46:01.100 --> 01:46:06.020 - On that tangent really quick, what is the greatest film on madness in your view? 01:46:06.320 --> 01:46:08.777 - Oh, well... - Would that be One Flew Over the Cuckoo's Nest? 01:46:08.860 --> 01:46:11.380 - I think One Flew Over the Cuckoo's Nest, I think 01:46:12.540 --> 01:46:16.457 oddly a very different film appeared at about the same 01:46:16.540 --> 01:46:19.860 time was I Never Promised You a Rose Garden, 01:46:20.560 --> 01:46:24.277 which is a much more sympathetic portrait of a different 01:46:24.360 --> 01:46:28.157 kind of psychiatry, a very Freudian psychiatrist, 01:46:28.240 --> 01:46:31.940 really about Frieda Fromm-Reichmann who worked 01:46:32.100 --> 01:46:35.750 at Chestnut Lodge in Maryland and treated 01:46:35.880 --> 01:46:39.640 schizophrenia with psychotherapy rather than with drugs 01:46:39.800 --> 01:46:46.026 or other forms of physical intervention. And that was a bestselling novel by 01:46:46.109 --> 01:46:46.942 a young 01:46:47.100 --> 01:46:54.100 girl who had been her patient with some fairly serious delusions 01:46:55.220 --> 01:47:00.620 and a very complicated family background, and again the film 01:47:01.540 --> 01:47:07.177 changed a lot of things in the novel. That's what films do. My book 01:47:07.260 --> 01:47:11.090 Madhouse at one point interested Hollywood, and one of the 01:47:11.180 --> 01:47:15.030 two principals said to me, "I really like this story. It's got a great 01:47:15.120 --> 01:47:18.820 first act and a great second act, but where's the third act?" Meaning, 01:47:18.940 --> 01:47:22.657 "Where's the happy ending?" And I had to say there wasn't any happy 01:47:22.740 --> 01:47:25.980 ending to that story. It was just rather grim. 01:47:26.080 --> 01:47:30.280 - Madhouse: A Tragic Tale of Megalomania and Modern Medicine 01:47:31.140 --> 01:47:32.826 is the book you're referring to. Yes, that's right. 01:47:32.910 --> 01:47:35.177 Now that reminds me of Flowers for Algernon. That 01:47:35.260 --> 01:47:38.757 doesn't have a happy ending, and it's not about mental health 01:47:38.840 --> 01:47:42.777 necessarily, but it's about the journey of institution in relation to 01:47:42.860 --> 01:47:47.610 the health of a patient. - Yes, Pat Barker's trilogy of novels about World War 01:47:48.200 --> 01:47:51.177 I was turned into a film. I think it was called 01:47:51.260 --> 01:47:55.217 Regeneration, and that was quite powerful. 01:47:55.300 --> 01:47:59.140 It was about World War I and the treatment of shell shock. Mm-hmm. 01:47:59.580 --> 01:48:06.480 And I thought was quite well done. And my friend Patrick McGrath, who's a novelist, 01:48:07.400 --> 01:48:11.220 wrote a book called Asylum. Patrick grew up 01:48:11.740 --> 01:48:15.457 in the grounds of Broadmoor. Broadmoor is England's 01:48:15.540 --> 01:48:17.820 premier hospital for the criminally insane, 01:48:18.660 --> 01:48:20.817 and he was babysat by some of the patients. 01:48:20.901 --> 01:48:22.577 And when you read his novels, you 01:48:22.660 --> 01:48:29.660 can see how that upbringing affected his rather macabre imagination. But anyway, 01:48:31.440 --> 01:48:35.330 so One Flew Over the Cuckoo's Nest, the poverty of the environment, 01:48:36.100 --> 01:48:42.660 room that the patients were in, I think fairly successfully recreates that 01:48:44.700 --> 01:48:50.949 way in which staff very often put patients down, didn't listen to them, 01:48:51.032 --> 01:48:52.337 or poked fun at 01:48:52.420 --> 01:48:56.520 them, or even were physically abusive, although you don't see that. 01:48:58.140 --> 01:49:03.180 Those were all features of mental hospitals. The general boredom of life, 01:49:04.540 --> 01:49:07.580 sort of there, but yeah, hard to reprea-- 01:49:09.340 --> 01:49:14.457 putting boredom on the screen will turn an audience off rather fast. 01:49:14.540 --> 01:49:18.640 - What about nurses and this kind of abusive element, you know? 01:49:18.940 --> 01:49:22.417 - Yeah, I think there was an abusive element in a lot of mental 01:49:22.500 --> 01:49:29.500 hospitals, and it was almost inevitable. Look at who had the 01:49:30.820 --> 01:49:34.780 most contact with the patients: it was the lowest paid, 01:49:35.940 --> 01:49:42.940 least respected ward attendants, very few even RNs, and you know, 01:49:43.740 --> 01:49:50.740 ratio of doctor to patient in the large state mental hospitals meant that patients 01:49:51.220 --> 01:49:53.250 hardly ever saw a physician, you know. 01:49:54.120 --> 01:49:57.877 Remarkable about the film, there are many remarkable 01:49:57.960 --> 01:50:01.060 things about the film as well as its polemical edge, 01:50:02.240 --> 01:50:06.137 think is that chief psychiatrist that you see 01:50:06.220 --> 01:50:11.180 in the film is the real head of Oregon State Mental Hospital. He really was 01:50:12.860 --> 01:50:16.520 introduction to acting, and I thought he was pretty remarkable, actually. 01:50:17.240 --> 01:50:20.660 Obviously, there's a lot of exaggeration there, but 01:50:20.980 --> 01:50:24.820 ECT was used in the fifties and sixties 01:50:24.940 --> 01:50:28.860 as a tool of discipline in the hospitals. It was also 01:50:28.960 --> 01:50:32.680 used therapeutically, but overwhelmingly it was used 01:50:33.840 --> 01:50:39.300 a tool of discipline and control. And that's true to life. Lobotomy... 01:50:40.760 --> 01:50:43.890 One of the interesting things we haven't talked about with all these treatments 01:50:43.973 --> 01:50:48.000 we've been discussing is that almost invariably, 01:50:49.260 --> 01:50:53.117 except for the case of the syphilitic patients, for obvious reasons, men 01:50:53.200 --> 01:50:56.320 were more troubled by that condition than women, 01:50:57.280 --> 01:51:01.057 it was women that got the brunt of these experiments. So 01:51:01.140 --> 01:51:04.790 Henry Cotton, about 70% of his patients who were treated were 01:51:04.940 --> 01:51:08.810 female. Lobotomy patients, it's hard to get 01:51:08.920 --> 01:51:12.857 overall numbers, but those of us who've looked at 01:51:12.940 --> 01:51:16.717 the records of a number of different hospitals again and 01:51:16.800 --> 01:51:23.800 again discover, again, 60 or 70% of the patients are female. ECT 01:51:24.660 --> 01:51:28.860 tends to be heavily female. That's complicated by the fact that 01:51:29.780 --> 01:51:33.577 it's used primarily as, as we were discussing in 01:51:33.660 --> 01:51:37.477 serious cases of depression and so-called treatment-resistant 01:51:37.560 --> 01:51:41.450 depression, and depression is a diagnosis that is 01:51:41.980 --> 01:51:45.757 more to be found among women than men. Not that there aren't very many 01:51:45.840 --> 01:51:49.617 men with depression, but again, the ratio is such. Men 01:51:49.700 --> 01:51:52.880 tend to get a different-- they get different diagnoses. 01:51:53.480 --> 01:51:58.360 Personality disorders, for example, are very, very common and are more a male 01:51:59.220 --> 01:52:06.220 diagnosis. Um, ADHD-...is more male than female and so on. So 01:52:08.780 --> 01:52:13.020 it's good to point that out. Uh, I think it helped 01:52:14.260 --> 01:52:18.020 end interest in ECT, except for a 01:52:18.140 --> 01:52:22.530 small handful of enthusiasts for decades, that film. 01:52:22.960 --> 01:52:29.960 Um, and probably even now it creates hesitation in people about the 01:52:30.260 --> 01:52:35.500 treatment. So it's one that has 01:52:35.840 --> 01:52:39.657 had a very powerful and long-lasting effect, I think. 01:52:39.740 --> 01:52:43.437 - I think the surprising thing is I recently learned a friend of mine tried 01:52:43.520 --> 01:52:47.360 everything, about 20 years ago, tried everything to 01:52:47.620 --> 01:52:53.640 --with depression, and ECT is the last thing he tried, and it changed his life- 01:52:54.020 --> 01:52:57.817 ...for the better. - That's not an uncommon story. Yeah. 01:52:57.900 --> 01:53:01.277 - And then I looked online and there's a lot of stories like this. 01:53:01.360 --> 01:53:07.600 And I-- before learning of that, my, I'm embarrassed to say, knowledge of ECT 01:53:08.400 --> 01:53:11.260 was just "One Flew Over the Cuckoo's Nest." 01:53:11.600 --> 01:53:14.417 - You know, it has a terrible history- 01:53:14.500 --> 01:53:18.867 in the, in the '40s, '50s and '60s. There are lots of,- - Abuses 01:53:18.950 --> 01:53:23.680 - Uh, the CIA funded Ewen Cameron up in Canada, 01:53:24.720 --> 01:53:28.397 and he was giving multiple ECTs a day and 01:53:28.480 --> 01:53:32.357 reducing peoples to... Well, they couldn't walk, 01:53:32.440 --> 01:53:35.711 they couldn't talk, they couldn't feed themselves, they were incontinent, 01:53:35.795 --> 01:53:36.257 and then he 01:53:36.340 --> 01:53:40.197 built them back up, or so he claimed, but in many cases, they were left permanently 01:53:40.280 --> 01:53:45.240 damaged. So I could recite lots of real horror stories about ECT, 01:53:45.880 --> 01:53:49.620 but it's also, if you're honest about the thing, 01:53:50.440 --> 01:53:57.270 what you just described, that is patients who were on the brink of suicide, 01:53:58.100 --> 01:54:01.390 who had long-running depressions, some of them 01:54:02.580 --> 01:54:07.136 had ECT and they describe it as lifesaving. 01:54:07.219 --> 01:54:12.550 And as I say when more controlled trials have been done recently, 01:54:13.540 --> 01:54:17.437 there's enough evidence now that it's hard to say, "This never 01:54:17.520 --> 01:54:21.240 works. This is just one of these desperate remedies we should consign to 01:54:21.360 --> 01:54:23.770 dark ages." The complicating thing is 01:54:24.800 --> 01:54:29.077 we'd have no clue why it works. It's a purely empirical treatment. 01:54:29.160 --> 01:54:32.880 - Right. Right. - And that itself I think tends to put people off. 01:54:33.740 --> 01:54:37.627 If you have a curable form of cancer and the surgeon says, 01:54:37.710 --> 01:54:44.520 "Well, I'm gonna remove it," and she does, that's that. But because we understand 01:54:45.140 --> 01:54:48.860 even a little bit, even if our knowledge of human biology is pretty 01:54:49.000 --> 01:54:52.760 primitive, we do understand a little bit that cancer is 01:54:53.960 --> 01:54:57.770 cells dividing uncontrollably and taking up and doing 01:54:57.860 --> 01:55:00.160 damage to the body and eventually killing you, 01:55:00.680 --> 01:55:04.480 and the fact that we can surgically remove it is a big 01:55:04.600 --> 01:55:08.620 deal. There are lots of disorders. I have high blood pressure. 01:55:09.600 --> 01:55:16.350 If untreated, my blood pressure is like a 20-year-old's thanks to treatment. 01:55:17.920 --> 01:55:21.677 It's an ongoing thing. I take the damn pill every day and it has a 01:55:21.760 --> 01:55:25.530 few minor side effects, but for me very minor ones. And it 01:55:26.440 --> 01:55:30.140 turns what could have killed me via a stroke or a heart attack 01:55:30.280 --> 01:55:33.880 into a condition that's very well controlled. So, 01:55:34.320 --> 01:55:38.260 you know, it-- All of these things, they're, they're complicated picture- 01:55:38.440 --> 01:55:42.100 It's easy with some of these things, with lobotomy, 01:55:42.860 --> 01:55:45.720 with insulin comas, deep sleep treatments, 01:55:46.810 --> 01:55:50.447 Henry Cotton's endeavors. Those you can just say, 01:55:50.530 --> 01:55:54.360 "Well, we'll throw them away." And for a long time, I think ECT 01:55:54.500 --> 01:55:59.460 would have formed part of that cast of characters. So when I first 01:56:00.900 --> 01:56:05.340 conceived the idea of writing Desperate Remedies, the book, 01:56:06.540 --> 01:56:10.320 it was back in 1981 and I was in London 01:56:10.860 --> 01:56:14.777 on a Guggenheim Fellowship at the Wellcome Institute. And I hadn't done 01:56:14.860 --> 01:56:18.780 research in detail, but I was aware there were all these things 01:56:18.980 --> 01:56:22.797 lurking about that had happened in the 1920s and '30s and I thought 01:56:22.880 --> 01:56:26.757 that would be a very interesting thing to study. And 01:56:26.840 --> 01:56:31.680 luckily I didn't do it right away or I did it piecemeal over the years 01:56:33.060 --> 01:56:36.370 and I ended up writing a much more comprehensive look at 01:56:36.920 --> 01:56:40.360 psychiatry really from its origins to now. 01:56:41.140 --> 01:56:44.697 And I couldn't have written that book back then, and I would've 01:56:44.780 --> 01:56:48.440 missed all the developments from 1980 onwards, which are 01:56:48.620 --> 01:56:52.257 very, very important to the, to the overall picture. 01:56:52.340 --> 01:56:56.537 - So forty years later, 2022. - Yes. Yes, exactly. 01:56:56.620 --> 01:56:58.007 - Your own Desperate Remedies: Psychiatry's- - Yeah. Yeah 01:56:58.090 --> 01:57:00.077 -... Turmoil in Quest to Cure Mental Illness. 01:57:00.160 --> 01:57:02.900 - I've written a lot of books and, and along the way-- 01:57:03.780 --> 01:57:07.360 part of the way, I think I've been productive and kept 01:57:07.460 --> 01:57:11.300 interested. I always had two... at least two projects on the go at once. 01:57:11.720 --> 01:57:15.557 You can't simultaneously write two things, but I'd have one and I'd work 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 01:57:19.386 --> 01:57:24.160 back. And it also meant when I was working on one main project, I had 01:57:24.280 --> 01:57:27.420 other things percolating in, in my head, 01:57:28.420 --> 01:57:31.997 and I would, I would come across things that were 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 01:57:38.820 --> 01:57:42.820 Desperate Remedies, I'd been thinking about those issues for forty years, 01:57:43.820 --> 01:57:47.477 and that made a big difference, I think, to the way I approached 01:57:47.560 --> 01:57:51.340 things and to what I thought. Uh, 'cause you just... You 01:57:51.460 --> 01:57:55.317 either like Thomas says, you say the same thing over and over 01:57:55.400 --> 01:57:59.257 and over again for forty years or 01:57:59.340 --> 01:58:03.020 you learn new things and you broaden what you know, and you 01:58:03.180 --> 01:58:07.137 think about things in a different way because you realize you 01:58:07.220 --> 01:58:10.400 haven't grasped the full complexity of what you're looking at. 01:58:11.220 --> 01:58:17.320 And so look, what I found with psychiatry is there are really 01:58:18.180 --> 01:58:21.780 a couple of fundamental things that have kept me engaged with the field. 01:58:22.740 --> 01:58:26.177 One, it's an arena where there's tremendous human 01:58:26.260 --> 01:58:29.600 suffering, and it spreads out and it's 01:58:30.300 --> 01:58:33.857 as far as I know -- and I wrote a big book called Madness in Civilization 01:58:33.940 --> 01:58:37.677 about from the ancient Greeks and ancient China to now -- in every 01:58:37.760 --> 01:58:41.297 society I've studied they have to cope with this. It takes 01:58:41.380 --> 01:58:45.197 different forms. It's regarded in different ways. It's treated 01:58:45.280 --> 01:58:49.020 differently, but that there are people that deviate 01:58:49.480 --> 01:58:54.680 so far from the norm of what we regard as culturally appropriate, 01:58:55.780 --> 01:58:59.810 they exist everywhere. So the suffering, 01:59:00.660 --> 01:59:05.580 the difficulty of studying it, and then the fact that it is such 01:59:06.560 --> 01:59:11.120 a complex and difficult subject to understand. 