Latest / The Smart Cookies podcast / Asylums, Lobotomies and ECTs - The Horrifying History of Mental Illness “Cures.” With Prof. Andrew Scull

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Asylums, Lobotomies and ECTs - The Horrifying History of Mental Illness “Cures.” With Prof. Andrew Scull · The Smart Cookies podcast

• 0:00
  He wants to become, as his daughter put it, the
• 0:02
  Henry Ford of lobotomy. You want an assembly
• 0:05
  line lobotomy. So how the hell are you going
• 0:08
  to do that? He reads about an Italian who's developed
• 0:11
  this technique to peel back the eyelid, stick
• 0:16
  an ice pick in with a hammer, bang through the
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  bone, wiggle the ice pick about, repeat on the
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  other side, Bob's your uncle, two black eyes.
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  You've been lobotomized in a few minutes. How
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  do you stay still for that? Well, we give you
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  two or three ECTs first so you're unconscious.
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  many books titled such as Madhouse, A Tragic
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  Tale of Megalomania in Modern Medicine, Madness
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  in Civilization, A Cultural History of Insanity,
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  and the latest, Desperate Remedies, Psychiatry's
• 1:08
  Turbulent Quest to Cure Mental Illness. These
• 1:11
  are all great for some light reading before bed,
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  as will probably be this conversation, which
• 1:16
  is my favorite type of conversation. Andrew,
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  welcome to the program. Very glad to be here
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  with you. Thank you for having me. I want to
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  delve primarily into your last book, desperate
• 1:28
  remedies, but I would be remiss not to at least
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  ask you what was happening before that. How did
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  ancient cultures conceptualize mental illness
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  or madness, as I imagined I called it, before
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  the advent of asylums, which we're going to talk
• 1:44
  about later on at the beginning of the 19th century,
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  I believe, because you write about that in your
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  earlier book, as I said, in madness in civilization.
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  Yes, I do. It's an enormously complicated story
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  that's very hard to, you know, boil down even
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  within the pages of that fairly long book. There
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  are lots of twists and turns. And, of course,
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  one of the things I would stress is that in every
• 2:13
  society known to me, madness exists. And it doesn't
• 2:19
  come to be called mental illness until quite
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  late on. although medical involvement attempts
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  medically to explain people acting in aberrant
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  ways, losing touch with the emotional life and
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  the cognitive life most of us share. That you
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  can see as early as ancient Greece, and you can
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  see it in ancient Chinese and Indian medicine
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  as well. But it's part of a very conflicted landscape
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  where very often madness is seen in supernatural
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  terms as either a punishment from God or the
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  result of being bewitched or possessed or the
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  work of the devil. All of these things survive,
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  indeed some of them survive, even into the contemporary
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  world, albeit not as the dominant discourse as
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  it once was. So always in negative terms, never
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  like this person might be enlightened or inspired
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  by the gods. Yes, that's not quite true, because
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  yes, indeed, there are examples of madness being
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  seen in rather more positive terms. a form of
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  divine inspiration, for example. The Hebrew prophets
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  in the Old Testament behave in ways that to many
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  people seem so far out of the ordinary as to
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  seem psychotic, but are often interpreted in
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  that context as speaking for Yahweh, for speaking
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  for God. and certainly the idea of fools or the
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  mad having some privileged access to another
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  reality. is one we can see coming through. And
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  you can see it actually as late as the 1960s,
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  where somebody like the Scottish psychiatrist
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  R .D. Lange announced that schizophrenia was
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  a kind of super sanity. It was the world that
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  was mad at the schizophrenic who was seeing things
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  in a kind of novel fashion. These things come
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  and go, but the general history, I would say,
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  of serious mental illness is for people like
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  that to be highly stigmatized, often treated
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  extremely badly, exiled, beaten, locked up, chained.
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  Generally, life for such people was nasty, brutal,
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  and quite short. And it's interesting because
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  if you look today at the statistics, If one has
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  serious mental illness, chances are you will
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  live 15 to 25 years less than the rest of us
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  for a complicated series of reasons. But obviously,
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  the fact that serious departures from the universe,
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  the rest of us, the common sense universe, the
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  rest of us think we share. is something that
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  is not conducive to good health and longevity,
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  let's put it that way. I like how you put it,
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  we think we share. Well, you know, the reality
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  is that we think we're all sharing the same universe,
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  and most of us behave in ways that seem to reveal
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  that we do. And some people see things or hear
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  things or experience things in such radically
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  different ways from the rest of us that we regard
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  them as being in an alternate universe almost.
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  Or, and there's another large group of people
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  who fall within the psychiatric ambit these days.
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  People who have become demented, who lose most
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  of the consciousness and the thinking ability
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  that the rest of us share. So, you know, on the
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  one hand, you have people whose cognitive abilities
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  and whose abilities to relate to other people
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  are badly damaged. You have people whose emotional
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  life is so very different and fraught that others
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  have a hard time coexisting with them and they
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  often have a hard time with life itself, sometimes
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  ending up killing themselves. And you have people
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  whose... cognitive and emotional life is becoming
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  increasingly stunted and increasingly unrecognizable
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  to the rest of us and there's a vast array of
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  things that fall under this label and to lump
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  them all together is often uh to misunderstand
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  a lot of what's going on and Part of the problem,
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  I think, even with contemporary psychiatric diagnosis
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  is that its categories tend to push together
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  under a single label things that are actually
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  quite heterogeneous. We once used to talk about
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  cancer as though it were a unitary phenomenon,
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  and we now recognize there are many, many different
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  forms of cancer. The one underlying... commonality
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  is the proliferation of cells in an uncontrollable
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  fashion. But when we look at the categories that
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  we usually use these days to talk about mental
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  illness, bipolar disorder, major depression.
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  schizophrenia, when we're talking about the major
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  categories, all of those, it seems to me, encompass
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  a vast array of things. Eugen Bleuler, who was
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  the Swiss psychiatrist who coined the term schizophrenia,
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  actually referred to what he called the schizophrenias,
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  plural. And I think that's quite revealing. Genetic
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  research in recent years, which has absorbed
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  a great deal of money in the last 35 years or
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  so, has actually tended to show there's a great
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  deal of genetic overlap between these different
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  categories that psychiatrists presently use to
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  categorize mental illness. But actually, the
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  other interesting thing that's happened with
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  those genetic studies is there was an assumption
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  since It's long been an observation going back
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  centuries that mental illness seems to run in
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  families. The expectation was in the 1970s and
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  80s when the genetics of mental illness finally
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  revived that we would discover a pretty strong
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  genetic link between the different forms of mental
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  illness. and people's genetic inheritance. And
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  in fact, that's not what genetics has found.
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  In fact, mental illness seems to be one of the
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  least genetically ordained illnesses, if you
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  like. So it's a real puzzle. There's no Mendelian
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  gene or even a handful of genes that, for example,
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  account for schizophrenia. genetic abnormalities
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  that taken together account for about 10 % of
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  the variance statistically and don't explain
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  in a straightforward fashion why people become
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  schizophrenic. It's very clear, it seems to me,
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  that mental illness is an enormously complicated
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  phenomenon which has both some biological component
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  to it, and a lot of social and psychological
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  components to it as well. And the artificial
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  separation of those two things is, it seems to
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  me, profoundly misguided. And it's one of the
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  problems with contemporary psychiatry, that is
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  psychiatry over the last three, four decades,
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  that it is focused so singularly on brains and
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  brain abnormalities, and assuming that's going
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  to unlock the whole picture here. And I think
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  for a whole variety of reasons, that's far too
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  simplistic. And psychiatry over the 200 years,
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  roughly, that we can talk about it existing,
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  has issued lots of promissory notes, lots of
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  claims that it's got the cure for mental illness,
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  and it's repeatedly dishonored them. it hasn't
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  right speaking of true interesting you would
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  say that because that was my next question uh
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  but let's start on maybe more hopeful notes aside
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  zombies which you've also uh mentioned before
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  i don't think there is a more tired flock to
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  death horror movie cliche than an asylum The
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  war just conjures up eerie images of screaming,
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  emaciated people in white rags, languishing in
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  dark halls, being subjected to inhuman experiments,
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  and then usually turning into ghosts and haunting
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  the place forever. But surprisingly, as you demonstrate
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  in your book, asylums didn't start off that way.
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  They were in fact places of genuine desire that...
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  That people who suffer from mental illness could
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  be treated differently in a much more humane
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  fashion, not like you said before, they were
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  beaten and locked up in ancient times and so
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  on. Right. Which would also result in them getting
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  better, right? So tell me about this nicer beginning.
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  Yes. So we can find examples of buildings that
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  contained mad folk in small to medium -sized
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  numbers, 50, 100. Going back quite a long way,
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  the most famous one in the English -speaking
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  world was known as Bedlam. It was actually Bethlehem
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  Hospital. It was originally a monastery. And
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  the monks became specialists in handling patients
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  with mental troubles. And over time, that evolved
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  eventually into a medical institution. But these
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  were relatively rare institutions. There were
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  very few of them. In the 18th century in England,
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  England becomes the first rich commercial society,
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  a market economy where lots of things enter the
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  marketplace. You can learn how to dance. You
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  can learn how to fence. You can hire somebody
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  to dispose of a dead body. You get undertakers
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  coming on the scene because that's a very stressful,
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  distressing, unpleasant experience. So all kinds
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  of things enter the marketplace. And one of the
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  things that enters the marketplace is the idea
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  that somebody will take your mentally ill relative
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  off your hands. You've had to lock them in the
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  attic or lock them up in the pigsty at the bottom
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  of the garden or throw them in jail. So we get
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  private madhouses that are set up to make a profit.
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  immediately acquire a very unsavory reputation.
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  One of the things they do is, of course, remove
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  a potential source of scandal from public view.
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  And mental illness is almost always stigmatized,
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  as we've already discussed. But what's going
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  on behind those closed walls? Well, actually,
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  in reality, a rather big mix of things. People
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  are learning how to cope not just with a single
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  lunatic, as they were being called back then,
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  but with several or maybe 50 of them. And that
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  requires developing skills of handling them.
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  It may be skills of chaining them up, putting
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  them in straitjackets, beating them, those kinds
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  of things. But some people also experiment with
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  more subtle ways of dealing with mental illness.
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  And it's out of that context that there emerges
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  the idea that the environment, if it were arranged
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  properly, and if the mentally ill were treated
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  as not wholly deprived of their reason, but still
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  having some semblance of humanity that could
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  be built upon to bring them back to some sense
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  of... more normal existence, that kind of notion
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  begins to gain ground. And most famously, in
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  an Anglo -American context, a Quaker institution
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  in York in North England, which is called the
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  York Retreat, develops things it calls moral
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  treatment that involve both an environment that
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  doesn't create the impression of a prison. that
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  allows for flexibility in handling of patients,
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  that rewards them for behaving well and doesn't
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  beat them for behaving badly but deprives them
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  of certain privileges, that doing that and creating
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  an environment where, for example, they have
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  pets to pet so that they're drawn out of themselves,
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  they're rewarded if they behave nicely by sitting
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  down to an English tea with the head of the institution.
