Psychiatry, Insane Asylums, Mental Illness, ECT, Lobotomies, Freud & Jung | Lex Fridman Podcast #502

So psychiatry is a profession that tries to deal with an enormously complicated thing: the human mind, the human emotions, the human ability to attempt to understand the world. And in particular, obviously, it focuses on people where our common sense approach to the world seems to break down. People whose emotional life is filled with turmoil, people whose ability to relate to others is badly damaged, people who see things in the world that the rest of us simply think aren't there. They're illusions, they're hallucinations, they're delusions. And this is a subject that has occupied some very clever minds over the years. And there's no question that in the course of at least the last three quarters of a century, there has been some limited progress in dealing with the problems that mental illness creates. Some of that is confined to the milder forms of mental distress; the more serious forms of psychosis and breakdown of emotional control, those are areas where I think again there's been some progress, but it's easy to overstate how much of that there's been. As we'll see probably later in our conversation today, the advent of modern psychopharmacology, which occurred in the early 1950s, was a serendipitous event. It wasn't planned for. It happened almost by accident, and it did mark in some ways an advance over some of the things that psychiatry had engaged in before that. And no question, for some people, that revolution and a parallel revolution in the psychotherapeutic realm have created some advance for patients, and we should not minimize that. What we have available to us are symptomatic treatments, not cures. We don't have a psychiatric penicillin for any of the conditions we're going to be talking about. That doesn't mean we can't do some things that help, but the help is quite limited. And it's important to understand both the ways in which we have progressed and the limits of that progress, and also to understand that when we treat something, sometimes we create new problems, what we call iatrogenic problems, things caused by the interventions that we use. That's true of some psychotherapeutic interventions and most certainly true of the drugs we use to treat mental illness these days. So, for example, in treating PTSD, we often get patients to confront the episode, the trauma which provoked their distress, and that is often a very, very fraught process. And for many patients, it actually makes things worse. For some patients, it makes them better. So that's a situation where you could see problems.

With both antipsychotics and antidepressants, the two main classes of psychotropic drugs that we use, they're at best partially effective, and they don't work for a significant fraction of patients who are given them. And one of the big problems psychiatry faces is that psychiatrists don't know in advance who's going to respond well to the drugs, who's going to respond badly, for which group of patients in the middle the side effects and the main effects, if that's what we want to call them, the therapeutic effect are finely balanced, and making those judgment calls about what to do are very, very difficult. Now, in terms of the crisis psychiatry faces at the moment, as I see it, there are a number of strands that point to this. Psychiatry's diagnostic system, that is still used, I mean, the fundamental basis of psychiatric diagnosis today was really first formulated in 1980 with the third edition of The Diagnostic and Statistical Manual of a profession.