01:59:13.240 --> 01:59:16.940 The very fact that we have such limits to our knowledge 01:59:18.660 --> 01:59:22.440 means there's space there to examine things in a, in a 01:59:22.540 --> 01:59:26.860 very in what needs to be a very complicated way. 01:59:27.700 --> 01:59:31.317 And so it's, it's intellectual puzzles 01:59:31.400 --> 01:59:35.857 attracted some very, very smart people, but there's a long way to go. 01:59:35.940 --> 01:59:39.187 - Yeah, we have glimmers of insights about how the, mind works but- 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 01:59:43.100 --> 01:59:47.340 early days of understanding this particular one. I have to, if it's okay- 01:59:47.500 --> 01:59:52.437 - Yes, of course -...so that we've been carrying multiple threads together. One 01:59:52.520 --> 01:59:56.377 of the threads that I think, uh, is really exciting to 01:59:56.460 --> 02:00:01.657 me and really important to the history of psychiatry is the psychotherapy side. 02:00:01.740 --> 02:00:05.397 We have mentioned the psychopharmacology that will also-- it would 02:00:05.480 --> 02:00:11.617 be nice to discuss when the two clash and there's a revolution where phar-- 02:00:11.700 --> 02:00:17.416 Psychopharmacology kinda wins over psychoanalysis for a time. 02:00:17.499 --> 02:00:19.020 But let us start 02:00:19.840 --> 02:00:23.560 at the somewhat beginning, in the nineteenth century 02:00:23.960 --> 02:00:27.757 when talk therapy starts coming to life maybe in the 02:00:27.840 --> 02:00:32.180 religious context with Christian Science and then psychoanalysis context. 02:00:32.320 --> 02:00:36.037 - Yes. So I'd mentioned late nineteenth 02:00:36.120 --> 02:00:40.017 century psychiatry confined as it was to the mental hospital and 02:00:40.100 --> 02:00:44.017 to people incarcerated in 02:00:44.100 --> 02:00:47.957 those places had become very biological. But there were people 02:00:48.040 --> 02:00:55.040 experiencing mental troubles of various kinds, sadness, confusion, 02:00:56.160 --> 02:01:00.120 loss of social relationships that were troubling them, 02:01:00.580 --> 02:01:04.217 grief, all sorts of things like that, that didn't 02:01:04.300 --> 02:01:08.257 involve time in a mental hospital but nonetheless 02:01:08.340 --> 02:01:12.260 involved a good deal of distress as they continued to do. 02:01:13.240 --> 02:01:17.077 And one of the things that was interesting about nineteenth century America 02:01:17.160 --> 02:01:21.080 is it spawned a number of new religions, sort of variants 02:01:21.180 --> 02:01:26.240 of Christianity. So you had Seventh Day Adventists 02:01:27.260 --> 02:01:34.197 group that still exists who actually spawned a sanitarium for their depressed 02:01:34.280 --> 02:01:38.180 congregants that was later taken over by two 02:01:38.560 --> 02:01:41.780 prominent members of the Adventist Church, the Kellogg family. 02:01:42.560 --> 02:01:48.797 everybody knows them through cereal. But they ran a huge sanitarium to which 02:01:48.880 --> 02:01:52.180 Abraham Lincoln's widow went, Tarzan went, 02:01:53.020 --> 02:01:56.877 Henry Ford went, lots of very prominent industrialists 02:01:56.960 --> 02:02:00.440 and politicians and, you know, it was kind of a 02:02:00.900 --> 02:02:04.817 a farm to go and recover your mental stability and 02:02:04.900 --> 02:02:10.680 health and it was all bound up also with beliefs about diet and 02:02:12.340 --> 02:02:16.057 defecation and all sorts of things. There were the 02:02:16.140 --> 02:02:20.037 Mormons or Church of Jesus Christ of Latter-day Saints. Many 02:02:20.120 --> 02:02:23.937 Christians don't believe they're really Christian but they think they are and 02:02:24.020 --> 02:02:27.780 call themselves such. So you have a number of these and one of them 02:02:28.680 --> 02:02:33.795 was Christian Science, which was the invention of a woman named Mary Baker 02:02:33.879 --> 02:02:34.712 Eddy. 02:02:40.450 --> 02:02:44.267 Developed the idea, and there are still Christian Science churches and Christian 02:02:44.350 --> 02:02:46.880 Science reading rooms all across America, 02:02:47.890 --> 02:02:51.587 that there wasn't such a thing as disease. That it could be prayed 02:02:51.670 --> 02:02:56.660 away; that it was just a lack of sufficient faith. So faith healing, 02:02:58.190 --> 02:03:01.907 tended to work, I think, better if it worked at all for 02:03:01.990 --> 02:03:08.990 psychiatric problems than it did if you had, say, cancer. But Christian Science 02:03:11.230 --> 02:03:14.430 achieved a considerable number of followers 02:03:15.430 --> 02:03:22.430 disproportionately women but not only women. And it began to treat 02:03:23.950 --> 02:03:27.920 many of the people suffering from what we would think of as the milder 02:03:28.370 --> 02:03:31.230 mental disorders. And it attracted 02:03:32.770 --> 02:03:38.027 both adherents and severe critics. Mark Twain, for 02:03:38.110 --> 02:03:41.570 example, was thoroughly dismissive of 02:03:42.050 --> 02:03:45.670 Mary Baker Eddy. But it was very successful for a time. 02:03:46.570 --> 02:03:50.350 There were other religiously based attempts to 02:03:51.270 --> 02:03:54.847 join in. The most important of which in New England was 02:03:54.930 --> 02:03:58.187 something called Emmanuel Movement centered around the Church of the 02:03:58.270 --> 02:04:03.947 Emmanuel in Boston, which was an attempt actually initially to 02:04:04.030 --> 02:04:10.650 bring medical and religious approaches to helping the mentally troubled. 02:04:12.190 --> 02:04:16.087 Rather quickly, the doctors involved decided this 02:04:16.170 --> 02:04:19.887 was veering too much in the direction of medically-based 02:04:19.970 --> 02:04:26.930 therapeutics. They kind of withdrew from enterprise. It dispensed-- There were 02:04:28.930 --> 02:04:34.690 talk therapies obviously with a strong religious component around them. 02:04:36.210 --> 02:04:40.930 This was also at a time when some... 02:04:42.990 --> 02:04:46.340 guess we can call them psychiatrists, they were often neurologists, 02:04:47.290 --> 02:04:51.670 were beginning to get lots of patients with these kinds of 02:04:52.950 --> 02:04:59.259 difficult to treat disorders. Neurology had emerged in America after the Civil 02:04:59.342 --> 02:05:00.176 War. 02:05:00.370 --> 02:05:03.967 Civil War provided a lot of naturalistic 02:05:04.050 --> 02:05:07.880 experiments on what happens to the human brain and the human nervous 02:05:07.970 --> 02:05:11.647 system when trauma affect - I don't mean psychological 02:05:11.730 --> 02:05:15.160 trauma, I mean bullets blowing holes in your brain. A 02:05:16.330 --> 02:05:20.287 group of new specialists emerged after the Civil War who 02:05:20.370 --> 02:05:23.910 claimed expertise in the brain and the nervous system. 02:05:24.010 --> 02:05:30.710 Well, one of the other side parts of that is insanity, because insanity is also seen 02:05:30.830 --> 02:05:37.830 as a brain disease. So there is a conflict that erupts in the 1870s and 02:05:38.450 --> 02:05:41.790 '80s between neurologists and psychiatrists. 02:05:42.750 --> 02:05:46.447 But the neurologist can't, for the most part, get into the asylum where the most 02:05:46.530 --> 02:05:50.287 seriously ill patients are. Gradually, what 02:05:50.370 --> 02:05:54.050 comes to their waiting room along with people like multiple 02:05:54.170 --> 02:05:58.010 sclero-- suffering from things like multiple sclerosis are people with 02:05:58.110 --> 02:06:04.790 functional mental disorders. There's the beginning of an outpatient practice, 02:06:05.670 --> 02:06:12.670 um which initially involves some drugs, the use of 02:06:14.290 --> 02:06:18.167 electricity. Not ECT, but the use, for example, of 02:06:18.250 --> 02:06:21.527 static electricity, because it produces obvious 02:06:21.610 --> 02:06:27.144 physiological responses. Electricity is seen as dominating the workings of 02:06:27.227 --> 02:06:28.060 the body. 02:06:30.050 --> 02:06:33.990 Sometimes tonics of one sort or another. Most notoriously of 02:06:34.090 --> 02:06:36.110 all, something called the rest cure. 02:06:37.190 --> 02:06:40.857 Silas Weir Mitchell, one of the leading lights of American 02:06:40.940 --> 02:06:47.940 neurology, develops complete bedrest, lots of calories, lots of food, complete 02:06:48.810 --> 02:06:52.487 lack of intellectual stimulation. Supposedly, this is going 02:06:52.570 --> 02:06:57.930 to cure you. Mainly aimed at women. I feel like that's another evidence-backed 02:06:58.950 --> 02:07:02.900 technique that works well. Well, you know, I've 02:07:02.990 --> 02:07:05.410 partaken in this and I know it has helped me. 02:07:08.150 --> 02:07:11.807 Laying in bed doing nothing, eating snacks. Virginia Woolf was one of the 02:07:11.890 --> 02:07:15.647 people subjected to this. She claimed it practically drove her mad or 02:07:15.730 --> 02:07:18.896 made her worse, you know? Just to clarify, we're talking about laying in bed, 02:07:18.979 --> 02:07:23.887 eating snacks. Eating lots of snacks. Very high calorie. Okay, Weir 02:07:23.970 --> 02:07:27.070 Mitchell wrote two popular bestsellers, 02:07:27.690 --> 02:07:31.587 self-help books, suppose you'd call them in the modern genre. One was 02:07:31.670 --> 02:07:37.670 called Wear and Tear. The pace of modern life, the telegraph, the 02:07:37.790 --> 02:07:41.127 railway was all too much. Your nervous system was 02:07:41.210 --> 02:07:45.047 overstressed. Either your batteries ran down, that was 02:07:45.130 --> 02:07:49.610 one analogy, or you overtaxed your system and went bankrupt. 02:07:50.810 --> 02:07:54.690 Wear and tear, that was the problem. The solution 02:07:54.810 --> 02:07:57.950 was Fat and Blood. That was the title of the other book. 02:07:59.270 --> 02:08:02.450 You got scrawny, nouveau, nervous, twitchy. 02:08:03.270 --> 02:08:07.070 And what you really needed was to build back up your strength. 02:08:07.250 --> 02:08:10.750 including your nervous strength. Isn't it fascinating to look at that? 02:08:11.010 --> 02:08:14.407 120 years plus ago? They're talking about 02:08:14.490 --> 02:08:18.527 how anxiety inducing society is, how much is going on. 02:08:18.610 --> 02:08:21.774 And we in the modern day talk in exact same way about social media, 02:08:21.857 --> 02:08:23.587 the internet, all that kind of stuff. 02:08:23.670 --> 02:08:28.974 Yeah, yeah, it is. We look back on the nineteenth century and think of it 02:08:29.057 --> 02:08:33.328 in idyllic terms of a much slower pace of life, and people, 02:08:33.412 --> 02:08:37.461 they thought it was stressful in exactly the ways we do. 02:08:37.545 --> 02:08:42.922 There was a class of potential patients. Some of them were seeking help in 02:08:43.006 --> 02:08:48.015 the neurologists and a few psychiatrists who moved out of the asylum. 02:08:48.098 --> 02:08:51.050 But there were also these mental healing 02:08:51.940 --> 02:08:55.300 groups that were religious, and they're all around 02:08:55.980 --> 02:09:02.597 at the beginning of the 20th century. And in 1909, a Viennese gentleman 02:09:02.680 --> 02:09:06.537 and two of his close colleagues travel across the 02:09:06.620 --> 02:09:10.437 Atlantic on a German steamer and arrive in New 02:09:10.520 --> 02:09:15.000 York and then transport themselves up to Worcester, Massachusetts, 02:09:16.080 --> 02:09:20.880 where Clark University is celebrating its 20th anniversary. 02:09:21.740 --> 02:09:25.517 Clark University was then set up-- it still exists, but it was 02:09:25.600 --> 02:09:29.190 set up to copy the German research university. The 02:09:29.920 --> 02:09:36.477 only comparable example at the time was Johns Hopkins in Baltimore, and Hopkins 02:09:36.560 --> 02:09:40.017 developed the leading medical school of the time 02:09:40.100 --> 02:09:45.693 borrowing from that German concept of mixing research and teaching and patient 02:09:45.776 --> 02:09:49.160 care. - I like how you're telling this in a cinematic way 02:09:50.200 --> 02:09:52.917 the story of Sigmund Freud and Carl Jung-- 02:09:53.000 --> 02:09:56.837 ...coming to America to give a lecture. I like, I like how it's like 02:09:56.920 --> 02:09:59.855 the movie opens and there, yeah. Yeah, well, here he is, you know, like, 02:09:59.938 --> 02:10:00.817 how do you feel who he 02:10:00.900 --> 02:10:04.837 is? He's fairly obscure. We should say the reason you're actually telling it that 02:10:04.920 --> 02:10:11.800 way is America has been a really defining place for psychiatry. 02:10:12.340 --> 02:10:15.997 Yes. And then Freud had his own views on America and so on. But this-- 02:10:16.080 --> 02:10:23.080 this was, in terms of the history, yes, psychiatric medicine, America as central. 02:10:23.620 --> 02:10:26.740 Right. Many of the in-house histories of psychiatry 02:10:27.000 --> 02:10:30.920 portray this as Freud conference. 02:10:31.780 --> 02:10:35.560 But it wasn't. Freud was almost an afterthought of the conference. 02:10:35.880 --> 02:10:39.617 Um, the head of Clark was a psychologist, and he was 02:10:39.700 --> 02:10:43.277 interested in Freud, but actually there were 02:10:43.360 --> 02:10:47.017 about thirty speakers at the Clark conference, two 02:10:47.100 --> 02:10:51.057 Nobel Prize winners in physics, Franz Boas, who 02:10:51.140 --> 02:10:54.760 was the leading anthropologist of his generation, and a 02:10:54.900 --> 02:10:58.300 host of other scholars, including a couple of Freud's 02:10:58.620 --> 02:11:02.477 fierce critics, one of whom, Stern, was on the same boat as 02:11:02.560 --> 02:11:06.477 him. And they avoided one another like the plague. But anyway, it's 02:11:06.560 --> 02:11:10.247 important to see that, and Freud, it's a mark of how 02:11:10.330 --> 02:11:14.157 important German science and German medical science was in the late 02:11:14.240 --> 02:11:18.250 nineteenth, early twentieth century, where it was THE most advanced 02:11:19.060 --> 02:11:23.240 in the world, that Freud delivered his lectures IN GERMAN, 02:11:24.600 --> 02:11:28.151 AND THE AUDIENCE, THAT WASN'T A PROBLEM FOR THE AUDIENCE 'CAUSE THEY'D ALL LEARNED 02:11:28.234 --> 02:11:32.377 GERMAN so they could read German literature on medicine. So quite an 02:11:32.460 --> 02:11:35.860 extraordinary thing. Um William James attends 02:11:36.440 --> 02:11:40.397 one of Freud's lectures and has a conversation with him. William 02:11:40.480 --> 02:11:44.157 James is one of the people thinking about the psychology of the 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 02:11:51.540 --> 02:11:55.297 heart condition. He dies not all that long afterwards, but 02:11:55.380 --> 02:11:59.147 he's not impressed by Freud. A handful of people are, 02:11:59.230 --> 02:12:02.897 some of the neurologists. And Freud's lectures explicitly 02:12:02.980 --> 02:12:06.417 attack religiously based psychotherapy, says 02:12:06.500 --> 02:12:10.940 psychotherapy is like a surgical operation on the mind. And only us doctors 02:12:11.760 --> 02:12:15.657 or only us thoroughly trained people cause actually he 02:12:15.740 --> 02:12:19.537 doesn't believe that psychoanalysis is only something that can be practiced 02:12:19.620 --> 02:12:23.610 by medically qualified, but the lecture is on 02:12:23.700 --> 02:12:27.297 psychoanalysis. Yes, it's five lectures. They're 02:12:27.380 --> 02:12:31.030 published subsequently, and he makes a very important 02:12:31.160 --> 02:12:38.000 convert there. Um James Jackson Putnam is a Boston Brahmin, one of the upper-class 02:12:38.340 --> 02:12:41.777 Bostonians who's extremely well connected and is 02:12:41.860 --> 02:12:45.517 professor of neurology at Harvard, and he becomes a 02:12:45.600 --> 02:12:50.760 Freudian at that conference. So mainstream American psychiatry 02:12:51.960 --> 02:12:55.760 pays very little attention to to Freud's arrival on the scene. 02:12:56.080 --> 02:13:03.080 And when he becomes a bit more visible, they tend to be very dismissive. They uh 02:13:04.220 --> 02:13:08.037 They regard the idea of talk therapy for something they regard as a biological 02:13:08.120 --> 02:13:12.017 condition as a ridiculous idea. Maybe just uh mention a few 02:13:12.100 --> 02:13:15.917 things. Sigmund Freud, of course, is widely acknowledged to be the father of 02:13:16.000 --> 02:13:19.800 psychoanalysis. And uh he has a bunch of ideas, one of which 02:13:19.900 --> 02:13:23.797 is there's this unconscious mind that is the source of many 02:13:23.880 --> 02:13:27.737 of our uh behaviors. Exactly. And then psychoanalysis is a way to 02:13:27.820 --> 02:13:31.797 delve deep into that mind, and the tools he used to do 02:13:31.880 --> 02:13:36.440 that is talking. Yes, Freud was trained as a neurologist himself 02:13:37.400 --> 02:13:41.280 uh and studied under the most famous late 02:13:41.480 --> 02:13:45.260 Nineteenth-century neurologist Charcot in Paris 02:13:45.880 --> 02:13:49.657 and translated Charcot into German and endeared himself to 02:13:49.740 --> 02:13:53.020 Charcot, by doing that, that's, um, a clever way to 02:13:54.360 --> 02:13:59.120 help your career along. But his Viennese colleagues didn't think 02:13:59.940 --> 02:14:03.620 much of Charcot, and they didn't think much of Freud's ideas either. 