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  and learning how to behave themselves in that
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  setting. That sort of thing emerges and moral
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  treatment becomes something that it is claimed
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  will restore people to sanity. And it is out
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  of that that the movement in the 19th century
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  to create asylums emerges. Mentally ill are being
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  locked up in attics and pigsties. They're being
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  locked up in jails. The conditions are horrendous.
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  And along come reformers who say, look, we have
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  this model institution that not only treats them
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  humanely, brings them back into the human race,
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  if you like, it cures them and it doesn't impose
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  those things. So the asylum is born. in a moment
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  of almost utopian optimism, that environmental
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  cues and psychologically astute handling of people
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  can coax them back from the abyss to join the
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  rest of us. And did this nicer form of early
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  asylum, did it produce any sort of tangible results?
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  Well, it's of course extremely difficult. after
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  the fact for us to go back. But I think the answer
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  is yes, in the case of many of these early institutions,
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  which were quite small. We're talking 30, 40,
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  50 patients, a charismatic figure running the
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  institution, attendants who are highly motivated
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  to treat, to turn the other cheek, if you like,
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  to treat patients as suffering, not as... people
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  who need to be beaten when they don't conform.
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  And I think, yes, there's probably something
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  to that. The difficulty is once you start to
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  try to generalize that, and particularly once
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  institutions start to grow in size to 100, 200,
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  300, 500, 1 ,000, eventually 10 ,000, you can't
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  sustain that kind of individual attention to
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  patients, nor can you reproduce the early enthusiasm
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  that I think produces a very positive placebo
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  effect, if you like. And so once we start building
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  asylums on the assumption that we're going to
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  produce a great deal of cure, The early asylum
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  proponents were saying, we're going to cure 60
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  or 70 or even 80 % of the patients as long as
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  we get them in here early. Well, they can't live
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  up to that promise. And then things start to
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  move by the time we're into the last four decades
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  or so of the 19th century. We have larger and
• 19:54
  larger institutions where fewer and fewer patients
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  are getting better. where the overwhelming bulk
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  of the patients in the institution have been
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  there for years, if not decades. And instead
• 20:07
  of a positive placebo effect, you get a nocebo
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  effect, you get a negative effect. People begin
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  to assume that madness is a condition that can't
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  be cured. And indeed, when... The people running
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  these institutions, whom we can now, by the latter
• 20:26
  decades of the 19th century, call psychiatrists,
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  they have to explain, why is it that you promised
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  a 70 % cures, and we look at the numbers, and,
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  you know, maybe a third of the patients who come
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  in in a given year emerge better. What gives
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  here? Well, increasingly the answer to that in
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  an era when we're moving towards a belief in
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  evolution is these patients in whom evolution
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  has worked in reverse. They are degenerates.
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  They are physically inferior to the rest of us.
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  Biology's gone wrong. It's gone backwards. They
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  have left the rest of us behind. They've become
• 21:16
  almost subhuman. Sounds a lot like eugenics.
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  It's what, at the end of the 19th century and
• 21:25
  into the 20th century, does produce eugenics.
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  The idea that something is irretrievably biologically
• 21:33
  wrong with these people, it produces in the early
• 21:37
  1900s in America a movement towards compulsory
• 21:42
  sterilization of the mentally ill. Mental illness
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  removes the... The self -control that it's presumed
• 21:50
  the rest of us exercise so we don't breed like
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  rabbits, these mentally ill people don't have
• 21:56
  those internal controls and let loose on society.
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  They can produce even more mentally ill people.
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  So one solution to that is to lock them away
• 22:07
  so they can't reproduce. So that becomes the
• 22:10
  justification for these homes. But that's expensive.
• 22:16
  So a secondary idea is, well, let's sterilize
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  them. There's a lot of opposition to that. Much
• 22:23
  of it religiously motivated. The Catholic Church
• 22:26
  in particular. is vociferously opposed to those
• 22:30
  kinds of measures. And while the state I usually
• 22:34
  live in, I'm presently in London, but much of
• 22:36
  the time I'm in California, California was one
• 22:39
  of the states that took the lead in sterilization
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  and was still sterilizing mental patients as
• 22:45
  late as 1960. So there was some of this going
• 22:49
  on, and the Supreme Court was asked to consider
• 22:53
  whether it was appropriate to involuntarily sterilize
• 22:57
  the mentally ill. That was in a case known as
• 22:59
  Buck v. Bell. It reached the United States Supreme
• 23:02
  Court in 1927, and the Supreme Court issued an
• 23:09
  eight to one decision saying, yes, the state
• 23:12
  had a compelling interest in snuffing out the
• 23:15
  reproductive capacity of these tainted creatures.
• 23:19
  Three generations of idiots is enough, said the
• 23:24
  chief justice. The state can proceed to sterilize
• 23:27
  people. Well, fortunately, in a democratic society,
• 23:31
  there were lots of constraints on that. And so
• 23:34
  while it happened. It didn't happen on a vast
• 23:37
  scale. Where it did happen on a vast scale was
• 23:41
  in Nazi Germany. When Hitler came to power in
• 23:44
  1933, pretty soon he passed a sterilization law,
• 23:50
  which was devised with the help of leading German
• 23:53
  psychiatrists and permitted the mass sterilization
• 23:59
  of tainted, mentally ill people. And that took
• 24:04
  place on a big scale. And then towards the outbreak
• 24:08
  of World War II, the Nazis said to themselves,
• 24:13
  why are we keeping these useless eaters, as they
• 24:16
  called them, alive? They're not contributing
• 24:19
  anything to the Reich. They're sucking resources.
• 24:23
  They're never going to get better. Why not kill
• 24:26
  them all? And indeed, the program that was called
• 24:29
  T4 after... the number of the house in Berlin
• 24:34
  where this program was hatched. The T4 program
• 24:39
  involved the murder of up to a quarter million
• 24:43
  mentally ill people in Germany. And it was there
• 24:47
  that the technology that became part of the death
• 24:51
  camps. the extermination of the Jews and other
• 24:55
  undesirables as far as the Nazis were concerned.
• 24:58
  That's where it was developed. That's where gas
• 25:00
  chambers disguised as showers, for example, were
• 25:04
  built. And Germans knew damn well what was going
• 25:07
  on. The buses that took the mentally ill to the
• 25:12
  mental hospitals where the crematoriums were
• 25:14
  belching the black smoke, where their bodies
• 25:16
  were being burned, were known by the locals as
• 25:19
  killing crates. They knew what was going on,
• 25:22
  as indeed their course did with the concentration
• 25:25
  camps. So the mentally ill were the ones that
• 25:29
  pioneered the final solution. It's a terrible
• 25:32
  story. And the Germans boasted that they modeled
• 25:39
  their mass sterilization bill on Californias.
• 25:45
  The superintendent, a woman incidentally, at
• 25:48
  Stockton State Hospital in California in 1937,
• 25:51
  said how delighted she was that Germany had taken
• 25:56
  her policy and adopted it on a nationwide scale.
• 26:00
  This is a terrible time. And that's one way in
• 26:06
  which the decline of the asylum until it became
• 26:10
  seen as a kind of holding pen for... um people
• 26:16
  who otherwise were socially problematic um that's
• 26:22
  one one way one direction in which it could go
• 26:25
  of course what we should understand is the following
• 26:29
  it was the asylum that gave birth to psychiatry
• 26:35
  in the modern sense of the term initially some
• 26:38
  of these asylums were run by lay people but medical
• 26:44
  doctors managed to persuade the lawmakers that
• 26:48
  they could add medical treatment to moral treatment,
• 26:52
  and that would be better than either taken on
• 26:54
  its own. And they were the only ones that could
• 26:57
  provide the medical treatment, so ergo they were
• 27:00
  the ones who should be running the institutions.
• 27:02
  And that indeed is what happened by the 1830s
• 27:07
  and 40s and 50s. In a way, it's a sort of chicken
• 27:13
  and egg problem. Psychiatry is born out of the
• 27:16
  asylum that's being built in the ways we've described
• 27:20
  for utopian reasons. On the other hand, the asylum
• 27:25
  doctors are the ones that provide the legitimacy
• 27:27
  for the asylum, that provide the claim that it's
• 27:31
  a treatment facility, not a prison. And indeed,
• 27:35
  they try to treat patients. And it is important
• 27:38
  to note that Although the image of the asylum
• 27:43
  by the 1870s and 80s was of a place where you
• 27:49
  emerged only in a pine box, that wasn't quite
• 27:53
  true. In fact, when patients came in in a given
• 27:58
  year, perhaps 35 or even 40 % of them within
• 28:03
  a year or so came out improved or, as they thought,
• 28:08
  cured. And maybe they were. removal from poverty,
• 28:14
  from grinding circumstances, maybe better diet,
• 28:18
  who knows, or maybe just some relief from the
• 28:23
  social conditions they were living in. But what
• 28:26
  that means is some people died, right? Roughly
• 28:31
  10 % mortality out of that cohort. But that left
• 28:36
  half or more of them behind. And if you didn't
• 28:39
  get out in the first year, you probably weren't
• 28:42
  going to get out. So over time, what that means
• 28:46
  is asylum populations grow and grow the size
• 28:50
  of the asylum. That means conditions for the
• 28:53
  patients get worse and worse on the whole. But
• 28:56
  it also means if you look at... the asylum most
• 28:59
  of the patients are chronic patients they've
• 29:02
  been there for years and years and that becomes
• 29:05
  the image of mental illness and that's what feeds
• 29:08
  into these ideas of degeneracy and eugenics okay
• 29:12
  but the people who are going into psychiatry
• 29:17
  For some of them, it's just a cushy career if
• 29:21
  they can get to be the superintendent of these
• 29:23
  institutions, largely an administrative job with
• 29:27
  a nice house and servants and so forth. But for
• 29:33
  the more ambitious among them, for people who
• 29:35
  go into a healing profession wanting to actually
• 29:39
  do something that improves a lot of the people
• 29:42
  they're treating, that's a very unsatisfactory
• 29:45
  state of affairs. So what we've talked about
• 29:48
  so far is how this movement towards a heavily
• 29:53
  biological view of mental illness in the late
• 29:56
  19th century could lead to these horrors, involuntary
• 29:59
  sterilization, death camps. It also might lead
• 30:06
  in another direction. Perhaps if it's biological,
• 30:11
  if it's something wrong with people's bodies,
• 30:13
  we can fix what's wrong with their bodies. Now,
• 30:17
  remember, that same period, the last third of
• 30:22
  the 19th century, is when medicine discovers
• 30:25
  germs and germ theory and bacteriology and the
• 30:29
  laboratory and the idea that disease is caused
• 30:32
  by infection. They don't really know. I have
• 30:35
  a slight suspicion we're going to be talking
• 30:36
  about focal sepsis soon. Yeah, fairly soon. But
• 30:39
  we're going to be talking about a bunch of these
• 30:41
  things, yes. So what happens here? In general
• 30:47
  medicine, that first has an impact through surgery,
• 30:53
  where instead of regarding pus as a sign of healing,
• 30:58
  we begin to go, oh my God, we don't want that,
• 31:01
  right? So we have antiseptic and eventually aseptic
• 31:05
  surgery. We try and keep a bacteria out of the
• 31:09
  operating theater, out of the wound. And we are
• 31:12
  able to... when you couple that with the invention
• 31:15
  of anesthetics in the 19th century, that means
• 31:18
  we can start operating for things that were previously
• 31:21
  fatal. If you had an appendicitis in 1850, it's
• 31:29
  going to burst your appendix. You're going to
• 31:31
  die of focal, you're going to die of sepsis horribly,
• 31:34
  right? No antibiotics, you're dead. Now we can
• 31:40
  move the appendix and miraculously you're better.