DSM-III, and then there's been DSM-III-R, DSM-IV, DSM-IV-TR, and now DSM 5. Finally, not with a Roman numeral but with an Arabic numeral. So they thought with DSM 5, when they needed to modify it, it would be like a piece of software. You have Windows 10, Windows 11, and so on, right? Now, that diagnostic system came into being because psychiatrists had a very hard time agreeing with one another about what was wrong with somebody, and that became embarrassingly clear first in the professional literature, which outsiders didn't read, and then via a very famous study that's a scientific fraud by David Rosenhan called On Being Sane in Insane Places, where he claimed to have sent in pseudo patients to the hospital, and they all were diagnosed as schizo. All but one of them diagnosed as schizophrenic, the other as somebody with bipolar disorder, and they were fake patients. So almost in a panic after that study appeared in Science, and because there was an abundant professional literature from the 1960s showing the same thing, that diagnosis was a very erratic process. The DSM-III task force led by Robert Spitzer, who was then at Columbia, was explicitly set up to try to create a sort of tick-the-boxes approach to deciding which box a patient belonged in. Were you schizophrenic? Were you this type of schizophrenic or that type of schizophrenic? Were you manic depressive or bipolar? Did you have various forms of depression? And to construct those boxes, what they relied upon was a list of symptoms. And if you had more than a certain number, if you had more than six of ten, six or ten or more symptoms of a certain sort, you could be diagnosed with major depression, for example. So that system came into being. It was partially embedded because it appealed to drug companies who were developing drugs to treat these various disorders. It appealed to insurance companies because it gave them a stable base to look at. It appealed to, as diagnosis always does, to patients and their families who are scrambling to deal with these enormous upsets in the mental life of either themselves or a family member. So it provided some sense of certainty around diagnosis. But that was always based simply on symptoms, in the way an 18th-century doctor might diagnose dropsy or diagnose some other kind of disorder. Fever, for example. Well, fever and other diseases they talked about in the 18th century are really a constellation of very different things under one label. And I think that's what is turning out to be true of the DSM labels. But that approach was really all that psychiatry could come up with if it wanted to make sure whether you were in Walla Walla or New York or San Francisco or Atlanta, you reached the same conclusion faced by the same patient, that you had a reliable diagnostic system. That didn't mean necessarily it was a valid diagnostic system, if you understand the distinction between validity and reliability. Reliability means you and I, faced with the same sets of facts, reach the same conclusion, but that conclusion may or may not reflect the underlying reality of things, right? So you had this diagnostic system, and it went through various iterations. Each time it went through an iteration, the number of possible psychiatric disorders you could get grew and grew and grew, and it became difficult to believe in some of those categories, shall we say, that they were really illnesses rather than some sort of social construct. But beyond that, psychiatrists wanted to be more like other medical doctors, to root their diagnoses in an understanding of the underlying pathology of the disorder. What was it that caused people to become schizophrenic? The sense was, if we could grasp that, we'd have a better handle on how to attack it, how to treat it. And when DSM-5 was mooted, the fifth edition, in the early 2000s, NIMH, then under the leadership of Steven Hyman, who's at Harvard now, and succeeded by Thomas Insel, who ruled NIMH for about 13 years, the two of them had pushed psychiatry and psychiatric research in a very particular direction. On the one hand, towards understanding the genetics of mental illness, and on the other, to looking at what the new discipline of neuroscience could contribute to understanding things. Both of them were heavily invested in the idea that mental illness was brain disease. And if it was brain disease, then the question was, what was making the mechanism here go awry? What was causing people's emotions or their cognitive skills or their sense of the world to become so disordered? And they invested a lot of money in that approach. When Insel stepped down, he gave an interview actually to somebody at MIT, and he's repeated it since in a book he wrote about his experiences, where he said, 'Well, you know, as I look back on my 13 years, I funded an enormous amount of scientific, really cool scientific research. I funded geneticists and I funded neuroscientists, and they did a lot of really interesting science. And after spending 20 billion dollars, the lot of the mentally ill has improved not one bit, right?' Which was a pretty devastating statement, I thought.

National Institute of Mental Health, yes. I shouldn't resort to jargon. But the National Institute of Mental Health had been founded in the late 1940s with the goal of improving, doing basic research, training people in the field, advancing the care of the mentally ill, and producing obviously cures and advances. And its mission has varied widely over the years since, but starting in the 1990s, the period when the first George Bush declared the decade of the brain, NIMH increasingly focused on the idea that mental illness was purely a brain disease. And there's something to that, and there's also some mistake in thinking about it that way.

It's the kind of thing that really appealed to medical school deans because once NIH and the drug companies too were funding basic research on neurobiology and basic research on genetics, the money flooded in. And psychiatry, which had been something of an orphan, became much more popular.

It's a very complicated area, and oversimplification is a real problem, I think. And I think even that dichotomy you just drew between the brain and the social or psychological, some mix of those things, I think in some ways that's a category mistake, that's a mistaken way of looking at the world, because the brain you have today, you're not born with. Human brains are remarkably plastic things. They develop in response to the environment. Social, psychological are embedded in our brains. Rigid separation, saying one or the other, no. Abundant evidence from epidemiology that social factors play an important role in the development of illness.