02:14:03.760 --> 02:14:08.040 So he had a bit of a hard time, but he did develop a successful 02:14:09.300 --> 02:14:14.340 practice in the sense that patients came to him. He was accompanied by 02:14:15.300 --> 02:14:21.160 two of his close disciples to the Clark conference, one of them Carl Jung. 02:14:21.600 --> 02:14:25.537 was then anointed the crown prince. He was supposed 02:14:25.620 --> 02:14:32.313 to inherit Freud's enterprise until the men had a very serious falling out, 02:14:32.396 --> 02:14:33.277 mm-hmm, uh 02:14:33.360 --> 02:14:39.360 just a little bit later in 1913, and Freud and Jung went their separate ways. 02:14:40.520 --> 02:14:43.397 That's a complicated story. Freud, as one of his 02:14:43.480 --> 02:14:47.397 close, uh, friends and collaborators, put it, was a great 02:14:47.480 --> 02:14:51.220 Hater, if you fell out with Freud, it was bad news. 02:14:51.580 --> 02:14:54.272 hater. If you fell out with Freud, it was bad news. Oh yeah, yeah, 02:14:54.355 --> 02:14:57.405 you were excommunicated if it was Adler, but Jung especially. 02:14:57.950 --> 02:15:01.827 - Jung was Swiss and he worked in the major mental hospital 02:15:01.910 --> 02:15:04.807 in Zurich, and he was attracted to 02:15:04.890 --> 02:15:08.287 psychoanalysis and to Freud. And for the first few 02:15:08.370 --> 02:15:11.450 years there, there was this obvious close alliance. 02:15:12.370 --> 02:15:16.350 Anyway, so Jung was the person who actually persuaded Freud to go 02:15:16.470 --> 02:15:19.947 to America. Freud initially-- Freud had a very low opinion of 02:15:20.030 --> 02:15:23.887 America. He said it should be renamed Dollaría because 02:15:23.970 --> 02:15:27.607 it was only interested in the dollar. And American women were far too 02:15:27.690 --> 02:15:31.470 pushy and powerful, and American food was dreadful and it poisoned him, and 02:15:32.170 --> 02:15:35.510 on and on. Um-- - So as you said, Freud was a master hater. 02:15:35.790 --> 02:15:39.727 - Yeah, he was. And one of the things he hated was America, even though 02:15:39.810 --> 02:15:43.510 America brought him some fairly rich patients. But-- 02:15:43.610 --> 02:15:49.280 ...the richest patients of all went to Jung, not to Freud. 02:15:49.730 --> 02:15:53.290 Um, and I think that probably exacerbated this split. 02:15:53.550 --> 02:15:57.087 - Let's actually focus first before the conference on the actual ideas of 02:15:57.170 --> 02:16:00.847 psychoanalysis. So Freud was the originator of psychoanalysis. This is 02:16:00.930 --> 02:16:04.910 19th century. So tell me about the original case of Anna 02:16:05.010 --> 02:16:07.387 O. and like what is psychoanalysis? 02:16:07.470 --> 02:16:12.550 - Yeah. So Freud's academic career had been failing in Vienna, 02:16:13.730 --> 02:16:17.367 and he faced a prospect of either having to emigrate to 02:16:17.450 --> 02:16:20.790 America, which he regarded with horror in the 1880s, 02:16:21.790 --> 02:16:25.327 or perhaps reviving his career by going and 02:16:25.410 --> 02:16:30.050 studying under the most famous neurologist of the era, Jean-Martin Charcot, 02:16:30.850 --> 02:16:34.570 who was then delivering lectures on hysteria in Paris. 02:16:35.250 --> 02:16:38.530 And so Freud went and spent some months there 02:16:39.570 --> 02:16:44.360 and came back imbued with Charcot's ideas about hysteria 02:16:45.670 --> 02:16:50.429 and found a Viennese medical establishment. 02:16:50.512 --> 02:16:53.890 He started a consulting career 02:16:54.030 --> 02:16:58.490 and that involved-- He had a close friend named Josef Breuer. 02:16:59.380 --> 02:17:06.380 And Breuer was more senior, had a very large practice, and referred patients to 02:17:06.690 --> 02:17:11.907 Freud. And the two of them began to be interested in this problem 02:17:11.990 --> 02:17:15.490 of hysteria. Breuer had treated 02:17:16.710 --> 02:17:20.647 a woman who's now known as the sort of foundation patient for-- the 02:17:20.730 --> 02:17:25.890 Ur patient for psychoanalysis, who was known to us as Anna O. 02:17:26.890 --> 02:17:30.750 She-- We actually know she was Bertha von Pappenheim, but that was 02:17:31.070 --> 02:17:34.010 hidden for a long time. A lot of these patients had 02:17:34.810 --> 02:17:41.180 pseudonyms because obviously the cases exposed a lot about their inner psychology 02:17:42.030 --> 02:17:45.710 and quite reasonably, even without the modern 02:17:45.830 --> 02:17:50.090 concerns about privacy, there was a reluctance to identify them. 02:17:50.590 --> 02:17:54.407 So Anna O. had nursed her father. She was 02:17:54.490 --> 02:17:58.307 Breuer's patient, not Freud's. She'd nursed her father through an 02:17:58.390 --> 02:18:00.470 illness, and he'd ended up dying, and she 02:18:01.350 --> 02:18:05.267 developed various physical symptoms that troubled 02:18:05.350 --> 02:18:10.390 her a great deal and was also somewhat depressed. And Breuer and Freud 02:18:11.650 --> 02:18:15.147 dealt with that by developing a notion that what she was 02:18:15.230 --> 02:18:18.540 suffering from was repressed memories and trauma. 02:18:19.910 --> 02:18:23.547 And this would become central to psychoanalysis, the 02:18:23.630 --> 02:18:27.170 idea of half-muttered memories lurking in your subconscious 02:18:27.910 --> 02:18:31.170 that emerged in distorted forms of 02:18:32.190 --> 02:18:35.607 psychological symptoms and ways of being in the world that 02:18:35.690 --> 02:18:39.527 were disruptive. Freud, of course, develops a much more 02:18:39.610 --> 02:18:43.467 elaborate theory of this in years to come. And 02:18:43.550 --> 02:18:47.160 Breuer collaborate on a book called Studies in Hysteria, 02:18:48.290 --> 02:18:53.820 and they're a series of case vignettes in there of patients Freud has treated. 02:18:54.650 --> 02:18:58.517 And he develops the notion that people have these 02:18:58.600 --> 02:19:02.287 past experiences. Initially, he thinks they're real, that they're-- For 02:19:02.370 --> 02:19:05.330 example, they have been sexually assaulted as a child, 02:19:06.170 --> 02:19:10.047 and that they can't face that, and so they hide it away 02:19:10.130 --> 02:19:14.000 from themselves. But they can't completely, so it emerges in this tortured 02:19:14.090 --> 02:19:16.750 series of forms. And 02:19:18.030 --> 02:19:23.667 as things develop, the notion of resistances emerges, that you can't easily 02:19:23.750 --> 02:19:27.387 retrieve these memories, and indeed, you resist them 02:19:27.470 --> 02:19:31.410 surfacing, and you have a hard time acknowledging them. And only 02:19:31.510 --> 02:19:37.490 with long and painful work will it become possible for-- But as you 02:19:38.830 --> 02:19:42.710 bring them into-- from the unconscious into the conscious world, 02:19:43.250 --> 02:19:47.087 you learn to cope with them in a different way and, and your personality 02:19:47.170 --> 02:19:49.070 is transformed and you're made better. 02:19:49.310 --> 02:19:53.330 - But crucially, the stuff that happens in childhood is important. 02:19:53.470 --> 02:19:57.869 - Yes. The early experiences have a dramatic effect, 02:19:57.952 --> 02:20:00.710 and I think even some biological 02:20:00.810 --> 02:20:04.747 psychiatrists would agree with that notion these days. That, 02:20:04.830 --> 02:20:08.547 you know, to the extent we abolish this distinction between mind and 02:20:08.630 --> 02:20:13.260 body and, and acknowledge that they are closely tied together, um, 02:20:14.390 --> 02:20:18.147 traumatic experiences in childhood, various socialization 02:20:18.230 --> 02:20:24.922 experiences, loss and so on deeply mark the human psyche, I think, and, 02:20:25.005 --> 02:20:26.150 and can have 02:20:27.430 --> 02:20:30.590 long-term effects that are, are very powerful. 02:20:31.050 --> 02:20:34.607 - Of course Freud added a bunch of stuff in the realm of 02:20:34.690 --> 02:20:37.910 psychosexual stages of childhood. 02:20:38.130 --> 02:20:41.870 - Yes. As he begins to develop his theories, he more and more 02:20:42.010 --> 02:20:48.346 comes to see at first the libido, which gets sort of transformed into the sex 02:20:48.430 --> 02:20:52.187 drive- ... And sexual experiences and the repression of 02:20:52.270 --> 02:20:56.530 sexuality and the modification of sexuality as people grow. 02:20:57.530 --> 02:21:01.300 Um, all of that enters the picture. It's one of the things that 02:21:01.400 --> 02:21:05.377 ends up dividing Freud and Jung, Jung somewhat because 02:21:05.460 --> 02:21:10.170 Jung downplays that sexual side of things after the break. 02:21:11.250 --> 02:21:18.250 Um, but so Freud develops a very complicated theory of mind initially 02:21:19.100 --> 02:21:22.400 reflecting his training as a neurologist. 02:21:23.300 --> 02:21:26.650 He tries to write an essay which survives called Project for a 02:21:26.740 --> 02:21:30.477 Scientific Psychology, and the scientific psychology is gonna 02:21:30.560 --> 02:21:33.780 tie psychology back into neurology. 02:21:34.740 --> 02:21:37.970 But he abandons that, and once he's abandoned that, 02:21:38.600 --> 02:21:42.400 he goes on to develop increased... an increasingly elaborate theory. He 02:21:42.500 --> 02:21:46.397 writes The Interpretation of Dreams, for example, because he 02:21:46.480 --> 02:21:53.480 begins to regard dreams as an arena where these hidden memories, these suppressed- 02:21:53.860 --> 02:22:00.760 ... things reemerge in disguised form in your dream life. And so 02:22:00.980 --> 02:22:06.000 that book marks an important step forward. He becomes 02:22:06.100 --> 02:22:11.290 interested in things like slips of the tongue, so-called Freudian mistakes. 02:22:11.380 --> 02:22:14.980 As seeing those as revealing what really is hidden from you. 02:22:15.700 --> 02:22:20.980 And so there's this very elaborate dissection of things that relies upon 02:22:21.900 --> 02:22:25.920 long extended talk therapy. 02:22:26.300 --> 02:22:30.280 - Of course underlying it he's building a 02:22:30.420 --> 02:22:34.167 model of how this whole mind thing works. There's- 02:22:34.250 --> 02:22:37.897 ... three interacting parts of the personality. First the id, which is the 02:22:37.980 --> 02:22:41.637 primitive entirely unconscious driven by pleasure principle seeking 02:22:41.720 --> 02:22:45.100 immediate gratification or basic drives such as sex and aggression. 02:22:45.620 --> 02:22:49.360 There's the ego, which is the rational mediator 02:22:49.520 --> 02:22:53.137 operating under reality principle balancing the id's demands with 02:22:53.220 --> 02:22:56.680 external reality. And finally, the super ego, 02:22:57.180 --> 02:23:00.957 which is the internalized moral standards and ideals producing 02:23:01.040 --> 02:23:06.617 guilt or pride and striving for perfection. So that's the structure. 02:23:06.700 --> 02:23:10.570 - Yeah. That is broadly speaking the structure that Freud ends up with, 02:23:11.280 --> 02:23:14.977 and the conflicts between these entities and 02:23:15.060 --> 02:23:19.940 the ways they interact are obviously the thing that 02:23:21.400 --> 02:23:25.300 creates your mental universe, your way of being in the world and 02:23:25.580 --> 02:23:29.700 in many cases creates pathology, which 02:23:30.640 --> 02:23:34.920 through the process of psychoanalysis you can transform 02:23:36.080 --> 02:23:39.900 grotesque unhappiness into ordinary unhappiness or something like that. 02:23:40.500 --> 02:23:45.000 You know? So- - Yeah, sure - Yes, you get that. And initially, 02:23:45.580 --> 02:23:50.052 Jung gets one of the heirs to the International Harvester fortune as 02:23:50.135 --> 02:23:51.140 a patient, and, 02:23:52.000 --> 02:23:57.157 um, the McCormick family are as rich as the Rockefellers 02:23:57.240 --> 02:24:02.410 and the Carnegies and the, you know, the Vanderbilts of that world. 02:24:02.940 --> 02:24:06.870 This guy is a US senator who ends up committing 02:24:06.980 --> 02:24:10.160 suicide in nineteen twenty-five after a lot of treatment from, 02:24:11.140 --> 02:24:14.957 from Jung when he fails to win reelection to the US Senate. He 02:24:15.040 --> 02:24:18.640 kills himself in Washington in the interregnum. But he also gets 02:24:19.020 --> 02:24:22.470 another one of that brood. One of the Rockefeller daughters, 02:24:22.800 --> 02:24:26.080 Edith Rockefeller marries a McCormick. 02:24:26.200 --> 02:24:30.097 And she has a lot of psychological issues, and she tries 02:24:30.180 --> 02:24:32.300 to get Jung to move to Chicago 02:24:33.140 --> 02:24:37.100 promising him she'll set him up in a mansion with lots of her 02:24:37.220 --> 02:24:40.840 friends as his patients, and Jung has no interest. 02:24:41.820 --> 02:24:46.060 So then she finally persuades him to come 02:24:47.300 --> 02:24:50.837 to New York and accompany her on the liner across to 02:24:50.920 --> 02:24:54.720 Zurich to be treated. She's agoraphobic, and 02:24:54.820 --> 02:24:58.600 so she has a hard time being out, out of her little cocoon. 02:24:59.380 --> 02:25:03.200 So she's treated there as an example of how peculiar she was. I 02:25:03.360 --> 02:25:09.060 mentioned the agoraphobia. So she occupies a huge array of suites with all her 02:25:09.160 --> 02:25:13.057 servants and so on in Zurich. And she takes a 02:25:13.140 --> 02:25:16.997 train journey, it's stopping train, and her chauffeur 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 02:25:20.980 --> 02:25:24.717 a station 'cause she can't bear it anymore. And she becomes a 02:25:24.800 --> 02:25:28.640 Jungian analyst, but she's very wealthy and she writes 02:25:28.760 --> 02:25:32.417 big checks to Jung which is the important thing. And then Jung 02:25:32.500 --> 02:25:35.780 attracts Paul Mellon and his wife Mary. 02:25:36.560 --> 02:25:40.020 And so Jung's works are published by Princeton 02:25:40.120 --> 02:25:43.780 University Press with a subvention from that Mellon Foundation. 02:25:44.500 --> 02:25:48.177 So it's a long-running thing. Freud doesn't get 02:25:48.260 --> 02:25:51.360 patients quite that rich. He gets some rich Americans. 02:25:51.820 --> 02:25:55.597 - We should say that Freud became-- Freud's ideas became quite 02:25:55.680 --> 02:25:59.900 popular among the intellectual and artist class in the nineteen twenties in America. 02:26:00.070 --> 02:26:03.390 - And another thing happened. World War I saw 02:26:04.540 --> 02:26:08.400 the breakdown of many soldiers from something that came 02:26:08.500 --> 02:26:14.577 to be labeled as shell shock. The label shell shock intimates its, the first 02:26:14.660 --> 02:26:18.597 theories about its origin, which was that shells bursting near 02:26:18.680 --> 02:26:22.317 you and bombs bursting near you shook up your body and your 02:26:22.400 --> 02:26:26.097 brain and created some physical damage that then 02:26:26.180 --> 02:26:30.670 accounted for the symptoms of shell shock: your mutism, your blindism, your 02:26:31.540 --> 02:26:34.960 constant shaking, your nightmares, all of that. 02:26:35.100 --> 02:26:38.747 But it became increasingly apparent that 02:26:38.830 --> 02:26:43.900 shell shock was actually a psychological thing. The trauma of war 02:26:44.720 --> 02:26:49.200 in significant number of cases brought about mental breakdowns. 