• 31:43
  So that does something for the prestige of medicine.
• 31:46
  The next thing that does something for the prestige
• 31:49
  of medicine, Robert Kennedy Jr. notwithstanding,
• 31:52
  is the infection of vaccines. Vaccines against
• 32:00
  something terrible called rabies. Vaccines against,
• 32:04
  for example, tetanus. Vaccines against diphtheria.
• 32:14
  You and I, being male, probably didn't read Little
• 32:17
  Women as we were growing up, but the girls probably
• 32:21
  do. And there's a scene of a leather -like thing
• 32:26
  growing over the throat of one of the children
• 32:31
  who dies. Imagine as a parent watching your child
• 32:35
  die like that and being helpless. And then a
• 32:39
  vaccine comes along. It's a miracle. So even
• 32:44
  though initially the rise of bacteriology, the
• 32:48
  laboratory, the notion that disease was caused
• 32:52
  in that fashion didn't provide the sorts of breakthroughs
• 32:55
  we think about with penicillin, for example,
• 32:58
  it did mark a real improvement in what doctors
• 33:04
  understood about disease and in some instances
• 33:07
  what they could do about disease. As is often
• 33:11
  the case, when you have a breakthrough like that,
• 33:16
  you tend to think it's the solution to everything.
• 33:19
  So germ theory dominates everything. All sorts
• 33:25
  of disease must be the result of germs. How about
• 33:29
  mental disease? Well, there's initially something
• 33:33
  that actually gives extra credence to that idea.
• 33:41
  You and I were around, I think, looking at you,
• 33:45
  when the AIDS epidemic happened. Suddenly, we
• 33:49
  have this terrible sexually transmitted disorder
• 33:52
  that kills people horribly and does terrible
• 33:56
  things to their bodies. The 19th century equivalent
• 33:59
  of that was syphilis. And one of psychiatry's
• 34:04
  early diagnostic triumphs in the 1820s in Paris
• 34:09
  was the identification of a subset of people
• 34:12
  with mental illness who suffered from something
• 34:16
  called general paralysis or general paralysis
• 34:19
  of the insane, or GPI for short. These were people
• 34:23
  who, as that term suggests, gradually became
• 34:27
  paralyzed, lost the ability to walk, lost the
• 34:31
  ability to talk, lost the ability to swallow,
• 34:33
  usually died on ingesting their own vomit. or
• 34:36
  from the bed sores they developed because they
• 34:39
  couldn't move anymore. That was sometimes thought
• 34:42
  in the early 19th century as the kind of end
• 34:45
  state of all mental illness. But that wasn't
• 34:48
  right. As the century wore on, people began to
• 34:52
  wonder about it. Was it somehow connected to
• 34:55
  sexual excess? That was right, because in the
• 35:00
  early 20th century, we finally discovered that
• 35:04
  people suffering from GPI were actually suffering
• 35:07
  from tertiary syphilis. Syphilis is a really
• 35:11
  nasty disease in that when you first get infected,
• 35:16
  it's visibly obvious you're in pain, you have
• 35:19
  sores, you have serious discomfort, but then
• 35:23
  it goes underground. And then it disappears,
• 35:25
  right? It disappears. It goes underground, sometimes
• 35:27
  for decades. So particularly in an era when...
• 35:32
  Middle class men married late because they had
• 35:35
  to establish themselves before they could marry.
• 35:38
  They resorted to prostitution, which was rife
• 35:41
  in the 19th century. They contracted syphilis.
• 35:45
  They thought they'd got over it. They became
• 35:47
  bankers and lawyers and ministers. And then in
• 35:51
  their 1840s and 50s, they dropped dead of a heart
• 35:53
  attack. That was syphilis. They didn't know it.
• 35:57
  at the time, but that's what it was. But sometimes
• 35:59
  syphilis attacks the central nervous system,
• 36:02
  the spinal cord in the brain. That was GPI. So
• 36:06
  you had on the one hand... uh these neurological
• 36:10
  symptoms but you also then thought you were jesus
• 36:14
  christ reincarnated you were napoleon you were
• 36:17
  mary the mother of god if you were a female version
• 36:20
  or sometimes even if you were male you had these
• 36:24
  bizarre delusions as well as these other symptoms
• 36:28
  so this is not a rare condition About a quarter
• 36:33
  of male admissions to asylums in New York, for
• 36:36
  example, in 1900, were suffering from GPI. One
• 36:41
  quarter. So when you find one major form of mental
• 36:47
  illness that by 1912 you know is an infectious
• 36:52
  disease, and the idea of infection being the
• 36:56
  cause of illness is everywhere, the natural leap
• 37:01
  forward is to say, gee, maybe the rest of mental
• 37:05
  illness is an infectious disease. And that's
• 37:08
  what a handful of psychiatrists, most notably
• 37:12
  a guy named Henry Cotton in New Jersey, but also,
• 37:16
  interestingly enough, the leading German psychiatrist
• 37:23
  of the late 19th, early 20th century, a man named
• 37:26
  Emil Kraplin, believed. that psychosis had a
• 37:32
  toxic origin. It was a germ that had caused the
• 37:37
  problems. If you believe that, what the hell
• 37:41
  are you going to do? Well, you don't have penicillin.
• 37:47
  You don't have sulfur drugs. You don't have anything
• 37:49
  that can attack and remove and cause bacterial
• 37:55
  infections to go away. So what do you do? You
• 37:58
  engage in what Henry Cotton himself called surgical
• 38:02
  bacteriology. This is where things get really
• 38:05
  dark. Yes, this is where things get the stuff
• 38:08
  of nightmares. You go in and where do you think,
• 38:12
  well, you know, this person's got bad teeth.
• 38:15
  Let's pull them out. That's obviously, it's very
• 38:17
  close to the brain. It's poisoning the brain.
• 38:20
  We pull teeth. So thinking there might be like
• 38:22
  a slight infection in the teeth. You've got chronic
• 38:25
  infections that are leaking. toxins into the
• 38:28
  bloodstream, into the lymph. They're getting
• 38:31
  into the brain, poisoning it, hence the madness.
• 38:35
  So teeth. Wait, even though you couldn't physically
• 38:38
  see anything, if you were Dr. Henry Cotton. Now
• 38:41
  you have a laboratory. You can take x -rays and
• 38:45
  see the teeth are decaying, right? You can culture
• 38:49
  the bacteria from the mouth and you say, see,
• 38:52
  they really are. So this is modern science being
• 38:55
  brought into the asylum. See, pull the teeth.
• 39:00
  They don't get better. Wow, what could be going
• 39:04
  on? Well, you know, the tonsils, they're also
• 39:07
  very adjacent to the brain and they're often
• 39:09
  infected. So let's slice out the tonsils. Let's
• 39:13
  do tonsillectomies. Tonsillectomies were being
• 39:16
  done on a mass scale when I was a kid. If you
• 39:18
  had sore throats, even after the advent of penicillin,
• 39:22
  lots of times you had your tonsils removed. As
• 39:25
  kids, we thought, oh, you're lucky you get to
• 39:27
  eat ice cream. Not really. But that was part
• 39:33
  of this focal sepsis notion. The idea that if
• 39:36
  you had a chronic, low -grade infection in your
• 39:39
  body that was being overlooked, it was leaking
• 39:42
  poisons into your system. And some of those poisons
• 39:45
  were ending up in your brain. And that was making
• 39:48
  you mad. Moving tonsils doesn't work. Should
• 39:51
  we abandon the theory? Nah. Look. Your mouth
• 39:56
  is full of toxic bacteria. You're swallowing
• 39:59
  them. Where are they going? Stomach. Colon. So
• 40:06
  Cotton starts removing people's stomachs. He
• 40:10
  says a stomach is like a concrete mixer at a
• 40:13
  building site. It's not essential. We can take
• 40:17
  it out. Colons, you could do without colons.
• 40:19
  We'll remove them. And I'm curing 80 % of the
• 40:22
  people I'm treating. And rich people from all
• 40:25
  over America come to be treated by cotton in
• 40:30
  this great new fashion. The New York Times proclaims
• 40:34
  this great breakthrough has happened. Oxford
• 40:38
  and Princeton University presses publish cotton's
• 40:42
  lectures in a series that's largely devoted to
• 40:45
  Nobel Prize winners. Actually, 45 % of the patients
• 40:49
  who received the abdominal surgery are dying.
• 40:53
  And when an outside investigation is done, it's
• 40:58
  headed by somebody who had trained Henry Cotton,
• 41:00
  who sends his young female assistant to study
• 41:04
  what's going on. And she, after 18 months of
• 41:07
  work, reports back, this man is killing patients.
• 41:11
  The more treatment they get, the worse the outcome.
• 41:14
  And what does Adolf Mayer, America's leading
• 41:17
  psychiatrist at America's leading medical school,
• 41:20
  Johns Hopkins University, do? He suppresses the
• 41:24
  report, kicks her out, and allows Cotton to proceed.
• 41:28
  And when Cotton unfortunately dies of a heart
• 41:31
  attack at his club, Adolf Mayer writes... An
• 41:36
  obituary in the American Journal of Psychiatry
• 41:38
  lamenting that this great psychiatric pioneer
• 41:41
  has died too early before the results of experiments
• 41:44
  can be fully known. I'm sorry, let me ask you
• 41:47
  this really fast. I'm sorry to interrupt. Let's
• 41:51
  say you're Dr. Henry Cotton. Somebody comes to
• 41:53
  your clinic suffering from, let's say, schizophrenia.