Yes. In fact, whenever you're trying to deal with a very complicated set of issues, you have to simplify. You have to make heuristic decisions about what you're going to neglect and what you're going to emphasize. But what I'm trying to say, well, you asked me about the crisis in psychiatry, and the simplest way for me to encapsulate the issue and the problem as I see it that's arisen, one of the problems, is a quote by Leon Eisenberg, who had a very long career at Harvard, and Eisenberg said towards the end of his career, he said, 'When I entered psychiatry, it was brainless psychiatry, leaving it mindless psychiatry.' Yeah, sums up the way the field to a large degree has moved. In the process, insights are lost, though in other ways, things are being gained. Freudians tended to neglect the biological, to suggest the brain as a biological organism was not something we needed to worry about. We worried at the level of a psychological model of how our minds work. And all too often, not exclusively because some of the psychiatrists I'm friends with are very sophisticated men and women and do grasp that you can't move in these bipolar directions. You've got to meet somewhere in the middle. But that sort of got lost, I think, in all the enthusiasm for neuroscience. I mean, when antipsychotic drugs were discovered in the early 1950s, we had no clue of how they worked. And one of the things that they helped us spawn as people began to say, 'Well, why did these drugs work? What did they do?' was to begin to understand that the brain wasn't just a set of electrical signals, as had been thought in the first half of the 20th century and before. But rather there was this very interesting chemical soup running around in our brains with neurotransmitters that help the brain work the way it did and perhaps explained why it went awry. So it was one of the many factors that gave rise to neuroscience. The first neuroscience conventions were in the 1970s, and they attracted a few hundred people. Now it's tens of thousands of neuroscientists. It's a huge enterprise. So diagnosis has come under threat. The categories that we have all become familiar with, that we're told are real diseases like bipolar disorder, schizophrenia, major depression, are beginning to falter, and we're beginning to worry about whether those diagnoses are real ways of thinking about the world and may in fact mislead us. Because if we think there's something called schizophrenia or the schizophrenias, as the inventor of that term put it, if we think there's something like that and we try to research where it comes from, but that's not really what's going on, obviously we're probably going to not make the progress we could be making if we had a better diagnostic system. And that's what DSM-V thought it was going to be able to do and discovered it couldn't. So it stayed basically with the symptomatic approach.

You invest a ton of money. You invest $20 billion, more than $20 billion in a particular approach. And at the time you're constructing this, you say, 'Finally, because of all the work that's being done in genetics, we now have decoded the human genome. We have PCR so we can chop it up and we can look at bits of it. We have a lot more understanding of the role of neurotransmission in the brain. Surely we're going to be able to recast our diagnostic system based on underlying pathology so that we won't be worrying about symptoms anymore. We'll be looking at the actual underlying pathological changes that have taken place.' But in the event, it turned out they couldn't do that. By about 2008, they had thrown up their hands and said, 'No, we're going to have to continue to refine, rely upon the same basic approach that we developed in 1980.' And when that document came out, and there'd been a lot of criticism, some of it from Robert Spitzer, who had been largely in control of DSM-III and DSM-III-R, and then his successor Allen Frances, who'd run DSM-IV, they both were fiercely critical about what was going on and said it was being done in the dark and it was done in secrecy and it wasn't scientific. And when it was about to come out, Thomas Insel and Steven Hyman, the two then existing and the preceding director of the National Institute of Mental Health, denounced the document as unscientific and useless. So if you're talking about a crisis, that's a crisis for the field. If its diagnostic system is being dissed by leading figures like that, what else was a problem? The difficulties with the drug existing therapies, particularly, had become more and more manifest. To make matters worse, partly because Big Pharma had sometimes behaved, shall we say, rather unethically sometimes with these drugs, it had hidden things that undercut their claims. It had manufactured studies. It had manipulated data. And it got caught out, and it paid billions of dollars in damages for some of the tricks it had got up to. Not just in psychiatry, I mean Vioxx, for example, the painkiller, was another huge scandal, and it was a $5 billion settlement. But the drug companies had suffered some reputational damage. Beyond that, they didn't have any real clues. Unfortunately, neuroscience hadn't thrown up new targets for different forms of drug development. And they decided they could make more money with spending their money on research on other diseases, not mental illness. A crisis was you were stuck with a set of drugs that Steve Hyman says, 'Aren't really any advance on the ones by accident we found in the fifties.' And there isn't new research unless it's small startups going on to develop new ones, so you have an increasing sense your diagnostic process is falling apart, your drug treatments' limitations are becoming more manifest, and as well for people with serious mental illness. Public policy has screwed things up badly. So if you, a person with serious mental illness, you will die on average 15 to 25 years before the rest of us. That gap has been growing rather than diminishing. So that's not a good thing. It's not something I want to lay entirely at the door of psychiatry. So don't get me wrong, I think a lot of this is public policy that has really abandoned treatment for the seriously mentally ill. And you see it on the streets of our cities. You see the sidewalk psychotics. You see people who are cycling between brief periods of inpatient care, the gutter, or the flop house and the jail. You see the three largest centers of inpatient psychiatric care, if you can call it that, in the United States today are the Los Angeles County Jail, Cook County Jail in Chicago, and Rikers Island in New York. That's shockingly, because by their very nature, of course, prisons aren't equipped to deal with serious mental illness.