02:26:50.180 --> 02:26:54.097 And in thinking about that, Freud's ideas about the 02:26:54.180 --> 02:26:58.057 unconscious mind and trauma and its connection 02:26:58.140 --> 02:27:01.957 to symptomatology acquired a new significance 02:27:02.040 --> 02:27:05.537 for a lot of people in that period. And then after the war, 02:27:05.620 --> 02:27:12.620 you're absolutely right among a certain smart section of society, those 02:27:13.660 --> 02:27:16.160 ideas developed a considerable purchase. 02:27:16.760 --> 02:27:20.360 Psychiatrists who were mostly stuck in the asylums 02:27:21.160 --> 02:27:24.917 dealing with psychotic patients wanted nothing to do with these 02:27:25.000 --> 02:27:28.160 ideas and this talk therapy. The mainstream 02:27:29.160 --> 02:27:32.980 psychotherapy which was mostly in a clinical setting 02:27:33.160 --> 02:27:39.540 Yeah, Freud's ideas were not popular. No. The only partial exception to that was 02:27:40.320 --> 02:27:44.260 The mental hospital in Washington DC--the only federal 02:27:44.360 --> 02:27:48.260 mental hospital, St. Elizabeths. William Alanson White, 02:27:48.360 --> 02:27:52.940 who was then the superintendent, was somewhat sympathetic to Freud's ideas and 02:27:54.080 --> 02:27:58.017 tried a bit, but you're talking about thousands 02:27:58.100 --> 02:28:01.917 of patients and the idea of talk therapy for them is obviously out of 02:28:02.000 --> 02:28:09.000 reach, plus they are much more severely disturbed, so it does happen. Novelists, 02:28:12.020 --> 02:28:15.040 painters, artists, playwrights, 02:28:16.160 --> 02:28:20.940 uh and the audience for those elite forms of culture 02:28:21.800 --> 02:28:28.611 do tend to embrace Freudian ideas. Sex sells in the theater and on the movies. 02:28:28.695 --> 02:28:33.771 Um, obviously. But beyond that, part of Freud's appeal to everybody, 02:28:33.854 --> 02:28:38.960 it was something he lamented at one point. He said, "You know, 02:28:39.660 --> 02:28:44.640 my case histories read like short stories. Like works of fiction. 02:28:46.100 --> 02:28:50.520 And in that sense, people think they lack the stamp of serious science. 02:28:51.380 --> 02:28:55.040 But I'm driven to that because that's how I unpack what's going on." 02:28:55.500 --> 02:28:59.440 Well, psychoanalysis is telling stories. It's getting people to recover 02:28:59.600 --> 02:29:02.740 stories, recover memories, to rebuild, right? 02:29:04.060 --> 02:29:11.060 Um, and its elements of psychological conflict and hidden motives and so forth 02:29:12.220 --> 02:29:15.817 naturally very appealing to people writing 02:29:15.900 --> 02:29:21.880 novels. People writing plays. People doing screenplays." And 02:29:22.700 --> 02:29:25.840 for artists of the modern sort 02:29:26.660 --> 02:29:33.660 the idea that we can extract things from the subconscious Surrealism and the 02:29:34.040 --> 02:29:37.797 like, for example, are clearly very heavily influenced by 02:29:37.880 --> 02:29:41.487 Freudian ideas But it's important to know circa 02:29:41.570 --> 02:29:46.920 1930 there are probably three hundred psychoanalysts in North America. 02:29:48.840 --> 02:29:53.720 if they each Classical psychoanalysis involving five hours a week 02:29:55.900 --> 02:29:59.740 They can't treat that many patients A few thousand 02:30:00.280 --> 02:30:03.770 when there are hundreds of thousands in the hospitals Right Mm-hmm So 02:30:04.140 --> 02:30:11.140 what changes that Hitler starts killing off Jews 02:30:12.340 --> 02:30:15.777 and killing off psychoanalysts The ones who can 02:30:15.860 --> 02:30:20.580 escape some of them go to England and some come to America 02:30:21.460 --> 02:30:25.257 the most famous escapee is Freud himself and his daughter 02:30:25.340 --> 02:30:28.897 Anna Who Princess Bonaparte who's one of 02:30:28.980 --> 02:30:32.210 Freud's great supporters bribes the Nazis to get him 02:30:32.300 --> 02:30:36.260 out And he travels by train to London Very sick with 02:30:36.840 --> 02:30:39.560 cancer of the jaw As he has been since the mid-'20s 02:30:40.440 --> 02:30:44.357 So he sets up shop in London and Anna succeeds him really 02:30:44.440 --> 02:30:48.177 as one of the central figures in British psychoanalysis But other 02:30:48.260 --> 02:30:53.920 analysts come here to America So the numbers of analysts probably by 02:30:54.820 --> 02:30:58.777 1940 America's not yet in the war have a bit more than 02:30:58.860 --> 02:31:02.417 doubled And more importantly psychoanalytic 02:31:02.500 --> 02:31:06.200 training has become much more organized here The institutes 02:31:06.540 --> 02:31:10.380 outside the universities control psych... And 02:31:10.500 --> 02:31:14.270 universities are not yet the knowledge factories they become after the 02:31:14.360 --> 02:31:17.517 war mm-hmm And that's a crucial mistake that 02:31:17.600 --> 02:31:22.380 psychoanalysis makes It's great because it controls its training completely 02:31:23.260 --> 02:31:27.000 The bad thing is when the center of gravity moves to the university 02:31:27.960 --> 02:31:34.457 it's not there and either resists being incorporated or the university resists 02:31:34.540 --> 02:31:38.477 incorporating it So I think that's a structural weakness for that 02:31:38.560 --> 02:31:45.560 But what really transforms things is World War II Five 02:31:47.840 --> 02:31:54.840 fifty minute hours famously They last fifty minutes 'cause then there's 02:31:55.780 --> 02:32:01.758 ten ten minutes for four analysts to recover before the next patient arrives 02:32:01.842 --> 02:32:02.675 Yes You 02:32:03.100 --> 02:32:10.100 are free associating on the couch 02:32:12.200 --> 02:32:16.860 and gradually being coaxed to see as material emerges 02:32:17.680 --> 02:32:19.280 what you're hiding from yourself 02:32:20.040 --> 02:32:23.867 I mean initially they tried This is in their early early days That they tried 02:32:23.950 --> 02:32:27.897 hypnosis yes But they've You know this is where Freud took the big leap and 02:32:27.980 --> 02:32:31.960 expanded free association Right So I mentioned 02:32:32.060 --> 02:32:36.850 Freud training under Charcot Charcot hypnotized his hysterical patients 02:32:37.980 --> 02:32:41.877 We now know a lot of that was fakery Not I don't think he 02:32:41.960 --> 02:32:45.637 was conscious of the fakery but the patients were on 02:32:45.720 --> 02:32:49.497 display over and over again and they worked their routines up very well and 02:32:49.580 --> 02:32:56.580 they deceived him and they deceived the audience But Freud came back from 02:32:57.220 --> 02:33:02.760 Paris bringing with him the idea that hypnosis was the way forward 02:33:04.040 --> 02:33:07.680 But after the break with Breuer Breuer had a general 02:33:07.780 --> 02:33:11.385 medical practice and lost interest in hysteria and didn't want anything to do 02:33:11.468 --> 02:33:15.180 with the revisions of Freud's work on hysteria 02:33:16.220 --> 02:33:22.440 After that happened Freud who was a very clumsy hypnotist by his own account 02:33:24.440 --> 02:33:28.237 began to develop this alternative of free association 02:33:28.320 --> 02:33:32.277 and getting people to speak whatever came into their head 02:33:32.360 --> 02:33:36.077 without a censor. That was the important thing, that the 02:33:36.160 --> 02:33:39.660 half-murdered memories were being hidden from you and your-- uh, 02:33:40.460 --> 02:33:43.907 the constellation of psychological forces in your unconscious was 02:33:43.990 --> 02:33:49.677 squashing them down but they were reemerging as other kinds of symptoms 02:33:49.760 --> 02:33:53.517 - So how well does psychoanalysis work? How 02:33:53.600 --> 02:33:58.340 much do we understand? We've talked about all these approaches that didn't work. 02:33:59.120 --> 02:34:00.820 How well did it work at that time? 02:34:01.020 --> 02:34:04.877 - You know, one of the things after World War II when psychoanalysis 02:34:04.960 --> 02:34:08.950 was making great strides in America and the Rockefeller Foundation was 02:34:09.040 --> 02:34:12.577 still heavily involved in promoting psychiatry and 02:34:12.660 --> 02:34:16.160 developing what it hoped would be new tools in it 02:34:16.980 --> 02:34:20.600 The then heads of the institute-- Of the 02:34:20.880 --> 02:34:24.340 funding program, Alan Gregg and Robert Morison, 02:34:24.680 --> 02:34:28.207 especially Morrison, kept pressing the analysts: 02:34:28.290 --> 02:34:31.140 "Provide us proof that what you do works." 02:34:31.960 --> 02:34:35.677 And the analyst kept resisting and resisting and resisting, saying 02:34:35.760 --> 02:34:39.677 "It's much more complicated than that. There's no easy measure because 02:34:39.760 --> 02:34:44.280 what we're doing is reconstructing entire personalities, entire ways of being." 02:34:45.780 --> 02:34:49.057 Sense People sense themselves, their ways of being in the world. 02:34:49.140 --> 02:34:52.250 "And we don't have easy ways to measure that." 02:34:52.500 --> 02:34:56.297 - To contrast that with the 80% promises over and 02:34:56.380 --> 02:34:57.617 over and over and over. Yes, yes, yes. 02:34:57.700 --> 02:35:01.700 - And it's a long and complicated pro... That was very important. Because 02:35:04.540 --> 02:35:10.417 another kind of psychotherapeutics is emerging in, in the aftermath, during 02:35:10.500 --> 02:35:14.440 and in the aftermath of the war as a rival for both 02:35:15.140 --> 02:35:19.120 psychiatry and for psychoanalysis. Initially 02:35:19.220 --> 02:35:23.057 not terribly successful, but as time goes on, 02:35:23.140 --> 02:35:26.588 a more and more important part of the story. 02:35:26.671 --> 02:35:29.560 So to focus on the war for a minute, 02:35:29.680 --> 02:35:33.357 Um, America's psychiatrists went to the military 02:35:33.440 --> 02:35:37.317 brass and to the politicians before America entered the 02:35:37.400 --> 02:35:41.220 war, and it had some advance warning because America didn't enter till 02:35:41.320 --> 02:35:45.137 Pearl Harbor, but the European war had been going on. And they said, 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 02:35:48.820 --> 02:35:52.607 First World War. We're gonna train these soldiers, gonna equip 02:35:52.690 --> 02:35:56.197 them, we're gonna put them in the battlefield and the 02:35:56.280 --> 02:36:00.180 psychologically vulnerable among them are gonna break down." 02:36:00.740 --> 02:36:07.740 "They'll be shell shock all over again, so we should screen all recruits to make 02:36:08.720 --> 02:36:12.880 sure they're not psychologically weak and susceptible." 02:36:14.820 --> 02:36:18.720 And they screen out 1 3/4 million people 02:36:20.100 --> 02:36:23.977 and say, "These men are not fit. So now we won't have the 02:36:24.060 --> 02:36:27.000 problems we had in World War I." Except 02:36:28.150 --> 02:36:35.060 it quickly turns out that those problems reemerge. Industrial warfare 02:36:37.080 --> 02:36:41.710 exposes people to seeing things and doing things 02:36:42.480 --> 02:36:45.920 that all of us in normal life would recoil from. 02:36:47.200 --> 02:36:51.780 And when we're forced to do them as soldiers, many of us-- 02:36:52.840 --> 02:36:58.054 Can't speak from experience, but from talking to people who've gone through all 02:36:58.138 --> 02:36:58.971 this-- 02:36:59.640 --> 02:37:03.517 Uh, many of them find the experiences and 02:37:03.600 --> 02:37:07.537 the memories those create intolerable. And they emerge in symptoms 02:37:07.620 --> 02:37:08.620 and they break down. 02:37:09.460 --> 02:37:13.277 So it became a huge problem for the American Army, as it did for all 02:37:13.360 --> 02:37:16.790 the armies. Actually, the Nazis just shot people. 02:37:18.660 --> 02:37:22.340 Broke down, bang, you're dead. We're not dealing with you. 02:37:23.340 --> 02:37:30.340 But, um, obviously the Allies, that was not the response. Um, and they quickly had 02:37:30.860 --> 02:37:36.960 to try to treat these troops, maybe get them back into the fighting 02:37:38.660 --> 02:37:42.397 lines, maybe get them into support positions. 02:37:42.480 --> 02:37:46.220 Something to cope with the problem, which was both, um, 02:37:47.000 --> 02:37:50.520 created extraordinary morale problems among the troops 02:37:50.800 --> 02:37:54.717 and it invited malingering, claiming you had these 02:37:54.800 --> 02:38:00.120 conditions when you didn't. It obviously cost a lot of the fighting force. 02:38:00.960 --> 02:38:04.750 In combat conditions, as much as 25% of the soldiers broke 02:38:04.840 --> 02:38:07.060 down. So it was a big, big problem. 02:38:09.280 --> 02:38:15.100 Before the war, there were about 2,000 psychiatrists in North America, in the US. 02:38:16.920 --> 02:38:20.677 At the end of the war, there were more than 2,000 psychiatrists in the US 02:38:20.760 --> 02:38:25.900 military. Okay, so you had to train people in a hurry, um, 02:38:26.960 --> 02:38:30.520 and even still, it was hard to get enough people 02:38:30.620 --> 02:38:34.597 trained. And it turned out that the head of the 02:38:34.680 --> 02:38:38.657 US military, not the first, but the first one died, the second 02:38:38.740 --> 02:38:42.377 one uh was a man named William Menninger from the 02:38:42.460 --> 02:38:46.060 Menninger Clinic in Kansas, where he and his brother 02:38:46.620 --> 02:38:49.820 ran a psychoanalytic treatment facility. 02:38:51.020 --> 02:38:54.820 So Bill Menninger became the head of Army psychiatry. 02:38:55.560 --> 02:38:59.417 He concluded that the best treatment for these soldiers breaking 02:38:59.500 --> 02:39:03.217 down was psychotherapeutic in nature. The origin of their 02:39:03.300 --> 02:39:09.200 condition was trauma, uh, and so in a watered-down way, Freud's 02:39:09.300 --> 02:39:12.917 ideas, those were the ones that the people that recruited 02:39:13.000 --> 02:39:19.460 quickly and retrained as psychiatrists absorbed. So they formed after the war 02:39:20.300 --> 02:39:22.640 a fairly coherent group of people, 02:39:23.620 --> 02:39:27.557 separate from the psychiatrists in the state hospitals who were still 02:39:27.640 --> 02:39:29.350 very biologically oriented. 02:39:31.980 --> 02:39:36.008 Another group emerged during the war precisely because you couldn't produce 02:39:36.091 --> 02:39:36.924 enough 02:39:37.500 --> 02:39:43.080 psychotherapists who were MDs quickly enough. Psychologists were drafted in 02:39:43.900 --> 02:39:49.480 and asked to treat. So what the psychologists discovered was, 02:39:49.820 --> 02:39:54.327 "Hey, we could do this stuff too, and we really like it." "It's interesting-" 02:39:54.410 --> 02:40:00.420 "...it's challenging. We should do that." So after the war, similar kind of problem. 02:40:01.640 --> 02:40:05.617 Mental illness is a massive problem. The returning soldiers, it's a big problem, 02:40:05.700 --> 02:40:09.800 but it's also a problem in the community. Um, 02:40:10.780 --> 02:40:14.657 these guys don't... The psychiatrists don't go and work in the 02:40:14.740 --> 02:40:20.617 mental hospital. They start outpatient treatment. And by 02:40:20.700 --> 02:40:26.837 1958, about 80% of psychiatrists are working in 02:40:26.920 --> 02:40:29.780 outpatient rather than in the hospitals, right? 02:40:30.580 --> 02:40:34.217 So the psychologists organize themselves and federal 02:40:34.300 --> 02:40:37.657 money -- Again, "We need you. We need you. We need more of 02:40:37.740 --> 02:40:41.057 you." So the VA, the Veterans 02:40:41.140 --> 02:40:44.917 Administration, and then once the National Institute of 02:40:45.000 --> 02:40:48.817 Mental Health is established, they start providing a lot of money 02:40:48.900 --> 02:40:52.840 for training, and they train not just psychiatrists, they train 02:40:52.960 --> 02:40:56.860 psychologists. So the question is: How are the psychologists gonna set 02:40:56.960 --> 02:40:58.290 up clinical training? 