• 41:55
  You proceed to remove their teeth or a vital
• 41:58
  organ, and they obviously get worse or they simply
• 42:01
  die, like you said. Obviously, you didn't achieve
• 42:04
  a great result. quite the opposite. And then
• 42:06
  this story repeats on hundreds, maybe thousands
• 42:09
  of patients, I don't know, over decades. How
• 42:12
  come nobody is saying anything? You talked about
• 42:16
  this investigation that was quashed. What about
• 42:19
  the families of these people? Well, yes, there
• 42:21
  are a couple of times where scandal threatens
• 42:23
  to erupt. A rival of Cotton in New York, a man
• 42:32
  named George Kirby, and his young PhD assistant,
• 42:37
  a man named Nicholas Kopeloff, try this technique,
• 42:40
  not going so far as to do the abdominal surgery,
• 42:42
  but they tried the teeth and the tonsils. And
• 42:46
  they report that those patients fare worse than
• 42:50
  a comparison group. Does that change the narrative?
• 42:54
  No, it does not. Kopeloff is not an MD, so we
• 42:57
  can discard his results. And there's no overarching
• 43:03
  mechanism to control cotton and people elsewhere
• 43:07
  adopt his techniques families start to clamor
• 43:11
  for them they're told the alternative is life
• 43:14
  on the back wards of the asylum and this will
• 43:16
  give you a chance of a cure and It's astonishing
• 43:20
  to me. The same thing happens in Britain to a
• 43:23
  lesser extent. There's a man with a rather unfortunate
• 43:26
  name who runs all the mental hospitals in the
• 43:29
  Birmingham area in the center of England. His
• 43:32
  name is Thomas Chivers Graves. And Graves, indeed,
• 43:36
  is where some of his patients end up. This does
• 43:41
  persist. Cotton goes to the United Kingdom twice.
• 43:47
  once in 1923 and another time in 1927. In 1927,
• 43:52
  all the leading figures in British medicine and
• 43:56
  surgery lionize him as the new Lister. Lister
• 44:00
  is the man who introduces antiseptic surgery.
• 44:03
  He's the one who's brought science to psychiatry
• 44:07
  and rescued it from the notions of Freud, or
• 44:10
  fraud, as they prefer to call him. Here's a real
• 44:15
  medical treatment. So it's astonishing that the
• 44:19
  teeth and the tonsils, Cotton's disciples continue
• 44:23
  to run Trenton State Hospital, where his base
• 44:25
  was, all the way until 1960. And they continue
• 44:29
  pulling teeth and tonsils all the way to them.
• 44:32
  I interviewed the dentist who, starting in 1918,
• 44:37
  had pulled literally hundreds of thousands of
• 44:40
  teeth. to cure these mental patients. He stopped
• 44:44
  doing it when he retired in 1960, and he still
• 44:48
  believed that Henry Cotton should have won the
• 44:50
  Nobel Prize. Really, it's fairly amazing. And
• 44:54
  we should talk then about some of the other biological
• 44:58
  treatments that emerge in this same era. Because
• 45:02
  Cotton's thing does die away, it's fair to say,
• 45:05
  by the late... 1930s most places have discontinued
• 45:10
  this and no longer believe it but ambitious mostly
• 45:14
  men in psychiatry are now looking for other ways
• 45:18
  in which biological interventions might cure
• 45:22
  mental illness yes and of course another fun
• 45:25
  one on the list is also one of the most horrifying
• 45:28
  procedures we've ever come up with with as species
• 45:31
  of course is lobotomy which was apparently A
• 45:34
  Nobel Prize winning idea. What on earth happened
• 45:38
  there? Well, so first as background, people had
• 45:42
  tried putting people in comas using insulin,
• 45:45
  one of the great breakthroughs in 20th century
• 45:48
  medicine, to put people into a coma and claimed
• 45:54
  that repeated comas of that sort, which could
• 45:56
  eventuate in death, you might not come around,
• 45:59
  were curing 80 % of schizophrenics. Sorry, what
• 46:04
  was the reasoning behind this, Matt? Well, if
• 46:08
  you can call it that, Sackle himself thought
• 46:12
  that what was happening, people said to him,
• 46:14
  you know, what happens when people go into diabetic
• 46:18
  comas like this, the brain's being deprived of
• 46:21
  oxygen? He said, yes, what's happening is the
• 46:24
  recent cells are dying off first, and those are
• 46:28
  the schizophrenic cells. So that's why it's going
• 46:30
  to cure people. People going into these comas
• 46:37
  often seized, had things that resembled epileptic
• 46:40
  seizures. Some other bright spark, a man named
• 46:44
  Maduna, the Austro -Hungarian emperor in Vienna,
• 46:49
  says, well, you know, You can't have both schizophrenia
• 46:53
  and epilepsy. That's false, but that's what he
• 46:56
  believed. So if we could artificially induce
• 46:59
  epilepsy, we'd drive out the schizophrenia. How
• 47:03
  are we going to do that? Well, he started injecting
• 47:06
  them. with a variety of substances. And then
• 47:08
  he happened upon one that became known in Europe
• 47:10
  as Cardiazol and in America as Metrazole. When
• 47:14
  you inject it, now imagine you're in a straitjacket,
• 47:17
  you're brought in, a guy with a stethoscope and
• 47:19
  a white coat brings out a big syringe and sticks
• 47:21
  something into your arm. What happens next? By
• 47:26
  Maduna's own account, you feel as though you're
• 47:29
  about to die. You're petrified. And then if you're
• 47:34
  lucky, A minute or two or five minutes later,
• 47:37
  you have a massive seizure, which may end up
• 47:40
  breaking bones in your back or breaking your
• 47:43
  hip socket because of the extremity of the contraction
• 47:47
  of your muscles. But it's going to cure your
• 47:50
  schizophrenia 80%. That had severe drawbacks
• 47:53
  because of all these fractures and because of
• 47:56
  the fact that it was so frightening. And he claimed
• 47:58
  people were amnesiac, that they didn't remember
• 48:01
  this fright. But who knows? People looking for
• 48:06
  a more humane alternative in Italy, Solletti
• 48:11
  and Beni, think about, well, maybe we could use
• 48:14
  electricity for this. They try it first on dogs,
• 48:18
  and they try one on the head and one on the anus,
• 48:21
  and the dogs die. Then somebody says, you know,
• 48:23
  you should go to the Rome slaughterhouse. They're
• 48:26
  killing pigs. And they dangle them from the hind
• 48:29
  legs, and as they come by, they stick electrodes
• 48:32
  on their heads, and they zap them, and then they're
• 48:34
  unconscious, and then they slit their throats.
• 48:36
  So they try it on a transient they pick up in
• 48:39
  their own train station. And that's where ECT
• 48:42
  comes from. ECT is cheap and very quick, and
• 48:47
  it doesn't require a lot of... Electroconvulsive
• 48:51
  therapy. Initially known as electric shock. And
• 48:55
  then since we don't like that shock thing, we
• 48:58
  call it electroconvulsive therapy. Or then we
• 49:00
  really prefer ECT because that even moves it
• 49:04
  further. What a nice euphemism. And it turns
• 49:07
  out, I mean, ECT is the only one of these desperate
• 49:10
  remedies, as I've called them, that survives
• 49:12
  into the present. It's still used on so -called
• 49:15
  treatment -resistant depression. That is, cases
• 49:19
  of suicidal depression. where people don't respond
• 49:22
  to antidepressants some psychiatrists prescribe
• 49:25
  it some swear by it some swear about it some
• 49:30
  patients swear by it some swear at it some claim
• 49:33
  it creates memory problems which it almost certainly
• 49:36
  does it does seem at least in the short to medium
• 49:40
  term to alleviate the depression for a number
• 49:43
  of people so it's there um and Reasonably reliable
• 49:49
  studies recently seem to suggest, for reasons
• 49:54
  we don't understand, it in some cases makes a
• 49:58
  real difference. So then you come to lobotomy.
• 50:03
  So there's this string, and there are others
• 50:05
  that we haven't had time to talk about. But if
• 50:10
  we're convinced that something's wrong in the
• 50:14
  body, where is it that mental illness resides?
• 50:17
  pretty obviously in the brain and a portuguese
• 50:21
  neurologist named i guess moniz uh in 1935 comes
• 50:26
  up that with the idea that one of the problems
• 50:30
  with people with mental illness is this perseveration
• 50:33
  the persistence of these hallucinations these
• 50:36
  delusions these tangled emotions and ideas that
• 50:40
  are going on and that they must have their root
• 50:44
  in the frontal portion of the brain the most
• 50:47
  developed part of the brain, the thing that most
• 50:49
  distinguishes us from the rest of animal creation.
• 50:53
  Now, on one version of the story, what leads
• 50:56
  him to think up the operation we call lobotomy
• 50:59
  is experiments in a primate lab in Yale University,
• 51:04
  where they're experimenting with chimps and rewards
• 51:09
  and punishments. And one of the chimps named
• 51:12
  Becky becomes almost uncontrollable. She can't
• 51:15
  solve the problems. She responds by throwing
• 51:18
  her feces at the lab as technicians, generally
• 51:21
  behaving badly. And Carlisle, the chief of the
• 51:27
  lab, goes in and severs her frontal lobes, and
• 51:31
  she becomes tame. She also becomes somebody who,
• 51:34
  were she a chimp in the wild, would promptly
• 51:37
  die. loses the ability to do things chimpanzees
• 51:43
  would need to do to survive. But what's notable
• 51:46
  when he presents that finding at a neurological
• 51:49
  conference in London in 1935 is that she, her
• 51:54
  bad behavior has ceased. On one version, that's
• 51:58
  where Moniz gets the idea. He says no. And There's
• 52:03
  some reason to think that he indeed was thinking
• 52:07
  along these lines quite separately from these
• 52:09
  Yale experiments. Regardless, what happens? He
• 52:13
  goes back to Lisbon. He gets hold of a bunch
• 52:17
  of asylum patients. And he persuades a neurosurgical
• 52:21
  colleague to conduct this surgery. He can't do
• 52:26
  it himself because he's crippled by arthritis.
• 52:29
  And besides, he's a neurologist, not a surgeon.
• 52:33
  So he begins by injecting alcohol into the frontal
• 52:35
  lobes of the brain. Then after a while, he cuts
• 52:40
  them. And he reports miraculous results in the
• 52:45
  medical literature. We now know those miracles
• 52:47
  didn't happen. But that's what was reported.