Yeah, well, you know, the asylums had acquired a very bad reputation, and I've written about some of the reasons why that happened, but when asylums were founded, it was a period of enormous optimism that we were going to be able to cure these people, that we would rescue them from attics and from jail cells, and through providing a therapeutic environment, coaxing them to work, creating a system where they learn to control themselves, not necessarily to drive their demons out, but to keep them under some sort of wraps. The expectation was when the asylums came along is that they'd not only rescue people from horrendous conditions in the prisons and the jails, but they'd actively cure them. And the earliest alienists, as they called themselves then, thought that they could cure 60, 70, 80 percent, maybe even more of patients, as long as they came in early. And really, asylums were built out of that sense of optimism, that sense that we, you know, that so much was environmental and so much was not exacerbating the condition by treating people like animals or treating them, you know, beating them and in other ways horrifically maltreating them, that would create a sense of cure. And really that underlay the construction of the asylums. And now having abandoned the asylums, which we did starting a little bit in the 1950s but really the late 1960s onwards, that was because there was going to be something miraculous called community care, but community care is a shell game without a pea. It's like one of those confidence tricks. There were no substitute community facilities for dealing with the really serious mentally ill.

So going back to the early 20th century was when the German psychiatrist Emil Kraepelin, working with thousands of records in German asylums, inductively developed a distinction between two very broad categories of mental illness. One he called dementia praecox or early dementia, and the other he called manic depressive illness, which was a more remitting illness that sometimes went away entirely, other times went back and forth, whereas dementia praecox was a one-way ticket down. Now that label was transformed by a Swiss psychiatrist Bleuler into the term we use today, schizophrenia, although Bleuler talked about the schizophrenias because he thought under that broad label there were a diverse group of things running around. And I think that was an important insight that tends to get lost sometimes. This was jamming together people with very serious psychosis, that is people who'd lost touch with what we like to think of as reality, whose emotional and cognitive lives were in total turmoil, who lost the ability to connect with other human beings. So their social skills atrophied. Well, this is something contemporary psychiatrists would refer to as the positive and negative symptoms of schizophrenia.

You're thinking people are plotting against you. You think the television is talking directly to you.

Yes. Your emotional life flattens out. Your language capacity deteriorates. Your ability to relate to other people either vanishes or becomes caught up in the web of delusions where you think people around you are plotting against you or doing terrible things to you.

Yes. The Greeks recognized and the Romans, ancient Greece and ancient Rome recognized different forms of insanity as they called it. So melancholia would have been the term the Greeks and the Romans would have used and it survived and was very much around. And I think that is a form of depression. What's happened now is major depression has become a catchall category. So it embraces both what we might think of as milder forms of emotional distress along with what melancholia referred to, which was really a kind of depression that had psychotic features. This loss of contact, as it were, with everyday reality.

Yes, very much so. So here's a very strange bit of historical record. The other distinction and the distinction we're grappling with, so we have people whose depression is of such a scale they're threatening to do away with themselves. They've retreated into complete almost immobility. They're overwhelmed by senses of sadness and loss and if they're religious then they're damned to hell and all those kinds of things. So we have this psychosis that we've been talking about. We have something also that the ancients recognize: dementia, the loss really the loss of our mind as it were. But then we also have other kinds of disturbance of our mental faculties that generally we think of as more minor but I don't want to make light of them because often people suffer from these things genuinely suffer pretty badly. But those things we in the 20th and 21st centuries tend to talk about as neuroses, neurotic diseases, psychotic diseases. In the 19th century neurosis was a term that meant things rooted in the brain as you can see from the root of the word and psychosis was stuff that came from the mind, the psyche. And yet sometime in the late 19th century those things crossed over and so when we talk in the present we do tend to distinguish between the core, really the most severe forms of mental disorder, which would include things like Alzheimer's disease and other forms of dementia, would include very serious depression, would include bipolar disorder where people oscillate either have extreme mania so they're not getting any sleep. They're talking at an extraordinary rate. Their behavior is very hard to tolerate, and they're exhausting themselves, and they may even die from exhaustion if it's not controlled. And very often that alternates with periods of depression. So that was a category that was captured initially as manic depressive illness and later on evolved into bipolar disorder and then separating out depression and major depression separately. But then there are a whole bunch of other things like, for example, phobias. People can't go outside because they find it too frightening. Milder phobias: 'I can't get in an airplane because it's going to crash,' 'I can't go to school because it's overwhelming for me.' So school phobia emerges as a diagnosis. A disorder that at first attracted Freud, hysteria.