02:40:59.120 --> 02:41:03.057 So what the psychologists come up with, the clinically oriented 02:41:03.140 --> 02:41:10.140 ones, is a training program where would-be clinical psychologists spend two years 02:41:12.680 --> 02:41:16.500 learning basic scientific psychology 02:41:16.600 --> 02:41:20.557 and research methods, and then they have two or three years 02:41:20.640 --> 02:41:26.850 of clinical work and an experience. And that's very clever because 02:41:27.840 --> 02:41:31.777 it means when they start looking for grants, they know how to 02:41:31.860 --> 02:41:35.677 do that, and the psychoanalysts don't have a clue how to apply for federal 02:41:35.760 --> 02:41:37.910 grant money, and they don't get any almost. 02:41:38.700 --> 02:41:42.020 Beyond that, these people begin to work on 02:41:42.300 --> 02:41:46.157 treating symptoms. The psychoanalysts think to treat a symptom is to 02:41:46.240 --> 02:41:49.620 play Whac-A-Mole. If you don't deal with the underlying 02:41:49.740 --> 02:41:55.521 problems of the personality, their interaction between your id ego 02:41:55.605 --> 02:41:56.760 and superego, 02:41:58.380 --> 02:42:01.630 you suppress that symptom, and another one will pop up over here. 02:42:04.080 --> 02:42:07.977 The clinical psychologists go, "We're gonna treat the symptoms of what 02:42:08.060 --> 02:42:12.907 are troubling people. We're gonna treat the symptoms, and we're gonna develop 02:42:12.990 --> 02:42:19.817 techniques that allow people to cope with those symptoms 02:42:19.900 --> 02:42:25.460 and eliminate them." And how are we gonna do that? We're going to do it 02:42:26.000 --> 02:42:31.860 primarily through what initially is cognitive behavioral therapy and 02:42:31.960 --> 02:42:37.060 later interpersonal therapy and some other variants emerge. But basically, what 02:42:37.900 --> 02:42:43.672 they try to do with those techniques is develop things that work relatively 02:42:43.755 --> 02:42:44.589 quickly, 02:42:45.260 --> 02:42:51.180 work specifically on one set of problems or small subset of problems, 02:42:52.020 --> 02:42:55.857 and try to get those under control. And how does 02:42:55.940 --> 02:42:59.120 it work? You've developed really bad habits. 02:43:00.440 --> 02:43:04.400 You... The way you react to being socially snubbed 02:43:04.500 --> 02:43:10.350 or being ignored or the way you deal with your coworkers or the 02:43:11.750 --> 02:43:14.740 trouble you're having with your disruptive child 02:43:16.460 --> 02:43:19.720 will help you see the patterns that you've fallen into 02:43:20.440 --> 02:43:24.257 and will give you exercises that will work to give 02:43:24.340 --> 02:43:28.237 you a better way of coping with those things that don't produce these 02:43:28.320 --> 02:43:32.017 symptoms. I'm oversimplifying obviously, but basically that's the 02:43:32.100 --> 02:43:33.540 fundamental thrust of this. 02:43:33.940 --> 02:43:38.610 - And one of the other contrasting things about CBT, Cognitive Behavioral Therapy, 02:43:39.460 --> 02:43:45.920 is that it doesn't have necessarily that heavy requirement of five hours a week. 02:43:46.060 --> 02:43:51.377 - Exactly. So these therapies could be packaged. They could be reproduced. 02:43:51.460 --> 02:43:54.360 They could be tested to see whether they worked, 02:43:55.380 --> 02:43:59.297 so they had an evidentiary foundation. The psychoanalyst would say, "It's gonna take 02:43:59.380 --> 02:44:03.337 us years, and it's hard to measure." These guys went, "Well, we'll 02:44:03.420 --> 02:44:07.210 measure what happens when we treat people this way?" 02:44:07.460 --> 02:44:08.293 - Psychologists. 02:44:08.400 --> 02:44:12.377 - Uh, yeah. The symptoms are what matter, not the underlie-- you know, the 02:44:12.460 --> 02:44:17.150 underlying more complex thing that psychoanalysts claimed to be treating. 02:44:18.200 --> 02:44:24.360 And so it's shorter. It's reproducible 02:44:25.540 --> 02:44:29.357 whereas psychoanalytic-- You know, every patient is a new patient, a new-- with a 02:44:29.440 --> 02:44:35.780 new set of complicated things going on. Here we are. We're gonna do this. 02:44:35.980 --> 02:44:40.580 - And the key figures here are Albert Bandura, Albert Ellis, Aaron Beck. 02:44:40.760 --> 02:44:44.880 - Yes. Um, Bandura and some other psychologists 02:44:45.700 --> 02:44:51.577 launching this movement, and then later on Aaron Beck, who went by 02:44:51.660 --> 02:44:58.527 Tim Beck who just recently died at... I think he was ninety-nine. Extraordinary. 02:44:58.610 --> 02:44:59.737 - No, no, I think he crossed 100. 02:44:59.820 --> 02:45:01.940 - Maybe 100. Yeah. Maybe 100. 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 02:45:06.100 --> 02:45:10.440 it, so wise. - Aaron Beck is a remarkable figure because he was 02:45:10.540 --> 02:45:17.260 also one of the first in the 1960s to look at psychiatric diagnosis 02:45:18.160 --> 02:45:22.017 and show how unreliable it was, how-- how difficult 02:45:22.100 --> 02:45:25.020 it was to get psychiatrists to agree on what was wrong. 02:45:25.220 --> 02:45:26.817 - So he was a psychoanalyst, right? 02:45:26.900 --> 02:45:30.157 - He had been trained as a psychoanalyst, became 02:45:30.240 --> 02:45:33.900 disillusioned with it, and so there were two strands, two important 02:45:34.020 --> 02:45:37.420 strands that stemmed from his work. First, this... 02:45:38.120 --> 02:45:41.320 He was one of the ones within the community itself 02:45:41.920 --> 02:45:45.717 who said to his fellow psychiatrists, "You know, we're 02:45:45.800 --> 02:45:48.793 not very good at this diagnosis business--" "... 02:45:48.877 --> 02:45:51.120 and maybe we need to work on that." 02:45:51.400 --> 02:45:55.500 Okay? And that was very important for the movement towards DSM-III. 02:45:57.160 --> 02:45:58.940 The other side of the coin was 02:45:59.920 --> 02:46:03.970 he broke with the idea that treating symptoms was a waste of time, 02:46:05.280 --> 02:46:08.997 and joined with the psychologists who already 02:46:09.080 --> 02:46:15.367 embarked on that journey to say, "How can we develop techniques to overcome 02:46:15.450 --> 02:46:21.800 these self-destructive ways in which people are responding? How can we help 02:46:22.840 --> 02:46:27.877 with their ability to interact?" So interpersonal 02:46:27.960 --> 02:46:31.800 therapy is, you know, much more concerned with the way in which 02:46:32.220 --> 02:46:35.997 if your relations with other people break down, that 02:46:36.080 --> 02:46:39.397 damages your emotional stability. If you 02:46:39.480 --> 02:46:42.957 repair those relationships, that helps your emotional 02:46:43.040 --> 02:46:50.040 stability come back. So all of this develops, and Americans are unusual. The-- 02:46:52.580 --> 02:46:56.320 Most of the rest of the world has what we call socialized medicine. 02:46:57.600 --> 02:47:01.200 Um, America doesn't have that, so we're used to paying for medical care. 02:47:01.880 --> 02:47:08.680 And so Americans were more willing, I think, to pay for clinical psychologists, 02:47:09.480 --> 02:47:14.700 and they attacked some of the problems of everyday living, the more 02:47:15.560 --> 02:47:20.070 uh, I was gonna say minor, but these are often quite distressing things. But 02:47:20.920 --> 02:47:24.777 those were-- those were the things they were most successful at doing. If I 02:47:24.860 --> 02:47:28.720 look at the literature on CBT, for example, and its 02:47:28.820 --> 02:47:32.460 uses in cases of schizophrenia, the evidence is pretty 02:47:32.580 --> 02:47:39.580 poor that it works. And even the evidence for the milder conditions is a bit more 02:47:40.240 --> 02:47:43.940 ambiguous than we like... That they like to pretend. 02:47:44.590 --> 02:47:48.057 The Cochrane Reviews, which are a systematic attempt to 02:47:48.140 --> 02:47:51.340 assess how strong the evidence for particular 02:47:52.120 --> 02:47:55.957 approaches to disease of all sorts are, say 02:47:56.040 --> 02:47:59.850 that at best, the evidence for CBT is of low and 02:47:59.980 --> 02:48:03.580 medium confidence, you know? But I think, again, 02:48:04.320 --> 02:48:07.417 there are patients for whom this helps, and 02:48:07.500 --> 02:48:14.500 indeed, for the milder forms of depression, I think CBT works better 02:48:15.560 --> 02:48:19.317 than the drugs without some of the side effects that the, the 02:48:19.400 --> 02:48:22.880 drugs have. And indeed, NICE, which is the 02:48:23.020 --> 02:48:26.300 British organization that passes on what treatments 02:48:26.500 --> 02:48:30.277 the National Health Service will support and which 02:48:30.360 --> 02:48:36.340 ones are, are sufficiently evidence-based has come to that same conclusion. 02:48:36.480 --> 02:48:38.930 - So I think one thing to just say about cognitive behavioral therapy, 02:48:39.013 --> 02:48:39.847 I mean, it's-- 02:48:40.760 --> 02:48:47.760 It has some elements of kind of surface level intuitive kind of things like-- 02:48:50.500 --> 02:48:54.217 ... being aware of and adjusting your thought patterns, being 02:48:54.300 --> 02:48:57.867 aware of triggers that get you-- down a negative spiral-- - Exactly 02:48:57.950 --> 02:48:59.850 -... and then basic behavior changes, 02:49:00.680 --> 02:49:05.620 habit changes that lead to a healthier life. So I think, I think this kinda, 02:49:07.020 --> 02:49:10.677 you know, getting your life together kind of process- 02:49:10.760 --> 02:49:14.557 ... is intuitive that that would have a positive effect on some 02:49:14.640 --> 02:49:18.390 percent of the population. But as you get more serious and serious into the 02:49:18.560 --> 02:49:24.180 land of mental disorders, it starts to be a little bit less conclusive. 02:49:24.580 --> 02:49:28.380 - Yes. I think that's an accurate statement of what-- the way 02:49:28.520 --> 02:49:32.477 I read the literature. And it's not a cure-all, but 02:49:32.560 --> 02:49:36.240 for some patients, this really does seem to improve things 02:49:36.680 --> 02:49:40.457 quite a lot. And it does make sense that you 02:49:40.540 --> 02:49:45.880 have developed poor ways of responding to signals from the outside world, 02:49:46.780 --> 02:49:51.837 and they've become habitual, and they've -- habits, as we know, are very 02:49:51.920 --> 02:49:52.900 hard to break. 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 02:49:57.403 --> 02:50:02.540 to try to reconfigure the ways you deal with the world. 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 02:50:07.520 --> 02:50:13.820 set, subset of people for whom this seems to have positive effects. 02:50:14.440 --> 02:50:19.140 - So this, this is the lay of the land. We talked about some of the darkness. 02:50:20.060 --> 02:50:23.857 Lobotomies and so on. There is some talk therapy ideas of 02:50:23.940 --> 02:50:27.840 psychoanalysis, and then there is, from the clinical psychology 02:50:27.960 --> 02:50:34.960 side, cognitive behavioral therapy. Then starts to emerge the psychopharmacology- 02:50:36.220 --> 02:50:39.460 ...that challenges this whole shebang of talk therapy, 02:50:39.700 --> 02:50:46.660 period. And can you talk about the accidental origins of psychopharmacology- 02:50:47.000 --> 02:50:48.800 ...that challenges this whole thing? 02:50:49.140 --> 02:50:52.700 - Hardly anybody had conceived of the idea that drugs could be 02:50:52.840 --> 02:50:54.580 used to treat mental illness. 02:50:55.400 --> 02:50:59.080 Drugs had been used in the mental hospitals back in the 19th and 02:50:59.220 --> 02:51:03.097 20th centuries, but they were usually things that were used 02:51:03.180 --> 02:51:06.737 to control patients, to calm them down. Opiates, for 02:51:06.820 --> 02:51:10.700 example various hypnotics that would put people 02:51:10.800 --> 02:51:16.246 to sleep when they were extremely agitated, and so forth. 02:51:16.329 --> 02:51:18.517 Sometimes marijuana was 02:51:18.600 --> 02:51:22.517 experimented with, as was alcohol in the 19th century interestingly 02:51:22.600 --> 02:51:26.633 enough-... given the revival of psychedelics. 02:51:26.716 --> 02:51:33.630 But the idea that a drug might be used to actually attack the underlying problem, 02:51:35.060 --> 02:51:41.690 it emerged by accident in the following kind of way. The drug industry in general 02:51:43.250 --> 02:51:44.083 Had emerged 02:51:44.870 --> 02:51:48.467 mostly in Germany, where I'd mentioned the most advanced medicine was being 02:51:48.550 --> 02:51:52.407 practiced in the late 19th century. From the 02:51:52.490 --> 02:51:57.444 chemical industry from, for example, refining coal tar into different 02:51:57.527 --> 02:51:58.360 substances, 02:51:59.510 --> 02:52:04.090 that's where we got aspirin. That's where we got a whole bunch of drugs. 02:52:05.090 --> 02:52:08.847 And gradually, the drug companies become more organized. They 02:52:08.930 --> 02:52:13.839 differentiate themselves from all the quack remedies that are around. 02:52:13.922 --> 02:52:14.790 And the war, 02:52:15.810 --> 02:52:19.527 I think greatly accelerates-- Again World War II 02:52:19.610 --> 02:52:23.567 greatly accelerates things, not least because we discover a 02:52:23.650 --> 02:52:27.127 real magic bullet called penicillin and then the other 02:52:27.210 --> 02:52:30.620 antibiotics that we subsequently come across. 02:52:31.510 --> 02:52:35.307 Penicillin had been observed by Alexander Fleming in 02:52:35.390 --> 02:52:39.267 his, famously, in his lab in some Petri tube 02:52:39.350 --> 02:52:43.227 Petri dishes where bacteria had been killed. Later was one 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 02:52:47.010 --> 02:52:50.300 discovery. It was really Howard Florey and his team at Oxford 02:52:50.950 --> 02:52:56.110 who developed the therapeutic potential of penicillin. 02:52:57.650 --> 02:53:01.270 And actually, Florey flew some of it in his jacket 02:53:01.390 --> 02:53:08.290 across the Atlantic to America, and it was Americans that solved the critical thing. 02:53:09.290 --> 02:53:12.687 It took Florey and his team weeks to 02:53:12.770 --> 02:53:16.674 develop enough penicillin to treat a single mouse. 02:53:16.758 --> 02:53:19.150 What America learned how to do 02:53:19.990 --> 02:53:23.927 was mass produce penicillin. And that 02:53:24.010 --> 02:53:27.270 was critical because it was vital to the war effort 02:53:27.710 --> 02:53:31.647 obviously. And after the war, it was vital 02:53:31.730 --> 02:53:36.150 to the civilian population because it was such an important breakthrough. 02:53:37.270 --> 02:53:44.087 So drugs, drug companies grew fatter on that. They 02:53:44.170 --> 02:53:48.870 embarked on research to try to find new substances they could use to treat things. 02:53:49.850 --> 02:53:53.490 Um, and a French company named Rhône-Poulenc 02:53:55.670 --> 02:53:59.547 came across a chemical that had actually been synthesized back in the 02:53:59.630 --> 02:54:03.040 1880s in Germany. It was an antihistamine, 02:54:03.210 --> 02:54:07.007 chlorpromazine. They didn't know what to do with it, but other 02:54:07.090 --> 02:54:10.140 kinds of antihistamines in the war had been used effectively, 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." 02:54:15.710 --> 02:54:19.607 And so they... The interesting thing to remember in 02:54:19.690 --> 02:54:23.597 those days is that investigating the property of new drugs was 02:54:23.680 --> 02:54:27.487 a Wild West phenomenon. There were no controls. You could 02:54:27.570 --> 02:54:31.357 do whatever you wanted, and you handed stuff out and said, 02:54:31.440 --> 02:54:35.287 "Why don't you try this and see if it works?" Right? So Rhône- 02:54:35.370 --> 02:54:39.210 Poulenc did that. They thought this might work as an 02:54:39.350 --> 02:54:42.987 antiemetic. If you have a child who's prone to car 02:54:43.070 --> 02:54:45.350 sickness, you give them an antiemetic drug. 02:54:46.270 --> 02:54:49.827 So that was one possibility. Another possibility, it might work for 02:54:49.910 --> 02:54:53.787 eczema so that people didn't scratch themselves. Well, there were a 02:54:53.870 --> 02:54:57.787 number of possibilities and somebody said, "Well maybe it will work as 02:54:57.870 --> 02:55:01.787 an anesthetic potentiator," meaning if you gave 02:55:01.870 --> 02:55:05.767 some of these you need to use less anesthetic or would act like a 02:55:05.850 --> 02:55:09.807 catalyst because it tended to make you sleepy. If you 02:55:09.890 --> 02:55:13.687 read the leaflets on Dramamine, one of the cautions is 'it'll 02:55:13.770 --> 02:55:16.750 make you sleepy, don't drive,' right? So 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? 