• 52:51
  Gets picked up by an American neurologist named
• 52:54
  Walter Freeman, who has... As luck would have
• 52:58
  it, one of the few then -trained neurosurgeons
• 53:01
  in the country, neurosurgeon is a very scarce
• 53:03
  specialty at that point because there's not much
• 53:05
  neurosurgeons can do. When they try to remove
• 53:08
  tumors from the brain, even if they're so -called
• 53:10
  benign tumors, it generally is catastrophic,
• 53:13
  if not fatal. So Walter Freeman and James Watts,
• 53:19
  who's trained at Yale where this primate lab
• 53:23
  was, start doing lobotomies. And in 1936, they
• 53:32
  report their first results. Let me guess, miraculous.
• 53:36
  Claiming it's miraculous. Freeman is a master
• 53:41
  at getting publicity, and he invites a couple
• 53:45
  of journalists, New York Times, The Washington
• 53:47
  Post, in to report on this medical miracle. A
• 53:50
  soul is saved by this simple operation on the
• 53:53
  brain. You transform a lunatic into... Sober
• 53:57
  person. Actually, when those results were announced
• 53:59
  in Baltimore, where Johns Hopkins is, there's
• 54:03
  uproar. Many of the psychiatrists in attendance
• 54:06
  shout him down and up steps Adolf Mayer. Now,
• 54:11
  Adolf Mayer is a Swiss -American who's highly
• 54:14
  trained, is America's leading psychiatrist in
• 54:18
  these years before World War II. And Mayer says,
• 54:22
  I believe in these gentlemen. They are scientists.
• 54:25
  We should let this experiment proceed. And that's
• 54:29
  a key to the thing actually continuing because
• 54:32
  it might otherwise have been stopped in its tracks.
• 54:36
  So Freeman and Watts now continue to do a lot
• 54:42
  of these lobotomies. One of the early ones in
• 54:45
  1942 is the daughter of Joseph Kennedy. who had
• 54:51
  been the United States ambassador to Britain
• 54:55
  and a Hitler sympathizer who was eventually removed
• 54:58
  because of that. I just read that story that
• 55:01
  they, due to fear of embarrassing the family
• 55:04
  name, she was put into a psych ward by her father,
• 55:07
  Joseph Kennedy, and then lobotomized, which left
• 55:09
  her incontinent, unable to walk and speak. Correct.
• 55:15
  Incontinent, basically unable to walk and speak.
• 55:18
  hidden away for decades, not spoken of by the
• 55:22
  family. Apparently they said she lives as a private
• 55:27
  citizen somewhere and she doesn't want to be
• 55:29
  disturbed. So really, really terrible story.
• 55:33
  Now, lobotomy continues. It attracts converts
• 55:36
  rather as Henry Cotton did, but on a relatively
• 55:40
  small scale. And then after the war, two things
• 55:44
  happen. 1949. Moniz is awarded the Nobel Prize
• 55:48
  in medicine for this wonderful invention, 14
• 55:52
  years after the first lobotomy, when you would
• 55:55
  have thought enough negative cases would have
• 55:57
  accumulated. Now, one thing to say here, if we
• 56:01
  use the analogy of a stroke, when people suffer
• 56:05
  a stroke, it injures portions of their brain,
• 56:08
  to a small degree if they're lucky, to a catastrophic
• 56:12
  degree if they're unlucky, and somewhere in between.
• 56:16
  And the brain is a remarkable organ in that it
• 56:19
  sometimes manages to sort of rewire itself, to
• 56:22
  recover function that initially are lost. Lots
• 56:25
  of therapy, eventually people sort of return.
• 56:29
  Something like that was true. Lobotomy had hugely
• 56:32
  variable results because although Freeman and
• 56:35
  Watts called their operation a precision lobotomy,
• 56:40
  the irony is just too much. In fact, what they
• 56:47
  damaged each time was highly variable, and some
• 56:50
  patients did survive it, and in a handful of
• 56:54
  cases were somewhat improved, although they had
• 56:57
  deficits that often had to be overlooked. But
• 57:01
  many lobotomies were catastrophic in their results.
• 57:05
  So one thing is Nobel Prize legitimizes the operation
• 57:11
  further. The other thing is... Walter Freeman
• 57:15
  is impatient. Neurosurgeons are scarce. The operation,
• 57:19
  when a neurosurgeon does it, takes an hour or
• 57:23
  two. It's an extraordinary process because Freeman
• 57:27
  would sit there while Watts was severing the
• 57:30
  brain tissue using something like a butter knife.
• 57:33
  And he would talk the patient through the operation.
• 57:36
  In other words, the operation was done under
• 57:37
  local anesthetic. You talk the patient through
• 57:42
  it. Why would you do that? Because by trial and
• 57:45
  error, Freeman had concluded when you started
• 57:49
  to get confused, that was when you'd stop cutting
• 57:52
  the brain. It's that primitive. So when you stop
• 57:57
  being able to count back by sevens from 100,
• 58:01
  90. Sounds like Dr. Hannibal Lecter. Yeah, sounds
• 58:04
  awful, right? And we have transcripts of this
• 58:08
  because he was proud of it. And some of them
• 58:10
  are quite awful. There's one I quote in my book
• 58:13
  where the patient says, stop, stop. And they
• 58:16
  ignore him. Freeman, as I say, was impatient.
• 58:19
  This took too long. He was convinced this was
• 58:21
  a miracle cure. He wants to become, as his daughter
• 58:25
  put it, the Henry Ford of lobotomy. You want
• 58:28
  an assembly line lobotomy. So how the hell are
• 58:31
  you going to do that? Well, get rid of this.
• 58:35
  neurosurgery crap. He reads about an Italian
• 58:40
  who's developed this technique to peel back the
• 58:43
  eyelid, stick an ice pick in with a hammer, bang
• 58:50
  through the bone, wiggle the ice pick about,
• 58:54
  repeat on the other side, Bob's your uncle, two
• 58:57
  black eyes, you've been lobotomized in a few
• 59:00
  minutes. How do you stay still for that? Well,
• 59:03
  we give you two or three ECTs first so you're
• 59:06
  unconscious. Freeman travels the United States
• 59:10
  with his kids in the back, some of his kids,
• 59:13
  proselytizing for this operation, going into
• 59:17
  state mental hospitals, showing people how to
• 59:20
  do it. Nothing but contempt for psychiatrists
• 59:24
  who he regards as third -rate doctors. He says,
• 59:27
  I could teach any damn fool, even a psychiatrist,
• 59:30
  to do this operation in 20 minutes. And sometimes
• 59:34
  he does 20 at a time. And even hardened nurses
• 59:42
  and doctors faint and collapse when they watch
• 59:46
  this heck going on. It's one of the reasons tens
• 59:51
  of thousands of lobotomies get done. It eventually
• 59:54
  falls into disuse in the 1950s, in part because
• 59:59
  of the advent of the drugs that we were talking
• 1:00:02
  about way back at the beginning of this broadcast.
• 1:00:05
  And Freeman moves to California. He sort of retires
• 1:00:14
  out there. He continues to lobotomize patients.
• 1:00:16
  I took part. in a PBS documentary called The
• 1:00:21
  Lobotomist that you can still view online. And
• 1:00:26
  one of the fellow participants, very sadly, was
• 1:00:29
  a man named Howard Dulley, who, as an 11 -year
• 1:00:35
  -old, his father divorced and remarried, and
• 1:00:39
  his stepmother found he was being a pain in the
• 1:00:41
  ass. I mean, he's an adolescent. He's got a stepmother.
• 1:00:46
  now his mother's gone away he's acting out she
• 1:00:50
  persuades his father to have him lobotomized
• 1:00:53
  by freeman and he undergoes this ice pick procedure
• 1:00:57
  and obviously he was still alive he'd managed
• 1:01:00
  a career as a school bus driver and it was one
• 1:01:05
  of the great sadnesses of participating in this
• 1:01:09
  documentary we were never personally in the same
• 1:01:13
  space But I could see this really shell of a
• 1:01:18
  person really is enormously sad. One of his last
• 1:01:22
  victims, I would say. So yes, there's this period
• 1:01:28
  where biology rules and biology leads to all
• 1:01:31
  these processes. And then curiously, something
• 1:01:36
  happens in the United States that's unusual.
• 1:01:39
  Freud and psychoanalysis. occupy a large part
• 1:01:43
  even now of many people's intellectual universe
• 1:01:47
  but freud for most of his lifetime was a prophet
• 1:01:52
  without much honor in mainstream psychiatry mainstream
• 1:01:55
  psychiatry wanted nothing to do with his ideas
• 1:01:58
  but there were a small group of people who were
• 1:02:02
  attracted to them certainly hollywood playwrights
• 1:02:07
  novelists artists and some and certainly some
• 1:02:13
  patients who thought of analysis away as reconstructing
• 1:02:19
  their personalities and solving various neurotic
• 1:02:23
  problems. How did that very small network of
• 1:02:28
  psychoanalysts, which was amplified in the late
• 1:02:30
  1950s, late 1930s, I'm sorry, in America, by
• 1:02:35
  the advent of psychoanalysts fleeing Hitler?
• 1:02:41
  many cases Jewish. This was Jewish science. If
• 1:02:45
  Hitler got his hands on them, they were dead.
• 1:02:48
  So they fled. Freud and his daughter flee to
• 1:02:51
  London. Many other analysts flee to New York.
• 1:02:55
  But we're talking about an analytic community
• 1:02:58
  at the outbreak of World War II of maybe 600
• 1:03:02
  or 700, counting the 200 or 300 American analysts.
• 1:03:06
  And that means they could treat, if they're treating
• 1:03:11
  and remember an hour five times a week or even
• 1:03:14
  three times a week a few thousand patients there
• 1:03:18
  are over 400 000 patients in america's mental
• 1:03:22
  hospitals in 1940 over 500 000 by 1950 right
• 1:03:28
  because freudian psychoanalysis entails that
• 1:03:30
  it's very intense right you have to spend a lot
• 1:03:32
  of time with a lot of time five times a week
• 1:03:35
  it's not a casual thing and it's going to last
• 1:03:38
  for months, years, sometimes decades. Woody Allen,
• 1:03:42
  I think, has been in psychoanalysis for 50 years.
• 1:03:46
  So it's a very long process. And you might think,
• 1:03:53
  well, it's a niche thing for only the very rich
• 1:03:58
  can afford such thing. And indeed, that's its
• 1:04:00
  present day status. But during the World War
• 1:04:05
  II, something very powerful happened. We all
• 1:04:10
  know about World War I and shell shock. We know
• 1:04:14
  the trench warfare and all the psychiatric casualties
• 1:04:18
  that came about from that. Among the American
• 1:04:23
  military, psychiatric casualties were two to
• 1:04:27
  three times as high in World War II. Two to three
• 1:04:31
  times as high. Now, going into the war, There
• 1:04:36
  were about 2 ,500 psychiatrists in America working
• 1:04:39
  in mental hospitals primarily. By the end of
• 1:04:42
  the war, the army alone had about 2 ,500 psychiatrists.