Oh, I did indeed, yes.

If you look back at the asylum era born in this period of intense optimism, and then the claims to be able to cure these vast numbers of patients were overblown. I do believe the early asylums actually did good work and that some patients did very well and recovered as a result of their stays. But what happened, they weren't discharging 80% of their patients. They were discharging 35 or 40% of their patients, and what that meant is every year left behind were a batch of chronic patients, and then the next year you repeated it. And over time, what that means is the ratio of new patients to chronic patients gets worse and worse. And more and more the image of the asylum is defined by the chronic patient who hasn't recovered and maybe spends years or decades there and only leaves in a pine box. So the image of the asylum declined drastically. As they became more and more overcrowded, conditions in them deteriorated. Patients were often abused. Psychiatrists didn't know what to do with them, and they faced a problem in the late 19th century. You'd promised 70% or 80% cures, but we're not seeing that. In fact, when we calculate cures and the numbers of people in the asylum, it's more like 10% or 12%. That's the way you could play with statistics because that's all the old patients mixed with the new. But still, it looks very bad. How do you explain this doctor? You've promised us one thing, and you delivered something quite different. The answer came in a way of blaming the victim, in a way of saying, 'Well, you know, what we didn't understand was that mental illness is a fundamentally biological condition. These people are evolutionary throwbacks.' Evolution was generally thought of as a progressive onwards and upwards, but these people had fallen back into a lesser form of existence. They'd lost their essential humanity because their brains were defective. So what emerged then was the idea of degeneration, the idea that these patients were degenerates. They were people with an inferior biology. You couldn't release them because they breed like rabbits. They didn't have any self-control because of their diminished humanity.

This is the narrative. And so what it did was provide a justification for locking up people in asylums that wasn't therapeutic at all. It was just keeping them out of the way.

So maybe we can release them if we make sure they can't breed.

It is the beginning of the darkness. My own state was one of the pioneers in this process, and it continued to sterilize mental patients up until about 1960.

That's correct. But even more serious consequences could flow from these set of issues. When you start talking, one British psychiatrist said that if his patients that were coming into the asylum had been puppies, we'd have tied them up in a sack because they were some horrible mongrel, not a purebred dog, tied them up in a sack with some lead weights, and thrown them in a pond and drowned them.

That kind of language is very, very dangerous. And what happened, California's law surrounding sterilization was advocated for in the West. By that I mean North America and Britain and much of Europe. There were enough checks and balances in a democratic system that even though there were enthusiasts, the eugenicists who said, 'Best get rid of these people, put them to death,' that never really, that never really acquired mass support. But what happened in Germany once the Nazis came to power is they seized on these notions and that the idea that the mentally ill were, as they put it, useless eaters, people consuming resources but never going to get better, just a burden on the state. Their lives weren't worth living because after all, they had this serious mental illness. So first you sterilize, and then you go, 'But we're still supporting all these people.' And so Hitler starts something called the T4 program after the street name of the house where this was concocted, Tiergartenstraße 4. And the mentally ill were the first people to suffer from the Final Solution. It was in the mass killing of the mentally ill, which may have been as many as a quarter million people, that the technology of the gas chamber was developed, and the technology of disguising the gas chamber as showers was developed. And so patients were taken away to a number of psychiatric centers and systematically put to death, and they had the crematoriums and the black smoke, and local people talked about the buses that were bringing them in as killing crates. So they were aware of what was going on.

Yes, absolutely. About that sort of thing, and lacking the checks and balances that at least until recently this country had, it was relatively easy for Hitler to do that. And particularly with the war looming, the idea that we're going to support all these useless people, let's kill them. And German psychiatry for the most part collaborated with that process.