02:55:22.070 --> 02:55:28.207 Literally it's like that. And one of the people who gets that drug is a 02:55:28.290 --> 02:55:32.230 lieutenant in the French Navy, Henri Laborit, 02:55:33.490 --> 02:55:37.407 and he tries it as an anesthetic potentiator and he also gives it to some 02:55:37.490 --> 02:55:43.150 of the patients who are awaiting surgery. Normally when you're awaiting surgery, 02:55:43.690 --> 02:55:48.447 you're a little bit anxious. These patients stop being anxious. 02:55:48.530 --> 02:55:52.367 Um, this was the era of lobotomies and he wrote to 02:55:52.450 --> 02:55:56.107 one of his relatives who worked in one of the Paris mental hospitals. He said, "This 02:55:56.190 --> 02:55:59.917 like, this works like a chemical lobotomy. These people don't care 02:56:00.000 --> 02:56:02.747 anymore about their surgery." - And that's supposed to be a good thing, right? 02:56:02.830 --> 02:56:07.710 - Well, lobotomy hadn't become the nasty word it would become in a few years. 02:56:08.670 --> 02:56:12.467 So one of his colleagues contacts Delay and Deniker, who 02:56:12.550 --> 02:56:16.337 work at Saint-Anne's which is the biggest mental hospital in Paris and says, 02:56:16.420 --> 02:56:19.430 "Hey guys this might work on your 02:56:19.910 --> 02:56:23.510 psychiatric patients. You should give it a try." And they do. 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 02:56:27.969 --> 02:56:32.110 a large dose and sure enough patients 02:56:32.210 --> 02:56:35.907 stopped acting out. They stopped smashing furniture. They 02:56:35.990 --> 02:56:42.730 become-- They're still sorta conscious but they're less mobile and they're 02:56:43.730 --> 02:56:49.090 much calmer. And this is why in the early stages 02:56:49.190 --> 02:56:52.907 Chlorpromazine which becomes known as Largactil or 02:56:52.990 --> 02:56:55.910 Mighty Drug in Europe and Thorazine here, 02:56:56.730 --> 02:56:59.797 it becomes known as a major tranquilizer because it has this 02:56:59.880 --> 02:57:03.547 tranquilizing effect. The hospitals see it as a boon 02:57:03.630 --> 02:57:07.430 because it'll help control the patients. They're not yet thinking of it 02:57:07.530 --> 02:57:11.387 as more than that. So that's the accidental way it, way it's 02:57:11.470 --> 02:57:15.860 discovered. It comes to North America via Quebec, 02:57:16.230 --> 02:57:19.147 where there's a psychiatrist up there Heinz 02:57:19.230 --> 02:57:23.047 Lehmann who actually works in the Protestant Hospital. Québec in those 02:57:23.130 --> 02:57:28.150 days is dominated by its Anglo speaking elite who oppressed 02:57:29.800 --> 02:57:32.470 the French Canadians pretty mightily 02:57:33.410 --> 02:57:37.570 But because of the French connection, he gets amounts of the drug. 02:57:50.810 --> 02:57:57.070 Rhône-Poulenc has had to sell the rights to an American company. 02:57:58.430 --> 02:58:01.927 In those days, American physicians don't trust European science or 02:58:02.010 --> 02:58:06.847 European medicine-- especially European medicine. So 02:58:06.930 --> 02:58:10.407 Rhône-Poulenc sells the rights. The first two drug companies it 02:58:10.490 --> 02:58:14.287 approaches say, "No thank you. This doesn't look very interesting to us. I 02:58:14.370 --> 02:58:18.187 don't think there's much of a market." And then SmithKline & French buys it 02:58:18.270 --> 02:58:25.270 up and within two years, two million people are taking this drug. It's a 02:58:25.790 --> 02:58:29.667 bonanza for them right? Not an accident 'cause 02:58:29.750 --> 02:58:33.587 they put their best salesman on the job of selling this 02:58:33.670 --> 02:58:37.447 and they realize the hospital psychiatrists mostly aren't 02:58:37.530 --> 02:58:41.270 interested. They haven't yet gotten to this idea of a chemical 02:58:41.490 --> 02:58:44.807 cure or a chemical treatment. - So it's the companies that wake up to this? 02:58:44.890 --> 02:58:47.690 - The companies wake up, they sell it to the 02:58:48.150 --> 02:58:51.510 politicians. They go to the state legislatures. They have 02:58:52.490 --> 02:58:56.950 moving pictures of an agitated patient who turns calm, you know. 02:58:57.170 --> 02:59:00.530 - So this is already the mechanism of big pharma? 02:59:00.750 --> 02:59:04.647 - Yeah. So it's starting to be big pharma. It transforms Smith Kline 02:59:04.730 --> 02:59:08.607 & French from a small operator into a big company, and then of course once 02:59:08.690 --> 02:59:12.547 that's successful, it turns out that chlorpromazine can 02:59:12.630 --> 02:59:16.447 be easily tweaked as a molecule, and so 02:59:16.530 --> 02:59:20.367 copycat drugs emerge on the scene. So this happens in 02:59:20.450 --> 02:59:25.070 America in 1954. The following year in 1955 02:59:25.910 --> 02:59:31.550 we get the so-called minor tranquilizers being invented and brought to market. 02:59:31.990 --> 02:59:36.730 - This is Miltown. - Yeah, this is Miltown heavily promoted by the first 02:59:37.570 --> 02:59:41.250 major television star of the mid-'50s Milton Berle, 02:59:41.890 --> 02:59:47.090 who calls himself Uncle Miltown and promotes the drug heavily on his show. 02:59:47.430 --> 02:59:50.730 - So these are mostly like tranquilizer type of effects? 02:59:51.050 --> 02:59:54.370 - Those work really-- They're muscle relaxant types of things and 02:59:55.010 --> 02:59:58.707 later on in the '60s we get Valium and Librium 02:59:58.790 --> 03:00:02.547 coming on adding to or replacing those, those first 03:00:02.630 --> 03:00:05.627 generation drugs. So you have major tranquilizers, minor 03:00:05.710 --> 03:00:08.430 tranquilizers. Minor tranquilizers 03:00:08.550 --> 03:00:13.510 and guess what? The Freudians don't want really anything to do with these drugs. 03:00:13.730 --> 03:00:17.830 - Right. Of course. - Uh, the hospital psychiatrist wants to wake up to the 03:00:18.590 --> 03:00:25.240 usefulness of Thorazine and its analogues do start using the drugs a lot, 03:00:26.130 --> 03:00:30.110 And that's really important, and in the early '60s, 03:00:31.370 --> 03:00:34.887 they changed their name. Instead of being major tranquilizers, they 03:00:34.970 --> 03:00:36.730 become antipsychotics. 03:00:37.550 --> 03:00:42.170 - Right. - So that suggests they actually attack the underlying psychosis. 03:00:42.350 --> 03:00:45.067 - Is there any evidence of that for them? 03:00:45.150 --> 03:00:50.510 - They do change the forms of psychosis in important ways, some good 03:00:51.330 --> 03:00:58.330 and some they fail to attack. So, um, they reduce the agitation, they reduce 03:01:02.810 --> 03:01:06.767 the delusions and the hallucinations, the things psychiatrists call the positive 03:01:06.850 --> 03:01:10.710 symptoms of schizophrenia those, those they help 03:01:10.810 --> 03:01:14.707 with for not every patient but for a significant 03:01:14.790 --> 03:01:17.627 number of patients, and they're very -- That's very important. 03:01:17.710 --> 03:01:19.167 - Why are they called the positive? 03:01:19.250 --> 03:01:22.630 - The positive symptoms activate things. They activate 03:01:22.750 --> 03:01:26.690 the hallucinations and the delusions. Those are changing, 03:01:26.790 --> 03:01:30.540 and they're visible usually because if somebody's deluded or hallucinating, 03:01:31.150 --> 03:01:36.747 you know about it pretty quickly... right? The negative symptoms are things like 03:01:36.830 --> 03:01:41.990 apathy, loss of ability to interact with people, poverty of language, 03:01:42.650 --> 03:01:46.890 lack of initiative. All of those things are devastating. 03:01:47.250 --> 03:01:51.660 - Just to state out loud and clear that both positive and negative affects 03:01:51.743 --> 03:01:52.577 so-called 03:01:53.190 --> 03:01:56.950 by psychologists of schizophrenia are both devastating and both negative. 03:01:57.270 --> 03:02:00.170 - Yes, yes. Uh, I think that's right. 03:02:00.270 --> 03:02:02.127 - In the common parlance of what negative means. 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, 03:02:06.510 --> 03:02:10.639 so it's embedded. Now, to the extent antipsychotics work, 03:02:10.722 --> 03:02:13.270 they work on the positive symptoms. 03:02:14.450 --> 03:02:18.307 They either dull them down so you're still hallucinating a bit and you're still 03:02:18.390 --> 03:02:21.570 delusional, but it's not-- it's very much less, 03:02:22.290 --> 03:02:28.210 and you are you're somewhat pacified. You're less overtly disturbed. 03:02:29.610 --> 03:02:33.850 But the negative side of things, not so much or not at all. 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 03:02:42.370 --> 03:02:47.186 others, and a significant number of psychotic patients that are non-drug 03:02:47.270 --> 03:02:48.103 responders 03:02:49.590 --> 03:02:53.417 just as a significant number of people with depression are not responsive to 03:02:53.500 --> 03:02:59.380 antidepressants. Moreover, initially the enthusiasm for these drugs 03:03:00.270 --> 03:03:06.130 everybody neglects the fact that they have serious side effects or 03:03:07.250 --> 03:03:13.207 many of them argue the side effects are an essential part of the 03:03:13.290 --> 03:03:17.127 treatment and you just have to put up with it. So what are we talking about 03:03:17.210 --> 03:03:20.850 when I say there are nasty side effects? 03:03:21.930 --> 03:03:25.630 Well among others, you may become incurably restless. 03:03:26.520 --> 03:03:30.407 So you're constantly in motion, you're moving around, you're never, never 03:03:30.490 --> 03:03:32.700 still. If you're in the presence of somebody 03:03:33.710 --> 03:03:37.647 like that, it becomes unbearable after a fairly short while, and 03:03:37.730 --> 03:03:40.950 it's unbearable often to the person who can't control it. 03:03:42.570 --> 03:03:46.030 Other patients develop Parkinson's disease symptoms. 03:03:47.270 --> 03:03:51.227 Is an awful affliction which unfortunately affects a 03:03:51.310 --> 03:03:54.770 significant number of people each year, and we don't have-- We have 03:03:55.310 --> 03:03:58.950 through L-DOPA a means to delay its impact 03:03:59.310 --> 03:04:03.490 but eventually that loses its efficacy and unfortunately we don't have a cure 03:04:04.920 --> 03:04:08.817 So you have those. And then perhaps the nastiest is what's 03:04:08.900 --> 03:04:10.400 called tardive dyskinesia. 03:04:11.640 --> 03:04:14.990 Tardive because it's late developing, it doesn't happen right away, 03:04:15.840 --> 03:04:19.477 and dyskinesia because what involves is jerky uncontrolled 03:04:19.560 --> 03:04:22.760 movements of the body and particularly of the facial muscles. So 03:04:23.520 --> 03:04:27.037 your tongue will protrude, you'll make strange noises, you'll 03:04:27.120 --> 03:04:30.977 twitch, you'll stagger about walking. If 03:04:31.060 --> 03:04:35.420 somebody like that is walking down the street towards you, you will think 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 03:04:40.340 --> 03:04:44.177 yes, they probably are a mentally ill person but what you're seeing 03:04:44.260 --> 03:04:47.560 is the iatrogenic effects of the drugs they're on. 03:04:47.660 --> 03:04:51.410 Okay? So that problem was ignored for 03:04:51.500 --> 03:04:55.460 about 20 years. A paper appeared in Science by George Crane, 03:04:55.900 --> 03:04:59.570 a Maryland psychiatrist, in which he said, 03:05:00.050 --> 03:05:03.900 "We as a profession have been ignoring this terrible problem." 03:05:05.120 --> 03:05:09.240 Yes, the drugs do some good, but they're also creating a lot of harm, 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, 03:05:16.220 --> 03:05:19.578 I think the American Psychiatric Association was very worried by 03:05:19.661 --> 03:05:20.494 that problem. 03:05:21.900 --> 03:05:25.929 And um, the drug companies were kind of worried about it, 03:05:26.012 --> 03:05:27.917 but didn't have any obvious 03:05:28.000 --> 03:05:35.000 solution till towards the end of the '80s something happened. Nineteen fifty-seven 03:05:35.840 --> 03:05:39.520 when the people were developing copycat versions of Thorazine, 03:05:40.280 --> 03:05:44.217 clozapine was developed by a small company which was subsequently bought 03:05:44.300 --> 03:05:49.777 up by a bigger company and introduced in Europe. It never came to America 03:05:49.860 --> 03:05:56.680 because of two things. First, it tended not to produce tardive dyskinesia, 03:05:57.620 --> 03:06:01.577 and at that time many in the profession thought if you didn't get those symptoms 03:06:01.660 --> 03:06:05.500 you weren't attacking the problem. Bizarre, right? 03:06:05.600 --> 03:06:10.610 Secondly in a significant number of patients 03:06:11.460 --> 03:06:14.860 it destroyed the patient's white blood cells and they died. 03:06:15.360 --> 03:06:19.297 Okay? Not a good outcome. So it was quickly withdrawn 03:06:19.380 --> 03:06:24.600 from the market, and it never made it to this side of the Atlantic. However, 03:06:25.580 --> 03:06:32.580 as this tardive dyskinesia problem became more acute, there was an attempt to revive 03:06:34.020 --> 03:06:41.020 clozapine, and it turns out it tends to work better in 03:06:41.600 --> 03:06:45.100 treatment-resistant cases, meaning cases that don't respond to the 03:06:46.020 --> 03:06:49.160 other antipsychotics that we have. 03:06:49.900 --> 03:06:54.960 And it could be revived but at the cost of weekly blood checks 03:06:56.160 --> 03:06:59.657 'cause you had to be very careful if your white blood 03:06:59.740 --> 03:07:03.280 cells count started to drop, you had to stop. 03:07:03.580 --> 03:07:07.770 Right? So it came to market in the late '80s, 03:07:10.460 --> 03:07:16.720 and very quickly other drug companies tried to find other compounds 03:07:18.300 --> 03:07:21.917 actually chemically not related to it, but that's hardly the 03:07:22.000 --> 03:07:27.680 point. The whole class of drugs became known as second generation antipsychotics. 03:07:28.040 --> 03:07:32.447 - So Clozapine, Risperdal-- - Yes, those kinds of ones. 03:07:32.530 --> 03:07:33.667 - Zyprexa. - Zyprexa among others. 03:07:33.750 --> 03:07:38.330 - Zyprexa. - Yes. And so there were a number of these, and they have actually 03:07:38.700 --> 03:07:40.620 -- Because they are chemically quite 03:07:41.520 --> 03:07:45.567 different from each other, but they're classed together in the public mind and - 03:07:45.650 --> 03:07:47.050 ...in the professional mind. 03:07:47.580 --> 03:07:51.337 They tend to have different side effect profiles and slightly different 03:07:51.420 --> 03:07:56.100 modes of action and differing levels of efficacy, I think. 03:07:56.260 --> 03:07:57.860 - Of course, there's not a real, 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, 03:08:03.760 --> 03:08:06.960 what is the actual protocol of how you figure out which to give? 03:08:07.100 --> 03:08:10.960 - Right. So in 2005 most of the-- I should 03:08:11.080 --> 03:08:14.957 say, once the Drugs Revolution came along, increasingly 03:08:15.040 --> 03:08:18.917 the studies were funded by the drug companies who owned the data and 03:08:19.000 --> 03:08:20.357 controlled the data-- - Right 03:08:20.440 --> 03:08:24.397 -...and only released what they chose to release, what was helpful for them and 03:08:24.480 --> 03:08:27.820 not what wasn't. - And they were heavily marketing stuff. 03:08:28.060 --> 03:08:34.440 - Oh yeah, very heavily mar-- And then, to get FDA approval of efficacy and safety 03:08:34.524 --> 03:08:36.920 you needed two trials. 