• 1:04:47
  As the war, America, as you will recall, enters
• 1:04:50
  World War II a bit late. America's psychiatrists
• 1:04:54
  persuade the government that if you want to avoid
• 1:04:58
  having all these shell -shocked soldiers around,
• 1:05:01
  which is damaging for morale, hugely expensive,
• 1:05:06
  catastrophic if you're trying to organize troops.
• 1:05:09
  We need to psychiatrically screen everybody who's
• 1:05:13
  being drafted into the military. So they do.
• 1:05:17
  Hundreds of thousands of people. They screen
• 1:05:19
  out 1 .75 million people as psychiatrically unfit.
• 1:05:24
  So we won't have problems. We've weeded out the
• 1:05:27
  ones who are vulnerable and we won't have any
• 1:05:31
  problems. What happens? as i said two to three
• 1:05:35
  times as commonly as in the first world war soldiers
• 1:05:40
  facing combat even sometimes anticipating combat
• 1:05:46
  break down and uh how are they treated they're
• 1:05:51
  treated using short -term psychotherapy if we
• 1:05:55
  can call it that there So talk therapy. Talk
• 1:05:58
  therapy, sometimes with a little aid of drugs,
• 1:06:00
  but basically talk therapy. Mostly it's relabeled
• 1:06:07
  as combat exhaustion or combat fatigue, not shell
• 1:06:11
  shock. So that suggests a little bit of rest
• 1:06:15
  and recuperation and you'll be all better. And
• 1:06:18
  as long as you're treated close to the front
• 1:06:21
  lines. The therapists are able to persuade them.
• 1:06:25
  They're letting their fellow members of their
• 1:06:29
  little unit down. You've got to be a man. You've
• 1:06:32
  got to go back. You've had the arrest. Go back
• 1:06:34
  and fight. Oh, yeah. A little bit of peer pressure
• 1:06:37
  will do the trick. And so if they get more serious
• 1:06:41
  treatment than that, if they get sent back away
• 1:06:43
  from the front lines, that's generally catastrophic.
• 1:06:46
  Those soldiers don't recover. And after the war,
• 1:06:50
  you have... a huge number of veterans who still
• 1:06:55
  suffer from psychiatric disorders. Some of them
• 1:06:59
  are on pensions for psychiatric disability. Many
• 1:07:03
  of them are consigned to newly built veterans
• 1:07:06
  hospitals with psych wards in them. One of the
• 1:07:12
  problems when you need more manpower, I said
• 1:07:15
  you start out with 24, 2 ,500, but they're working
• 1:07:19
  in mental hospitals. There's only so many of
• 1:07:21
  them you can pull out to become an army psychiatrist.
• 1:07:24
  So you've got to train people really fast, right?
• 1:07:27
  You take MDs, you give them a few weeks of training
• 1:07:29
  and turn them loose. But even doing that, you
• 1:07:33
  can't train enough people fast enough. That's
• 1:07:36
  one of the problems of highly trained manpower.
• 1:07:42
  created overnight, just as America's discovering
• 1:07:45
  it can't create enormously sophisticated missiles
• 1:07:49
  when it's used them all up in the space of a
• 1:07:52
  few weeks. So that's how psychologists get involved
• 1:07:58
  for the first time in psychotherapy. As far as
• 1:08:04
  the medical men are concerned, psychologists
• 1:08:06
  can be kept under the thumb of the doctors. because
• 1:08:10
  of military hierarchies and they kind of get
• 1:08:14
  invited into the tent and that's where we see
• 1:08:17
  the origins of clinical psychology the profession
• 1:08:21
  that these days is the major deliverer of psychotherapy
• 1:08:25
  to patients because most mds don't do that anymore
• 1:08:29
  because it's not financially rewarding enough
• 1:08:33
  It takes, you know, you can do one patient for
• 1:08:36
  an hour, or if you're seeing people every six
• 1:08:38
  or ten minutes, you can churn through a lot more
• 1:08:41
  in the space of an hour dispensing medication,
• 1:08:44
  right? So that's where that comes from. And after
• 1:08:50
  the war, you've got two sets of problems. The
• 1:08:54
  mental hospitals, which were in dreadful state
• 1:08:56
  in the 1930s, partly because of the Great Depression
• 1:09:00
  and the cutting of state budgets. Were they still
• 1:09:03
  asylums? They were called mental hospitals by
• 1:09:06
  now, but they were still basically asylums. And
• 1:09:09
  they were in a particularly dreadful state after
• 1:09:12
  the war. Some of their trained men and women
• 1:09:15
  power had been drafted out to deal with their
• 1:09:17
  military casualties. They'd been starved of funds.
• 1:09:23
  In the case of English and French mental hospitals,
• 1:09:26
  patients were literally starved. Many of them
• 1:09:29
  died of starvation during the war. But in any
• 1:09:32
  event, they were ripe for journalistic exposes.
• 1:09:36
  And indeed, those were forthcoming. One American
• 1:09:42
  journalist had visited Buchenwald and Dachau
• 1:09:46
  and the death camps and came back and wrote a
• 1:09:50
  piece after he visited America's state hospitals,
• 1:09:53
  which he titled America's Death Camps. And he
• 1:09:57
  likened American mental hospitals. to the Nazi
• 1:10:01
  concentration camps he'd just seen. Albert Deutsch,
• 1:10:04
  who was a journalist who had written the first
• 1:10:07
  sort of popular history of America's encounter
• 1:10:11
  with mental illness, also visited state hospitals
• 1:10:15
  in these years, and he was generally a sympathetic
• 1:10:17
  observer. He wrote a series of articles which
• 1:10:21
  became a book called The Shame of the States,
• 1:10:23
  which published photographs. of naked patients
• 1:10:27
  lying around in midst of pools of urine and feces
• 1:10:31
  and just deplorable conditions and described
• 1:10:36
  the state hospitals as cesspits, really. He was
• 1:10:43
  trying to get more money injected into the system.
• 1:10:46
  He wasn't trying to destroy the hospitals, but
• 1:10:48
  to get them rebuilt as therapeutic places. But
• 1:10:52
  it helped damage the legitimacy of the hospitals
• 1:10:54
  a great deal. So you have still vast numbers
• 1:10:59
  of patients coming into America's mental hospitals.
• 1:11:03
  As I say, by 1950, over a half million. By 1955,
• 1:11:07
  which is the peak year for American mental hospitals,
• 1:11:11
  on an average day, 558 ,000 patients in the mental
• 1:11:16
  hospitals. American population is more than double
• 1:11:20
  what it was in 1955. So there ought to be, if
• 1:11:24
  we hospitalized at the same rate, well over a
• 1:11:27
  million patients in mental hospitals. How many
• 1:11:31
  are there these days? Less than 40 ,000. Something's
• 1:11:36
  happened. We can talk about what's happened,
• 1:11:38
  if you like. But so that's happening. There are
• 1:11:43
  America's veterans. in the veterans hospitals
• 1:11:47
  suffering from psychiatric disorders, some of
• 1:11:51
  them getting lobotomies, huge need for trained
• 1:11:54
  professional manpower. And this is a period where
• 1:11:59
  America transforms itself. The war has meant
• 1:12:05
  mass mobilization, the breakdown of the constraints
• 1:12:08
  on the federal government, the advent of a massive...
• 1:12:13
  intervention into the economy and into everything
• 1:12:17
  else. The birth of the modern research university.
• 1:12:22
  Vannevar Bush, who's the science advisor, writes
• 1:12:27
  a very famous book on the need for big science,
• 1:12:35
  the need for the government to invest in science.
• 1:12:37
  Science has contributed to winning the war, most
• 1:12:40
  obviously. in the atom bomb, but in radar in
• 1:12:45
  all kinds of ways. And so we get the National
• 1:12:48
  Science Foundation. We get the National Institutes
• 1:12:51
  of Health. And in 1949, we get the National Institute
• 1:12:56
  of Mental Health. And we get the Veterans Administration,
• 1:13:01
  which is also funding a lot. It's the second
• 1:13:06
  or third largest medical system in the world.
• 1:13:10
  the Veterans Administration. It's a huge complex.
• 1:13:14
  So there's a lot of federal money flowing in,
• 1:13:17
  some of it flowing into training new nurses,
• 1:13:22
  social workers, psychologists, and psychiatrists.
• 1:13:27
  Some of it flowing into research, more and more
• 1:13:30
  of it flowing into research. And that becomes
• 1:13:35
  something that American universities become addicted
• 1:13:39
  to. My campus regularly ranks in the top five
• 1:13:46
  in the country in terms of federal research dollars
• 1:13:49
  it gets, although with the current administration
• 1:13:53
  in power in Washington, that may be changing,
• 1:13:56
  particularly because we're one of the hotbeds
• 1:14:00
  of climate science research. So there's this
• 1:14:04
  big transformation. The guys who have worked
• 1:14:09
  in the military branch of psychiatry think that
• 1:14:14
  psychotherapy and early treatment is the answer,
• 1:14:18
  and they persuade these new federal guys to underwrite
• 1:14:23
  that. And so what happens in America after the
• 1:14:27
  war is psychoanalysis achieves a position dominating
• 1:14:32
  American psychiatry. Two vital areas. First of
• 1:14:39
  all, in academic psychiatry, which becomes increasingly
• 1:14:43
  important as money flows into the system. And
• 1:14:46
  secondly, in this new market for outpatient psychiatry.
• 1:14:52
  And by as early as 1958, the outpatient psychoanalytically
• 1:14:59
  oriented people vastly outnumbered. the psychiatrists
• 1:15:04
  toiling away in the mental hospitals. They're
• 1:15:07
  state employees. They're badly paid. They're
• 1:15:09
  often imported from abroad because no one wants
• 1:15:12
  those jobs because they're so awful. Meantime,
• 1:15:16
  psychoanalysts are coining it. Psychoanalysis
• 1:15:21
  in the 50s and 60s is more lucrative than most
• 1:15:25
  medical specialties, and it attracts the best
• 1:15:28
  and brightest recruits to the profession. It
• 1:15:32
  dominates medical school faculty in the field.
• 1:15:37
  And so that's quite unique to the United States.
• 1:15:42
  May I just ask just quickly, we talked about
• 1:15:47
  these horrible biological interventions that
• 1:15:50
  usually not only did not produce results, they
• 1:15:53
  mutilated people, basically, and made them worse.
• 1:15:56
  We talked about asylums at the beginning, and
• 1:15:59
  you told me it was really hard to go back and
• 1:16:02
  measure whether people actually got better after
• 1:16:05
  leaving them. How about psychoanalysis in the
• 1:16:08
  50s and the 60s? They had a huge problem. They
• 1:16:12
  resisted the idea that they had to show demonstrable
• 1:16:16
  results. They resisted the idea that they have
• 1:16:19
  to show results. That's a very humorous position.