That's the really nasty direction that that language could lead to. And it was symptomatic of the kind of stigma that tends to attach itself to mental illness and this sense of hopelessness. So but if you're a healing profession, if you enter psychiatry thinking, 'I'm going to do this to help people, to cure people, to make their lives better,' to just become a glorified boarding housekeeper keeping them under lock and key or in the alternative to collaborate in the sorts of awfulness that the Nazis perpetrated, that's something from which decent human beings tend to recoil and decent psychiatrists tended to recoil. And so still thinking as they did by the end of the 19th century that mental illness was predominantly a biological problem, some of them began to say, 'Well, maybe biology as well as being the problem could provide the solution. Maybe we should look for ways to intervene in the biological systems of these people and make them better.' The same logic that applies I would say in the present for many working in the field.

But in a very different form, exactly.

Yeah. So one of the organizations that recognized that mental illness was an acute social problem, very costly to the state, inflicting all kinds of suffering on people was The Rockefeller Foundation. What we don't realize today is that the involvement of the federal government in medical research and indeed scientific research is a World War II and post-war development partly the Cold War and Sputnik and all of that. But that's when big science and big medicine got funded in extravagant ways. Before the war, science was an orphan. It didn't get money from the government much and medicine even more so. So to the extent medical training was reformed, that was the product of investment by The Rockefeller Foundation enormously wealthy by the standards of the time. And come about 1930, The Rockefeller Foundation decided it needed to concentrate its resources and pick priorities for the money it was investing. And it may seem a rather strange thing within the whole range of medical areas that it could choose, it chose psychiatry as the one that it was going to invest in. And I think it did so in part precisely because scientific research in psychiatry was so backward, partly because it was such a pressing public problem. And partly, and this was less public but nonetheless I think played an important role, several of the trustees of The Rockefeller Foundation had direct experience of mental illness in their families. Wives who'd been institutionalized as schizophrenic. In one case, a wife who murdered the children and killed herself leaving her husband as a major actor in The Rockefeller Foundation bereft and of course inclined then to support research in this area. And Rockefeller spread its money very widely, precisely because it didn't know where to spend most of its money. So it did some support of psychotherapeutics. It supported a number of the then extant therapeutic experiments going on, and it supported work in genetics. And one of the geneticists it supported, Ernst Rüdin in Germany, who was the leading German researcher in genetics and mental disorder. And Rüdin, because he's absorbed the lessons from California about sterilization, became a very enthusiastic proponent of that, and then a supporter of murdering mental patients.

We can discuss a series of therapeutic experiments on people who were shut up in a double sense. They were locked away, and their voices were not heeded because it was the product of their madness. And so what we see in the first five decades really of the 20th century is people with a variety of motivations including the desire to improve the lot of the mentally ill engaging in uncontrolled experiments that had terrible results. And the science behind it was shaky but nonetheless it existed. It wasn't just plucked out of the sky. And yes, it eventually those things break down. I mean, the clearest case of that because it's the most extreme of these at least in the public imagination is lobotomy. The idea that you are going to solve psychotic breakdowns in people by excising part of their brain initially by drilling holes in the skull and injecting alcohol or using what looks like a butter knife to break connections between the brain. And then later when that process seems to be too slow, the Henry Ford of lobotomy, his daughter said Walter Freeman aspired to be the Henry Ford of lobotomy, the one who could mechanize the production of it and get it done fast. He invented the ice pick lobotomy where you used an ice pick in the orbit of the eye having rendered somebody unconscious after two or three electric shocks and you banged it through the bone and wiggled it about and severed, I mean, it's just hard to even describe.

Yes. Freeman starts his work in 1936 borrowing from the work of the preceding year of Portuguese neurologist named Egas Moniz. And Moniz wins the Nobel Prize in medicine in 1949 for lobotomy. So it's important to see that. That was 14 years of experience and yet that won a Nobel Prize. I'm sure that's one they'd like to retract.

And his particular specialty after the war became this ice pick lobotomy because there were over half million patients in America's mental hospitals. Freeman was convinced this operation was a cure all. And so he traveled around in a camper truck which he called the Lobotomobile and he would descend in the summer on state hospitals and he would teach them how to do this ice pick lobotomy.

Yes, those are the tools he used. Originally, he used an actual ice pick and then he developed this.

This is the state of the art with a hammer or a mallet.

Yes, I'm sorry. It's very distressing. I don't know.