03:08:37.760 --> 03:08:41.730 You might have conducted 15 trials and 13 of them had been failures, 03:08:41.840 --> 03:08:45.717 but if you had two that worked, that was enough. That's what you 03:08:45.800 --> 03:08:52.480 needed. That was the gold standard. So 2005, National Institutes of Mental Health 03:08:52.820 --> 03:08:56.060 funds this drug study, not an industry study, 03:08:57.280 --> 03:09:01.117 and what it wants to look at, the first generation drugs are 03:09:01.200 --> 03:09:04.737 now out of patent and they're cheap. The second generation are 03:09:04.820 --> 03:09:10.500 patented and are quite expensive, ten times as expensive in some cases. 03:09:11.420 --> 03:09:15.257 So we do something called the CATIE Study, and it's 03:09:15.340 --> 03:09:18.690 published in the New England Journal of Medicine. And there are two 03:09:19.020 --> 03:09:22.257 interesting findings. So you have one first generation 03:09:22.340 --> 03:09:26.157 antipsychotic, one of those very early drugs, and you 03:09:26.240 --> 03:09:30.360 have four more recent drugs that you're looking at. 03:09:31.460 --> 03:09:37.277 And you ask a number of questions. Are the new drugs more 03:09:37.360 --> 03:09:40.980 efficacious than the old drug? No. 03:09:41.820 --> 03:09:47.580 Hmm. Were patients willing to tolerate these drugs? And that was a 03:09:47.940 --> 03:09:54.220 finding that I thought was much underreported at the time. Between 67% and 03:09:54.360 --> 03:09:57.610 82% of the patients, depending on which drug they were on, 03:09:58.100 --> 03:10:01.725 dropped out of the trial because either the drug wasn't working or they couldn't 03:10:01.808 --> 03:10:05.777 stand the side effects. So that tells you, these are our 03:10:05.860 --> 03:10:09.710 best drugs, you know, there are real complications here. 03:10:10.340 --> 03:10:16.280 And then as we delve further into it, do they have nasty side effects? Well, 03:10:17.340 --> 03:10:24.340 less tardive dyskinesia somewhat, but a whole new set of side effects. If you take 03:10:27.580 --> 03:10:32.760 these pills, you will gain, in most cases, a lot of weight, 03:10:35.200 --> 03:10:38.957 10, 20, 30, 40 pounds, 50 pounds. What 03:10:39.040 --> 03:10:43.030 does that do? That gives you metabolic syndrome; 03:10:43.160 --> 03:10:47.280 it gives you diabetes; it gives you heart trouble. So 03:10:48.460 --> 03:10:53.300 important to state when we're looking at this 'cause 03:10:54.680 --> 03:11:00.360 there is no-- There is no free lunch with medicine. If you take an aspirin, 03:11:01.820 --> 03:11:05.537 it may cause your stomach to bleed, sometimes enough 03:11:05.620 --> 03:11:09.840 to really put you in serious jeopardy. Most of the time it's fine. 03:11:10.900 --> 03:11:17.197 Um, everything... Every drug that's brought to market has the main 03:11:17.280 --> 03:11:21.460 effect we're looking for and some side effects which may be 03:11:23.140 --> 03:11:27.860 minimal for most people but for some people maybe worse than that. 03:11:27.943 --> 03:11:29.180 So we've got to-- 03:11:30.680 --> 03:11:33.430 It's one of these cost-benefit analyses, right? You-- 03:11:33.520 --> 03:11:35.320 You're getting some relief from your 03:11:36.380 --> 03:11:40.317 psychiatric symptoms, but you're courting these other 03:11:40.400 --> 03:11:44.037 dangers that may or may not arise, and going in, we don't 03:11:44.120 --> 03:11:49.837 know where you're gonna fall. We don't know; trial and error. 03:11:49.920 --> 03:11:53.317 - You mean every individual that walks into the picture, they don't know where on 03:11:53.400 --> 03:11:54.550 distribution they fall? 03:11:54.680 --> 03:11:59.660 - Right. And we have no biological markers at the moment that would tell us. 03:12:00.640 --> 03:12:04.920 One or two of my friends in the, um, psychiatric genetics industry, 03:12:05.760 --> 03:12:09.410 uh, if that's the right term for it, but, you know, in that research area 03:12:09.760 --> 03:12:13.320 are saying, "Well, we haven't done very well to find the genetic 03:12:13.580 --> 03:12:16.920 roots of mental illness," but maybe we can 03:12:17.800 --> 03:12:21.650 learn to distinguish which patients are gonna respond well to drugs and which 03:12:21.820 --> 03:12:26.280 will, which shouldn't be given them because they're not going to. Um, 03:12:27.140 --> 03:12:31.060 that's a promissory note. It's not something that they actually can do now. 03:12:31.180 --> 03:12:33.236 It's just we hope we'll be able to do this, 03:12:33.320 --> 03:12:35.370 and I hope they're able to do it too. But 03:12:36.300 --> 03:12:40.057 You know, you can't have an enormous amount of confidence in that. Maybe 03:12:40.140 --> 03:12:43.840 it'll happen, or maybe some other mechanism will emerge that 03:12:43.940 --> 03:12:47.717 allows us to see who the responders and nonresponders are. 03:12:47.800 --> 03:12:51.637 Who's gonna suffer the worst side effects if they're put on these medications? And 03:12:51.720 --> 03:12:58.380 The side effects do vary, so, um, though a lot of what I've described is 03:12:58.500 --> 03:13:00.200 common to this class of drugs. 03:13:00.440 --> 03:13:02.504 - And sometimes it's hard to describe the side effect. 03:13:02.587 --> 03:13:03.777 You're talking about the human 03:13:03.860 --> 03:13:07.177 mind. Yeah, yeah. So describing the side effects, it's not like ble- 03:13:07.260 --> 03:13:11.217 bleeding or like diarrhea or- - Well, yeah. 03:13:11.300 --> 03:13:15.360 - Weight gain, that's describable, but like the effect on your personality... 03:13:15.820 --> 03:13:20.297 - Yep, that's much harder, much harder. People, you know, 03:13:20.380 --> 03:13:25.990 some of the patients who drop out drop out because they find 03:13:26.260 --> 03:13:30.137 the richness of their mental life is completely gone, and they don't want 03:13:30.220 --> 03:13:35.297 to tolerate that. They'd sooner tolerate some hallucinations. That's a hard one. 03:13:35.380 --> 03:13:38.557 - So there's a that picture, the SSRIs that also came to be 03:13:38.640 --> 03:13:41.600 Prozac, Zoloft, Paxil during that time. Yes, Paxil, all of 03:13:41.700 --> 03:13:45.420 that. Well again, they're the second generation of antidepressants. 03:13:45.800 --> 03:13:49.417 Mm-hmm. So that's a complicated story. Again, it's an 03:13:49.500 --> 03:13:52.640 accident. They're at treating patients with advanced 03:13:52.740 --> 03:13:57.609 tuberculosis in the 1950s. Now, that's a very unpleasant thing that's also gonna 03:13:57.692 --> 03:14:00.437 kill you, so tuberculosis, very 03:14:00.520 --> 03:14:04.700 advanced cases. You're coughing your lungs up. You're depressed as all get out. 03:14:05.740 --> 03:14:09.600 And here we have two new drugs, Iprsoltanto we can 03:14:09.700 --> 03:14:15.057 use that maybe will treat the condition when you give it to the patients, and 03:14:15.140 --> 03:14:22.140 these depressed tuberculosis patients start acting happy, dancing about. Their 03:14:22.240 --> 03:14:28.970 mood changes. Bingo! We've got something that maybe we can use over here to 03:14:29.100 --> 03:14:34.837 treat depression. However, the drug companies in circa 03:14:34.920 --> 03:14:41.817 1960 think of depression as a small market because what they're talking about is the 03:14:41.900 --> 03:14:45.857 kind of melancholic psychotic depressions that leads people 03:14:45.940 --> 03:14:50.144 into the mental hospital. And that's not an insignificant group, 03:14:50.227 --> 03:14:51.500 but it's not a huge 03:14:51.620 --> 03:14:57.487 group. So it's really much later on that things begin to change. Right now, 03:14:57.571 --> 03:14:58.840 it's fair to say 03:14:59.540 --> 03:15:04.057 Depression is the common cold of psychiatry. It's, you know, 03:15:04.140 --> 03:15:05.980 it's abundant there, the 03:15:06.140 --> 03:15:11.157 depressive diagnosis, probably the most commonly given among psychiatrists, 03:15:11.240 --> 03:15:11.917 so part of 03:15:12.000 --> 03:15:15.777 that is a deeper understanding of the human mind, and a big part of that is 03:15:15.860 --> 03:15:19.300 probably the drug companies convincing the world. 03:15:19.820 --> 03:15:23.157 - Well, it's transforming, yes. So, there were big disputes for 03:15:23.240 --> 03:15:28.960 example, when DSM-5 was being contemplated about whether grief, 03:15:29.900 --> 03:15:33.867 bereavement would count as a mental disorder, 03:15:33.950 --> 03:15:37.460 as count as a form of depression if you 03:15:39.300 --> 03:15:44.600 lose a parent, if you lose, even worse, a child, um 03:15:45.300 --> 03:15:49.620 It's a deeply-- how can I put it? Deeply upsetting, yes. 03:16:13.760 --> 03:16:19.140 Some psychiatrists say yes and some no, but it's an example of what happens 03:16:20.180 --> 03:16:23.720 in psychiatry, repeatedly, what I would call diagnostic creep, 03:16:24.060 --> 03:16:27.917 which is a term, actually, an Australian named Nick Haslam came 03:16:28.000 --> 03:16:31.697 up with. But it's a phenomenon I described before that. You 03:16:31.780 --> 03:16:34.500 start with a core of unambiguous 03:16:34.940 --> 03:16:38.677 deviations from the norm that are so serious that any 03:16:38.760 --> 03:16:42.340 competent member of the culture knows that's that. But 03:16:43.020 --> 03:16:46.737 then it-- you begin to say, "Well, there's this penumbra," you see, and 03:16:46.820 --> 03:16:53.087 just outside that core, there are people who are also disturbed, not perhaps as 03:16:53.170 --> 03:16:56.997 sufficiently disturbed that you actually recognize it, but it's 03:16:57.080 --> 03:17:02.943 happening. And so that has tended to happen over and over again. 03:17:03.026 --> 03:17:08.080 Parents with an autistic child won't necessarily agree with what I'm 03:17:08.200 --> 03:17:12.420 about to say, but the chief editor of DSM-IV, 03:17:13.420 --> 03:17:17.197 Allen Frances, is convinced the huge increase in the number of 03:17:17.280 --> 03:17:21.197 diagnoses of autism is more driven by the 03:17:21.280 --> 03:17:24.720 fact he loosened the criteria for the diagnosis than it is 03:17:24.840 --> 03:17:29.110 because there are more actual cases. Autism used to be a fairly 03:17:29.940 --> 03:17:33.737 rare phenomenon, and now sadly it's a very broad one. And I understand 03:17:33.820 --> 03:17:37.417 why parents react very negatively to that because the 03:17:37.500 --> 03:17:41.210 diagnosis is the key to all sorts of social supports and 03:17:41.420 --> 03:17:45.217 educational supports and all the rest, and they're dealing with a 03:17:45.300 --> 03:17:50.840 child who is extremely difficult. But there is a real difference between 03:17:51.740 --> 03:17:55.300 the most severe forms of autism where people lose 03:17:55.440 --> 03:17:59.257 capacity to speak and very often any ability to 03:17:59.340 --> 03:18:01.640 interact with other people and so forth, 03:18:02.580 --> 03:18:06.520 and the other cases that are of a still serious but milder sort. 03:18:07.140 --> 03:18:10.250 Diagnostic creep is not driven just by 03:18:10.700 --> 03:18:14.920 psychiatric imperialism, the desire for more territory, more patients. 03:18:16.260 --> 03:18:20.157 It's driven as well by patients and people and, 03:18:20.240 --> 03:18:24.040 and they resist it being pushed back very often. 03:18:24.440 --> 03:18:28.320 So families have formed organizations like NAMI, but 03:18:28.500 --> 03:18:31.976 those aren't the mentally ill. Those are the family members of the mentally ill, 03:18:32.060 --> 03:18:32.387 and there 03:18:32.470 --> 03:18:35.980 are differences in the perspectives and the interests of the family 03:18:36.080 --> 03:18:39.957 members and the patients-... And that's easy to forget. 03:18:40.040 --> 03:18:42.500 - I think one of the things you talk about is, 03:18:43.560 --> 03:18:48.100 uh, I mean, the quote you had was use the word madness. 03:18:48.480 --> 03:18:53.410 But that madness or mental health maladies, 03:18:54.360 --> 03:18:57.680 if you're suffering from them, it's a deeply lonely experience. 03:18:58.520 --> 03:19:02.511 And then if you're around somebody suffering from it, 03:19:02.594 --> 03:19:04.900 it's a very social experience. 03:19:05.780 --> 03:19:09.697 - Yeah. Yeah, this is actually -- that's a paraphrase of -- I was 03:19:09.780 --> 03:19:13.637 quoting one of my friends and fellow historians of psychiatry, Michael 03:19:13.720 --> 03:19:17.457 MacDonald. The most solitary of afflictions for the sufferer and the 03:19:17.540 --> 03:19:21.277 most social of maladies for those around them. And there's lots of 03:19:21.360 --> 03:19:23.180 ways in which you can see 03:19:24.320 --> 03:19:28.277 that very powerfully, and that's why I think there are a ton of people who 03:19:28.360 --> 03:19:32.980 suffer in various ways from, from mental disturbances of one sort and another. 03:19:33.880 --> 03:19:37.737 But the effects aren't confined to them. They extend out 03:19:37.820 --> 03:19:41.297 to everybody else around them, and that's really 03:19:41.380 --> 03:19:45.157 powerful. So we had this first generation there were 03:19:45.240 --> 03:19:47.720 actually two different kinds of antidepressants, 03:19:48.620 --> 03:19:51.917 MAOIs as they're called in the trade, and 03:19:52.000 --> 03:19:55.677 tricyclics which were called tricyclics 'cause they had a 03:19:55.760 --> 03:19:59.320 third ring of a certain element in their molecule. 03:20:00.120 --> 03:20:03.510 Those had as I say, a limited market, but 03:20:03.600 --> 03:20:07.177 also there were complications associated with 03:20:07.260 --> 03:20:10.600 them that it was easy to overdose and die. And so 03:20:10.940 --> 03:20:14.837 giving a depressed patient a bunch of pills that if they took too many 03:20:14.920 --> 03:20:18.717 of them would kill them was tricky. They also could 03:20:18.800 --> 03:20:24.660 kill you another way because for example, you couldn't -- certain dietary 03:20:25.480 --> 03:20:28.380 items, cheese, cured meats, 03:20:29.280 --> 03:20:34.640 in combination with them were very, very health threatening, maybe even fatal. 03:20:36.460 --> 03:20:38.680 Now, in the late '80s, 03:20:40.600 --> 03:20:45.600 the drug companies came across a new class of antidepressants 03:20:46.400 --> 03:20:50.097 that didn't have those side effects. As we'll see, they had other side 03:20:50.180 --> 03:20:54.157 effects, but not those. And the most famous of those 03:20:54.240 --> 03:20:57.900 was Prozac. There were a class of drugs called 03:20:58.720 --> 03:21:02.437 SSRIs, and again forgive the acronyms, but what it means is 03:21:02.520 --> 03:21:05.420 selective serotonin reuptake inhibitors. 03:21:06.780 --> 03:21:10.320 Serotonin is something manufactured in our bodies, actually 03:21:10.780 --> 03:21:14.137 in our digestive system, and it performs a variety of 03:21:14.220 --> 03:21:19.380 functions in the body. But it's also one of the neurotransmitters in our brains. 03:21:20.500 --> 03:21:25.380 And the way these drugs worked was by 03:21:27.100 --> 03:21:32.580 slowing the reuptake of serotonin in the brain, which was 03:21:33.440 --> 03:21:37.117 marketed by the drug companies as the 03:21:37.200 --> 03:21:40.210 solution to depression. That when you got depressed, 03:21:41.160 --> 03:21:45.037 it was because you didn't have enough serotonin in your brain, and these pills 03:21:45.120 --> 03:21:51.832 solved that problem. It was like, well, Tipper Gore, Al Gore's ex-wife, 03:21:51.916 --> 03:21:57.100 was like many politicians' wives, depressed for reasons I fully understand 03:21:57.600 --> 03:22:01.317 or at least partially understand. And she 03:22:01.400 --> 03:22:05.280 went to her psychiatrist and that was one of the things she was given, 03:22:05.500 --> 03:22:12.500 and she became one of the big public advocates for SSRIs which 03:22:12.600 --> 03:22:15.540 still are the most prescribed antidepressants. 03:22:15.960 --> 03:22:17.997 - Do they work? And what are the side effects? 03:22:18.080 --> 03:22:21.947 - Yeah. So here's where we get into slippery territory. Every 03:22:22.030 --> 03:22:26.090 time you do a controlled study of these antidepressants, 03:22:27.430 --> 03:22:34.030 they beat placebo in a statistically significant margin, 03:22:35.010 --> 03:22:38.907 but not necessarily in a clinically significant margin. 