• 1:16:22
  Well, ultimately, that leads them into trouble.
• 1:16:25
  I wish that worked in school when I was going
• 1:16:27
  there. We wish it worked in a lot of life, right?
• 1:16:31
  Exactly. But, yeah, for a while. You see, it
• 1:16:36
  becomes culturally dominant whether you look
• 1:16:40
  to movies and plays and novels or you look to
• 1:16:44
  the social sciences. Freud is everywhere. And
• 1:16:48
  then suddenly Freud isn't everywhere because
• 1:16:50
  in the 1970s things begin to turn. And then in
• 1:16:55
  1980, something happens that spells the death
• 1:16:59
  knell of psychoanalysis, really. It takes a few
• 1:17:02
  more years for that to have its full effects.
• 1:17:05
  But it's a bit like Lewis Carroll's Cheshire
• 1:17:08
  Cat, a little bit. You know, the Cheshire Cat
• 1:17:12
  gradually disappears until all that's left is
• 1:17:15
  his smile. In the 1980s, psychoanalysis disappears,
• 1:17:20
  except all that's left is a bunch of fractious...
• 1:17:23
  disciples who are busy squabbling with one another
• 1:17:26
  and have fewer and fewer patients. The average
• 1:17:29
  psychoanalyst these days has something like one
• 1:17:33
  and a half patients a week. That doesn't work
• 1:17:35
  very well. So this resistance, they go, you know...
• 1:17:41
  We're transforming whole personalities. It's
• 1:17:44
  not easy to measure that. So you'll just have
• 1:17:46
  to trust us that this works. For a while, that
• 1:17:50
  sort of gets by. Eventually, particularly as
• 1:17:53
  once the insurance companies get into funding
• 1:17:56
  some forms of treatment, they're not going to
• 1:18:03
  fund years and years of psychoanalysis on this.
• 1:18:06
  They say that gradually these people are going
• 1:18:08
  to be transformed human beings. And in fact,
• 1:18:12
  many of the children of psychoanalysts that I
• 1:18:15
  know are more screwed up than most people. It's
• 1:18:19
  just not. It's a complicated story, obviously
• 1:18:24
  more complicated than we have a chance to really
• 1:18:27
  get into here. What's interesting is the drugs
• 1:18:31
  revolution happens in the despised part of the
• 1:18:34
  profession, not in the universities, not among
• 1:18:37
  these private practice psychoanalysts and fellow
• 1:18:40
  travelers who call themselves psychodynamic psychiatrists.
• 1:18:44
  It comes out of the mental hospitals where you
• 1:18:47
  have this half million and more patients languishing.
• 1:18:51
  That's where Thorazine, the first of the antipsychotics,
• 1:18:56
  gets introduced in North America. And that's
• 1:19:00
  where the antidepressants gradually come in,
• 1:19:03
  and then they migrate out of the asylum. But
• 1:19:06
  the psychopharmacological revolution of the 1950s
• 1:19:10
  bubbles away beneath the surface. The psychoanalysts
• 1:19:15
  still have this very lucrative private market
• 1:19:17
  for a while. And remember, Americans are used
• 1:19:20
  to paying for medical care in a way that most
• 1:19:23
  other advanced industrial societies don't do.
• 1:19:28
  When the collapse happens, it's like watching
• 1:19:31
  the collapse of the Shah's regime in Iran or
• 1:19:34
  watching the collapse of the Soviet regime. It's
• 1:19:38
  a bit like what it was Hemingway's comment about
• 1:19:41
  bankruptcy, right? It happens slowly, slowly,
• 1:19:43
  slowly. It happens gradually and then suddenly.
• 1:19:46
  And suddenly all at once it collapses. And it's
• 1:19:49
  a reflection of a number of things. Drugs revolution,
• 1:19:54
  obviously, powerfully. Managed care. the involvement
• 1:19:58
  of insurance companies, the beginnings of insurance
• 1:20:00
  coverage for some sorts of treatment for mental
• 1:20:04
  illness, primarily drugs. But if it's going to
• 1:20:07
  be psychotherapy, it's going to be the type of
• 1:20:12
  quick and dirty focus on removing the symptoms
• 1:20:15
  treatment, cognitive behavioral therapy, that's
• 1:20:19
  developed principally by those clinical psychologists
• 1:20:24
  I alluded to when we talked about World War II.
• 1:20:27
  That's a heavily feminized profession. I'm not
• 1:20:30
  much of a sociologist these days. I'm more of
• 1:20:33
  a historian. But if I can venture a sociological
• 1:20:36
  generalization that holds up pretty well, when
• 1:20:39
  an occupation becomes heavily feminized, it loses
• 1:20:43
  prestige and it moves down in terms of rewards.
• 1:20:47
  Clinical psychologists don't get paid at the
• 1:20:50
  rate of MDs. That's why MDs won't. deliver psychotherapy
• 1:20:56
  on the whole except for this very small niche
• 1:20:58
  psychoanalytic market um whereas clinical psychologists
• 1:21:03
  will and they for the for the psychoanalysts
• 1:21:08
  during the 50s and 60s the idea that you would
• 1:21:11
  attack the symptoms somebody was experiencing
• 1:21:14
  i have panic attacks so i would like something
• 1:21:18
  that reduces my panic well No, your panic attack
• 1:21:22
  is a symptom of your underlying psychodynamic
• 1:21:25
  problems that we've got to address. And if we
• 1:21:29
  try to suppress it, it'll just pop up over here
• 1:21:32
  as a different kind of symptom, right? It's whack
• 1:21:35
  -a -mole time. The clinical psychologists go,
• 1:21:37
  you have anxiety, you have problems going to
• 1:21:43
  school, you have agoraphobia, problems going
• 1:21:46
  out, you have problems getting on an airplane.
• 1:21:49
  because you're afraid it's going to crash. We
• 1:21:52
  have tools that will solve that problem for you
• 1:21:54
  in a matter of a few weeks or a few months. Bingo.
• 1:22:00
  And it has some lab support, so it's science.
• 1:22:03
  So that's what happens. You see in the 1980s
• 1:22:10
  psychiatry swinging back to biology very, very
• 1:22:14
  quickly, aided by the fact that if they do...
• 1:22:18
  Genetic research, neuroscience, psychopharmacological
• 1:22:22
  research, there's big bucks to be had in the
• 1:22:25
  form of research grants. And they get rewarded
• 1:22:28
  in their careers because they're bringing in
• 1:22:30
  those dollars to the greedy universities. And
• 1:22:35
  on the other hand, there's a different group
• 1:22:41
  of professionals who are moving into the space
• 1:22:44
  for people with milder kinds of genuine problems
• 1:22:49
  of one sort or another, which can be treated
• 1:22:52
  symptomatically. And that's the universe that
• 1:22:56
  we see today. The other big thing that's happened,
• 1:23:00
  of course, again in these same years, is beginning
• 1:23:03
  very slowly in the late 1950s, really accelerating
• 1:23:09
  in the late 1960s forward, those mental hospitals,
• 1:23:13
  those asylums we started talking about, simply
• 1:23:16
  disappear. And we're told we're in the new era
• 1:23:19
  of community care where patients are going to
• 1:23:23
  be welcomed back into a community that is happy
• 1:23:28
  to see them in its midst and is going to absorb
• 1:23:31
  them and they're going to be cared for in a more
• 1:23:34
  humane fashion outside the asylum. And what,
• 1:23:38
  in fact, has happened? There is no community
• 1:23:42
  care. There's no community. There is no care.
• 1:23:47
  To the extent there's any care, it's the prescribing
• 1:23:50
  of drugs, maybe via injections that last for
• 1:23:53
  a while. The mental hospital has been replaced,
• 1:23:58
  but by what? The three largest places of inpatient
• 1:24:04
  care, if that's the right word, for mentally
• 1:24:07
  ill people in the United States today are the
• 1:24:10
  Los Angeles County Jail, the Cook County Jail
• 1:24:13
  in Chicago, and Rikers Island in New York. That's
• 1:24:17
  the largest collection of patients in inpatient
• 1:24:20
  settings, and it's a prison. So the asylum was
• 1:24:23
  set up to rescue patients from the prison. We
• 1:24:26
  get rid of the asylum. We stick them back in
• 1:24:28
  the prison. If they're not in prison, they're
• 1:24:30
  a large part of the homeless population, the
• 1:24:33
  sidewalk psychotics that have become such a feature
• 1:24:36
  of the American urban landscape. Or they're in
• 1:24:40
  so -called board and hair care homes and flop
• 1:24:43
  houses. They are abandoned to their fate. And
• 1:24:49
  we spoke at the beginning about the life expectancy
• 1:24:53
  of people with serious mental illness being 15
• 1:24:56
  to 25 years less. Those social circumstances
• 1:25:00
  are a large part of the reason they die so much
• 1:25:04
  younger. They don't get medical care for their
• 1:25:07
  underlying medical problems. Some of the drugs
• 1:25:10
  they're on, if they indeed take them, produce,
• 1:25:14
  for example, obesity and all the problems that
• 1:25:16
  come in its wake. And so we have moved into an
• 1:25:24
  era where I think public psychiatry has largely
• 1:25:29
  vanished. People with serious mental illness
• 1:25:33
  are extremely hard to live with. Families sometimes
• 1:25:37
  try to cope, usually over a or even a decade
• 1:25:43
  or so, they throw up their hands in despair because
• 1:25:46
  it's so impossible. And then they're out in the
• 1:25:50
  street. Or we have horror stories like Rob Reiner
• 1:25:54
  and his wife being shot by their schizophrenic
• 1:25:57
  son, or the person you alluded to at the beginning,
• 1:26:01
  who's put on all these different pills as a human.
• 1:26:05
  guinea pig being experimented along with if this
• 1:26:08
  drug doesn't work perhaps this one will and if
• 1:26:10
  we add this one maybe it'll work no no i thought
• 1:26:14
  of the following because i see it as a kind of
• 1:26:16
  like the main thread of this conversation my
• 1:26:18
  ex -girlfriend was a medicine student when we
• 1:26:20
  were together and i still remember how she said
• 1:26:22
  that there was a little joke going around the
• 1:26:24
  school when students were choosing their specialization
• 1:26:26
  apparently saying when something like this, I
• 1:26:29
  hope I'm not going to butcher it. GP, so general
• 1:26:32
  practitioners know a lot, but they can't do anything
• 1:26:35
  because they're just writing referrals and stuff.
• 1:26:37
  And then surgeons can do a lot, but they don't
• 1:26:40
  know anything because they're basically butchers
• 1:26:42
  that they don't diagnose people, right? And then
• 1:26:44
  psychiatrists, not only they don't know anything,
• 1:26:48
  but they also can't do anything. So there's,
• 1:26:51
  I wouldn't call it like an inferiority complex,
• 1:26:55
  but an awareness. Right, that you won't be able
• 1:26:58
  to help people as much in this field. Do you
• 1:27:02
  think that that made psychiatrists more eager
• 1:27:05
  to try out something they see as a silver bullet?
• 1:27:08
  Because we talked about the silence at the beginning.
• 1:27:10
  They didn't really work as they intended. We
• 1:27:13
  talked about ice picks and lobotomies and injecting
• 1:27:17
  people with insulin. And yet these people at
• 1:27:23
  the positions of power, these psychiatrists,
• 1:27:24
  these doctors were clinging on to these theories,
• 1:27:28
  even though it was obvious they didn't produce
• 1:27:30
  results. Do you think they just really wanted
• 1:27:32
  to help people at least in the beginning? Or
• 1:27:34
  was it all about hubris? If I can turn you into
• 1:27:38
  a psychoanalyst for a second. Human motivations
• 1:27:39
  are extremely complicated things. And obviously,
• 1:27:42
  I think what you'd have is an array of people.
• 1:27:46
  There were people in it for... um disreputable
• 1:27:50
  reasons and there were people in it who the the
• 1:27:53
  problem is that um being a true believer it doesn't
• 1:27:57
  protect you right so if i could go back to your
• 1:28:00
  to your joke what i would say about that is like
• 1:28:03
  it's a good joke on one level and if it relies
• 1:28:07
  on of course um hyperbole exaggerating for effect
• 1:28:14
  General practitioners indeed can do a great deal
• 1:28:17
  for many of their patients, although a lot of
• 1:28:20
  the time they have to confess the limits of their
• 1:28:22
  knowledge and refer them on. One of the things
• 1:28:24
  that's troubling about the prescription of psychiatric
• 1:28:27
  drugs these days is most of them are prescribed
• 1:28:30
  by general practitioners, by primary care doctors,
• 1:28:35
  as we would say in America. And they've usually
• 1:28:37
  had about six weeks of training in psychiatry.
• 1:28:40
  That's it. Some very smart... And very well -motivated
• 1:28:46
  people that I know are engaged in psychiatry.
• 1:28:50
  They very much want to produce breakthroughs.
• 1:28:55
  They persuade themselves that they're on the
• 1:28:59
  brink of these things. When I talk with psychiatric
• 1:29:02
  geneticists, oh, we're about to do this and this.
• 1:29:05
  When I talk with people into neuroscience, well,
• 1:29:08
  it hasn't worked out so well so far. In the next
• 1:29:12
  10 years, when I talk with some of the leading
• 1:29:18
  folks in these fields, these are the things you
• 1:29:20
  get. And one has to hope they're right, but the
• 1:29:23
  history suggests that we'd be somewhat skeptical.
• 1:29:27
  And we need to, I mean, the real message, I think,
• 1:29:31
  if there is one to take away, is the need for
• 1:29:35
  humility. the need to be aware of the limits
• 1:29:38
  of our knowledge, the desire not to get swept
• 1:29:42
  away with the next big thing that's supposedly
• 1:29:45
  going to be so great. Right now, psychedelics.
• 1:29:52
  Well, Ibogaine. Yeah, there's all kinds of stuff
• 1:29:55
  swirling around out there. Transcranial electrotherapy.
• 1:30:03
  Joe Rogan wrote a text to Trump if they can fast
• 1:30:06
  track Ibogaine for PTSD and apparently they did
• 1:30:09
  it. These guys, I mean, you know, if you're taking
• 1:30:12
  medical advice from Ronald Kennedy Jr. or from
• 1:30:15
  Trump who wants you to inject bleach, you know,
• 1:30:19
  you're a lost cause. He does have that fantastic
• 1:30:23
  theory that we have a finite energy in the body.
• 1:30:26
  And the more you move, the more you use it. So
• 1:30:29
  it's best not to move. Otherwise, you can drop
• 1:30:32
  that prematurely. Because in the 19th century,
• 1:30:36
  people often believed you had a finite amount
• 1:30:39
  of nervous energy. So you shouldn't waste it
• 1:30:44
  too much. If you overworked your brain, you were
• 1:30:46
  going to be in trouble. That sort of thinking
• 1:30:54
  always attracts people. And one of the things
• 1:30:58
  I would say about this, this is a fantastically
• 1:31:02
  complicated subject. Some very smart minds have
• 1:31:07
  tried to solve this problem. And it's not that
• 1:31:10
  no progress is made. And so we shouldn't throw
• 1:31:14
  out the baby with the bathwater. We shouldn't
• 1:31:15
  say, no, we can't do anything. But what we need
• 1:31:18
  to be aware of is. how finite, how limited our
• 1:31:23
  present knowledge is. If you ask what causes
• 1:31:28
  schizophrenia, what causes bipolar disorder,
• 1:31:32
  what causes major depression, the honest answer
• 1:31:35
  to that, which you will get from very good psychiatrists,
• 1:31:40
  we don't know. We have some clues. We don't know.
• 1:31:45
  Until we know. It's kind of a stab in the dark
• 1:31:50
  to be doing things. That's not a counsel of despair,
• 1:31:55
  but it is a need to be realistic about the limits
• 1:32:00
  of what we can do and not to jump on the latest
• 1:32:04
  bandwagon, be it focal sepsis or lobotomy or
• 1:32:10
  drugs or psychotherapy of one sort or another.
• 1:32:14
  Not that none of those, not that... Drugs and
• 1:32:18
  psychotherapy don't, for some people, improve
• 1:32:21
  things, but none of them are surefire cures for
• 1:32:25
  what is a very distressing, very disabling thing,
• 1:32:29
  something that destroys the lives very often,
• 1:32:33
  not just of the sufferer, but of the people around
• 1:32:36
  them. To have a schizophrenic spouse, a schizophrenic
• 1:32:42
  parent, a schizophrenic child, or an autistic
• 1:32:48
  child, is a devastating thing. And we shouldn't
• 1:32:53
  lose sight of the suffering that's there, and
• 1:32:57
  nor should we minimize the importance of trying
• 1:33:00
  to improve on what we know now, what we're able
• 1:33:06
  to do. So, for example, one of the problems I
• 1:33:10
  find with this overemphasis on neuroscience and
• 1:33:16
  genetics is as Tom Insell who ran NIMH for 13
• 1:33:22
  years said he said look I funded all this cool
• 1:33:26
  cool science and scientists I spent north of
• 1:33:29
  20 billion dollars and the lives of people with
• 1:33:34
  serious mental illness haven't improved one bit
• 1:33:37
  that's an indictment we should have research
• 1:33:42
  that moves in more than just two directions.
• 1:33:45
  Last question, Andrew. One thing that always
• 1:33:48
  struck me with psychiatry and also psychotherapy
• 1:33:50
  is that doesn't seem to take our environment
• 1:33:52
  or the system we live in into account. that much
• 1:33:55
  because i would say that the way we organize
• 1:33:56
  society is extremely pathological in itself and
• 1:33:59
  becoming more so you know this sort of fast -paced
• 1:34:02
  stress -inducing urban hellscape where you're
• 1:34:04
  constantly rushing to work to make ends meet
• 1:34:07
  while any sense of community is being replaced
• 1:34:09
  by addictive digital simulations people point
• 1:34:12
  people pointed to that in the in the late 19th
• 1:34:15
  century they said look the advent of rail travel
• 1:34:18
  people are moving at these vast speeds telegraphs
• 1:34:21
  you know ambition the constant churn of the economy.
• 1:34:25
  Those ideas have been around for a very long
• 1:34:30
  time. I would say there's a lot of epidemiological
• 1:34:34
  evidence that fractured families, poverty, living
• 1:34:39
  in hellish surroundings have very bad effects
• 1:34:42
  on people's mental well -being. That should be
• 1:34:45
  no surprise to anybody. But that social side
• 1:34:49
  of things started to be neglected heavily. when
• 1:34:53
  Reagan came to power. Jimmy Carter had just had
• 1:34:57
  a commission on mental health that took a very
• 1:34:59
  broad view of things. Reagan, who had been a
• 1:35:03
  prime mover in scrapping California's mental
• 1:35:06
  hospitals, told NIMH, stop all this research
• 1:35:09
  on social and psychological crap. Focus on medicine.
• 1:35:14
  That's where the answer is going to be. Focus
• 1:35:16
  on biology. And biology, at least until the Trump
• 1:35:20
  administration came along, seemed to be a fairly
• 1:35:23
  apolitical science, if you like. Although these
• 1:35:27
  days, it's not so clear. I see their attempts
• 1:35:33
  to have a political group of commissars. decide
• 1:35:39
  which nimh grants should be allowed to proceed
• 1:35:42
  and which ones are too woke to be allowed i don't
• 1:35:45
  know it's a you know i i spent more than 50 years
• 1:35:49
  in this field and sometimes i i wonder as i think
• 1:35:52
  some of my um psychiatrist friends have been
• 1:35:56
  in a field the same at the time wonder about
• 1:36:00
  in many ways it's a very depressing subject but
• 1:36:02
  it's a very important subject it's one that touches
• 1:36:05
  so many lives is so profound in its effects it
• 1:36:09
  is universally around us it is part and parcel
• 1:36:12
  of our civilization and of every civilization
• 1:36:15
  i know and it meant it brings in its train immense
• 1:36:20
  suffering and tremendous social losses so trying
• 1:36:25
  to get a handle on it remains vital thing and
• 1:36:30
  I hope the history, at least to some degree,
• 1:36:34
  partly providing cautionary tales and partly
• 1:36:39
  providing the evidence that we need to constantly
• 1:36:45
  be aware of larger contexts when looking at this
• 1:36:48
  problem. One of the saddest things that happens
• 1:36:50
  now for me is I get emails from family members
• 1:36:54
  who are in the midst of some of this awful travail
• 1:36:58
  asking for advice and i have to say to them i'm
• 1:37:03
  not in a position to give advice it would be
• 1:37:06
  highly inappropriate for me to do that but i
• 1:37:10
  have deep sympathy for what you're experiencing
• 1:37:13
  and i'm well aware of just how heart -rending
• 1:37:17
  it can be to be confronting these problems so
• 1:37:21
  i've enjoyed talking with you we've gone much
• 1:37:23
  longer than i anticipated Yes, likewise. Thank
• 1:37:27
  you so much, Andrew. I really appreciate it.
• 1:37:29
  Thank you for listening. Please subscribe to
• 1:37:30
  the Smart Cookies Podcast on YouTube. Follow
• 1:37:32
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• 1:37:34
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  up long ago and you should know that because
• 1:38:05
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