03:22:38.990 --> 03:22:42.970 And this is when you see drug ads, be very careful. This one 03:22:43.070 --> 03:22:45.270 significantly improves X or Y. 03:22:46.490 --> 03:22:49.930 Does that mean clinically or does it mean statistically? Because 03:22:51.010 --> 03:22:54.547 the fact-- if you -- when we measure improvement with 03:22:54.630 --> 03:22:57.890 depression, we tend to use rating scales of various sorts. 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 03:23:07.010 --> 03:23:10.650 on a 60-point scale, it may be enough to show 03:23:10.810 --> 03:23:14.590 statistical significance. These drugs look a little better than placebo, 03:23:15.450 --> 03:23:20.330 but doesn't really affect your quality of life much. And for most patients, 03:23:21.190 --> 03:23:26.330 antidepressants are marginally better 03:23:27.510 --> 03:23:32.510 than placebo, but a lot of the effect is the placebo effect. 03:23:32.600 --> 03:23:39.430 And they come with very difficult side effects. A lot of people describe them as 03:23:39.570 --> 03:23:42.410 numbing drugs. They--...flatten everything out, 03:23:43.230 --> 03:23:46.270 So you can't experience the highs and lows that normally 03:23:46.590 --> 03:23:50.780 we take as part of human experience. And then, um, 03:23:51.670 --> 03:23:55.067 the numbing extends elsewhere in your body. In particular, lots 03:23:55.150 --> 03:24:02.150 of patients find a complete loss of libido. They... 03:24:03.490 --> 03:24:07.407 They can't get an erection. They can't climax if they're a 03:24:07.490 --> 03:24:09.720 woman. Their sex life just goes away, 03:24:10.870 --> 03:24:14.450 and sometimes it doesn't come back after you stop the drugs. 03:24:15.370 --> 03:24:19.340 Next layer of problems, getting off the drugs for some people turns 03:24:19.430 --> 03:24:26.227 out to be hell on wheels. They get worse depression than they had before. They 03:24:26.310 --> 03:24:30.930 get a feel-- uh, terrible feelings. Their brain is sparking something's wrong. 03:24:31.830 --> 03:24:35.767 And so many patients find themselves trapped on those drugs for 03:24:35.850 --> 03:24:39.430 a long time, and we don't know what the effects of that are gonna be. 03:24:39.690 --> 03:24:43.527 So it's a very mixed picture, you know. That's why I 03:24:43.610 --> 03:24:46.460 think groups like NICE in England are saying, 03:24:47.970 --> 03:24:54.620 "Use CBT as the first line, not drugs." But again, 03:24:55.930 --> 03:24:59.607 it's also fair to say, I think what we find and there was a 03:24:59.690 --> 03:25:02.850 recent Lancet study that I think was revealing on this point. 03:25:04.710 --> 03:25:08.587 It's like this with both antipsychotics and antidepressants. You have 03:25:08.670 --> 03:25:12.467 a group of people who respond pretty well, and the side 03:25:12.550 --> 03:25:16.890 effects for them are bearable or even they don't experience them. That's great. 03:25:18.670 --> 03:25:22.410 You have a group of people, and it's significant. With depressed patients, 03:25:22.530 --> 03:25:27.870 we're talking 40 or north of forty percent who aren't responding. Okay? 03:25:29.630 --> 03:25:33.310 So drugs aren't doing anything for them, and they're running a risk. 03:25:34.570 --> 03:25:38.590 And then in the middle, you have a group of people who get some positive 03:25:39.550 --> 03:25:46.550 improvement, but they also get side effects, and that's where, you know, this 03:25:47.270 --> 03:25:50.900 cost-benefit analysis, if we can call it that, comes into play, and it's 03:25:51.010 --> 03:25:53.830 very difficult. And the problem is going in, 03:25:54.830 --> 03:25:57.310 you don't know which group you're gonna fall in. 03:25:57.650 --> 03:26:01.650 And your, and your doctor doesn't know which group you're gonna fall in. And 03:26:02.990 --> 03:26:08.470 more importantly, one of the things the Drugs Revolution did was it moved 03:26:09.450 --> 03:26:12.430 the diagnosis and the prescribing of things 03:26:13.450 --> 03:26:17.287 away from psychiatry alone, so many of these 03:26:17.370 --> 03:26:21.150 things, particularly antidepressants, are dispensed by primary 03:26:21.250 --> 03:26:23.310 care docs, not psychiatrists. 03:26:23.890 --> 03:26:28.690 - Let's zoom out. We did say that there's a real crisis. 03:26:30.050 --> 03:26:33.707 From an individual perspective suffering from psychosis or suffering from 03:26:33.790 --> 03:26:38.790 depression-... What are you supposed to do? What 03:26:39.270 --> 03:26:43.450 works, and what is the hope for the future in the next ten, twenty out? 03:26:43.950 --> 03:26:50.950 - So you probably need to try the drugs because the suffering is very intense. 03:26:52.310 --> 03:26:55.727 But you need to be aware of things, and you need a clinician who's 03:26:55.810 --> 03:27:02.810 monitoring very carefully. More generally, psychiatric research needs to broaden. 03:27:04.310 --> 03:27:09.070 We have spent all our monies on drugs, 03:27:10.090 --> 03:27:13.907 on neuroscience, and on genetics, but there are 03:27:13.990 --> 03:27:17.370 other things we could do that would improve the lives 03:27:17.570 --> 03:27:24.487 of families and patients more immediately. So we need to spend some time on the 03:27:24.570 --> 03:27:28.427 psychosocial dimensions of mental illness and to allow 03:27:28.510 --> 03:27:35.510 psychiatrists to build careers in those fields. One of the problems if you're an 03:27:35.610 --> 03:27:40.070 academic psychiatrist, your whole 03:27:40.890 --> 03:27:44.270 future is dependent on you bringing in grant monies, 03:27:44.950 --> 03:27:48.727 and there aren't grant monies available to study: Are there better 03:27:48.810 --> 03:27:52.710 ways we could cope with the problem of homelessness? Are there better 03:27:52.810 --> 03:27:56.687 ways we could ease the problem for families who are having to cope 03:27:56.770 --> 03:27:59.220 with somebody in their midst who's hallucinating? 03:28:00.350 --> 03:28:03.190 That sort of thing, I think, would help. 03:28:03.790 --> 03:28:07.727 - What about talk therapy on both the CBT, cognitive behavioral 03:28:07.810 --> 03:28:11.447 therapy, and psychoanalysis? We left psychoanalysis in this 03:28:11.530 --> 03:28:14.070 place where society left it behind. 03:28:14.350 --> 03:28:17.310 - I think it's become a niche product now. Only, 03:28:18.250 --> 03:28:22.167 only the very wealthy can afford to do it, and some of them 03:28:22.250 --> 03:28:26.500 indeed do make use of it, and some of them claim that it helps them. 03:28:27.000 --> 03:28:30.837 - Oh, do you think there's future in it? I will add an extra-- I 03:28:30.920 --> 03:28:37.920 would add an extra bit to that. Carefully is with the advent and the rapid 03:28:38.220 --> 03:28:41.817 improvement of artificial intelligence systems- 03:28:41.900 --> 03:28:48.779 ...that are able to communicate with individual humans and learn a lot about 03:28:48.862 --> 03:28:49.695 them, 03:28:50.260 --> 03:28:53.937 and have a conversation about the deepest secrets that you 03:28:54.020 --> 03:28:57.620 sometimes actually would even be uncomfortable telling even a therapist. 03:28:58.760 --> 03:29:05.760 That starts to go into the realm of Freud and Jung and psychoanalysis. 03:29:05.930 --> 03:29:09.420 - Well, yes, and we did see actually COVID 03:29:11.100 --> 03:29:14.837 with the isolation that it produced and the fact people couldn't go to their 03:29:14.920 --> 03:29:21.400 therapists directly. We did see the rise of some of this distant 03:29:23.180 --> 03:29:27.037 learning of this, and some of it may indeed be mechanizable 03:29:27.120 --> 03:29:30.690 in the way you described. It's very important 03:29:31.560 --> 03:29:35.437 that psychiatrists broaden their perspective on 03:29:35.520 --> 03:29:39.157 these things, and some already have. I think 03:29:39.240 --> 03:29:43.910 public policy is in a mess when it comes to serious mental illness, 03:29:44.820 --> 03:29:49.480 but I'm pessimistic about fixing that 'cause it would cost bunches of money. 03:29:50.320 --> 03:29:53.420 If we were talking about something where we could cure people, 03:29:53.940 --> 03:29:57.860 transform them from, as they used to say, tax eaters to taxpayers, 03:29:58.700 --> 03:30:02.497 there'd be incentive to do it. But the honest answer is right 03:30:02.580 --> 03:30:06.260 now that's not where we are. And so we 03:30:06.600 --> 03:30:12.290 face dilemmas. I think helping people as much as we can with social supports --And, 03:30:13.980 --> 03:30:17.657 you know, social interaction is tremendously important to 03:30:17.740 --> 03:30:21.740 people's mental health. If they lack it, if they're lonely, if they're isolated, 03:30:22.480 --> 03:30:29.417 it does bad things to people. So somehow providing that kind of support, providing 03:30:29.500 --> 03:30:33.440 some sense of agency to people who often lack it 03:30:33.560 --> 03:30:37.437 would be very helpful. Uh, I hope somebody has a 03:30:37.520 --> 03:30:39.870 breakthrough and produces a better drug because 03:30:40.680 --> 03:30:44.477 unlike some people, I would be astonished if the major forms 03:30:44.560 --> 03:30:48.140 of mental illness didn't have a biological component to them. 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 03:30:52.280 --> 03:30:56.017 important part of the story, and therefore, you know, the 03:30:56.100 --> 03:30:59.720 fact that major drug companies have abandoned research in this area, 03:31:00.500 --> 03:31:04.457 they've been bad actors in many ways, but the drugs have 03:31:04.540 --> 03:31:07.850 had some positive effects, and the fact that there's no research 03:31:08.480 --> 03:31:15.264 being done by the people with the most money to develop better treatments 03:31:15.347 --> 03:31:16.181 is well, 03:31:16.300 --> 03:31:20.340 one word for it would be depressing. You know? That's not what we wanna see. 03:31:20.580 --> 03:31:26.877 - So the path forward is a mix-....of continued research on drugs, but from a 03:31:26.960 --> 03:31:30.660 patient perspective, extreme caution in use of those drugs. 03:31:31.180 --> 03:31:34.800 Uh, talk therapy, whether it's CBT or psychoanalysis, 03:31:35.890 --> 03:31:39.817 further investigation research on that front. Then the psychosocial 03:31:39.900 --> 03:31:42.007 component of social family- 03:31:42.090 --> 03:31:45.340 .....people around you, less loneliness, investigating how 03:31:45.940 --> 03:31:51.500 from a cultural social perspective and from a public policy perspective, can we 03:31:52.320 --> 03:31:55.900 increase the amount of social connections that people who 03:31:56.040 --> 03:31:58.320 suffer have and all of that together? 03:31:58.840 --> 03:32:02.717 - Yes. And breakthrough with people who have a very hard time 03:32:02.800 --> 03:32:06.520 making those connections or who've lost the ability to make them. 03:32:07.480 --> 03:32:08.530 - If we can zoom out, 03:32:09.320 --> 03:32:13.310 looking back at this rich history of human beings, and we did look at the 03:32:13.400 --> 03:32:17.200 darkness, but I think there's a very large number of people 03:32:18.200 --> 03:32:22.740 that want to help those who suffer. So, 03:32:23.860 --> 03:32:27.487 looking at the history of people trying to figure out- 03:32:27.570 --> 03:32:32.570 how to help those who suffer, what gives you hope about our future? A real hope 03:32:33.720 --> 03:32:37.640 for the future of psychiatry that we can actually help people who suffer. 03:32:39.640 --> 03:32:46.640 - Well, I think we have a profession with many very well-meaning people 03:32:50.180 --> 03:32:54.800 who see the suffering on a day-to-day, face-to-face basis. 03:32:56.120 --> 03:33:02.540 And I like to think that among them will be people who 03:33:02.640 --> 03:33:06.320 move this thing forward. And the fact is we 03:33:06.440 --> 03:33:10.060 have moved things forward. We have tended to dwell a lot on 03:33:10.800 --> 03:33:14.460 some of the very unsavory aspects of the past, 03:33:15.320 --> 03:33:19.840 and even some of the drawbacks of what we have available to us in the present. 03:33:20.780 --> 03:33:23.720 But it is important to see at times 03:33:24.980 --> 03:33:28.297 highly motivated people have been able to do very good 03:33:28.380 --> 03:33:33.810 things to help people with these conditions. And there is, 03:33:34.740 --> 03:33:39.050 I think, hope in the future that we will see more of that, 03:33:39.940 --> 03:33:46.940 Than has been the case. And that involves, in some senses, a shift in the 03:33:47.660 --> 03:33:51.840 mentality of a whole profession in, in a more 03:33:52.940 --> 03:33:57.420 caring kind of direction or less technocratic kind of direction, less 03:33:58.460 --> 03:34:05.460 reliance on something as simple as giving people pills, because that can help, 03:34:07.060 --> 03:34:10.480 but it's clearly not gonna be the solution to the whole thing. 03:34:11.010 --> 03:34:17.797 We need a system that is aware of and catering to the, 03:34:17.880 --> 03:34:21.777 suffering that people experience and finds ways, if they 03:34:21.860 --> 03:34:27.500 can't eliminate it entirely, to ameliorate it in ways that people will 03:34:28.550 --> 03:34:33.030 sense is actually of help to them. It's a, it's a 03:34:34.310 --> 03:34:37.570 very difficult area, this one. It's one that, 03:34:38.270 --> 03:34:44.410 touches some of the most profound aspects of ourselves as human beings 03:34:45.210 --> 03:34:50.250 and I think as difficult as this problem is 03:34:51.590 --> 03:34:55.050 it's very important not to be cynical. Not to give up hope, 03:34:55.210 --> 03:34:59.067 not to deny the possibility of progress, 03:34:59.150 --> 03:35:03.130 because that's always there. And has happened and 03:35:03.910 --> 03:35:08.010 I hope will happen with increasing pace in the years ahead of us. 03:35:09.250 --> 03:35:11.250 - And if you're listening to these words 03:35:11.910 --> 03:35:15.841 and you're right now in this moment of your life where you yourself are 03:35:15.925 --> 03:35:16.758 suffering, 03:35:18.670 --> 03:35:24.390 please know we're with you. We're in this together. Stay strong. 03:35:25.030 --> 03:35:30.990 There's hope. Legitimately, as one human to another, I love you. Brother, 03:35:31.110 --> 03:35:33.560 sister, if you're listening to this, stay strong. 03:35:34.630 --> 03:35:37.930 Andrew, thank you for this incredible work of history that you do. 03:35:39.110 --> 03:35:42.727 Incredible work of raising awareness, stepping into a 03:35:42.810 --> 03:35:46.727 difficult topic, and trying to find the wisdom, the insights 03:35:46.810 --> 03:35:49.810 in it. And thank you for this incredible conversation today. 03:35:50.510 --> 03:35:52.770 - Lex, thank you for having me, and 03:35:54.010 --> 03:35:57.827 I felt you were remarkably prepared to push me in various 03:35:57.910 --> 03:36:01.437 directions. So you'd obviously done a lot of 03:36:01.520 --> 03:36:05.840 preparation to get this in the right frame. And I hope, 03:36:06.930 --> 03:36:10.770 that people will get something positive 03:36:10.890 --> 03:36:14.807 from this conversation along with some of the darkness we've inevitably 03:36:14.890 --> 03:36:16.210 had to talk about. 03:36:17.210 --> 03:36:19.808 - Thank you for listening to this conversation with Andrew Scull. 03:36:19.891 --> 03:36:22.982 To support this podcast, please check out our sponsors in the description, 03:36:23.066 --> 03:36:25.266 where you can also find links to contact me, 03:36:25.410 --> 03:36:28.877 ask questions, give feedback, and so on. And 03:36:28.960 --> 03:36:33.667 now let me leave you with some words from Friedrich Nietzsche: 03:36:33.750 --> 03:36:35.450 "To live is to suffer, 03:36:36.530 --> 03:36:39.870 To survive is to find meaning in the suffering." 03:36:41.130 --> 03:36:44.150 Thank you for listening, and I hope to see you next time.