Well, it's really very, very, very, very difficult. I came across, for example, picture of a woman, naked woman being dragged away by attendants to be lobotomized and she's resisting with all her might and to no avail. You have a picture there of Walter Freeman lobotomizing a patient in Washington State. Freeman was ambidextrous and when he taught neurology, he would draw simultaneously with his left and right hand and he could do it perfectly. When he was performing lobotomy, when his right hand got tired, he switched to his left hand and he sometimes would do 20 or 30 lobotomies in an afternoon. And he boasted, he said, 'You know I could teach any damn fool to perform a lobotomy in twenty minutes even a psychiatrist.' Because Freeman was a neurologist and he had a lot of contempt for psychiatrists. So this was a very ugly episode. How did it die away? It really took generational change. Some of these lobotomists continued to operate into the sixties even to the early seventies, but the younger generation who became acquainted with the really worst failures of that regime; the people on the back wards who were incontinent, who were basically zombies had lost all mental power. They rebelled against this and by then they had a different treatment in the form of antipsychotic drugs which looked much more like what regular medicine was doing, and didn't have these horrible overtones. And of course in the popular mind I think the probably the most famous instance of telling the public about some of these interventions was the film of Ken Kesey's novel One Flew Over the Cuckoo's Nest where you see Jack Nicholson giving I think the performance of a lifetime who is given ECT, electroconvulsive therapy, in a very dramatic rendition of what that was not really what was going on by the 1970s with ECT but nonetheless certainly what had been going on back in the past. And then finally when ECT doesn't smash him to bits they lobotomize him and the film ends obviously with him being smothered to death because Chief can't bear to see him in the state that he's in. So that fixed in the public mind some of the images of these things. It is one of the things that gave Electroconvulsive therapy such a bad name.

Yeah. So as I mentioned for psychiatrists who went into the field and were ambitious but who also wanted to think of themselves as therapeutic agents, to just sit there passively and contain the patients was very unattractive. And so they looked around for ways in which perhaps biological interventions could be used to ameliorate this condition that they still saw in largely biological terms. Now in some ways one of the crucial early ways in which this thinking went and which affected a large number of patients was this: one of the few diagnostic triumphs of psychiatry in the early nineteenth century as the profession began to emerge was that it began to distinguish a group of patients who were deemed to be suffering from something called general paralysis of the insane. That encapsulates two things about what was going on. First of all, paralysis; the gradual loss of motor control, ability to walk, ability to swallow, ability to talk. So those are primarily what we'd think of these days as neurological issues. But those were accompanied by bizarre psychiatric symptomatology. These were people who thought they were Napoleon or Jesus Christ or the richest and sexiest man in the world or Mary the mother of God. They were primarily men but there were also female victims. At the turn of the twentieth century as many as twenty-five percent of the people being admitted to asylums were suffering from General Paralysis of the Insane or GPI for short. There have been a lot of suspicions about this being connected somehow to sex and to moral dissolution and so forth but what evolved in the early twentieth century was the discovery of the actual origins of this disorder. So I've said psychiatry has been looking for the underlying pathology that lies behind mental diseases. This was one that at Rockefeller Institute they discovered that the organism that causes syphilis was residing in the brains of the people who were suffering from GPI. This was in fact tertiary stage of syphilis. Syphilis is still a real public health problem. It was like AIDS in the late nineteenth century. It was everywhere. And when you first contract syphilis in the primary phase you have pain but then it goes underground and you think it's gone and it lurks the way chicken pox virus lurks and can surface years later right? It lurks, it lurks and it's insidiously damaging sometimes it attacks the heart and people drop dead of a heart attack in their forties, oh he died of a, you know it's natural heart attack but in fact it was the syphilis. Or it attacks the central nervous system the spinal column in the brain and then you get the paralysis and then you get also the psychiatric symptomatology. So when that was discovered that sort of suggested that mental illness might have an infectious origin. Tertiary syphilis GPI went on to win for somebody who developed a treatment for it a Nobel Prize one of only two awarded for psychiatric innovations. One was a lobotomy the other was giving people malaria to cure their syphilis.

So there was an Austrian doctor, Wagner Jauregg, who had long thought that fever could be used to cure mental illness. And he tried rat bite fever. He tried giving people typhoid vaccine that creates a fever to no avail. And towards the end of World War I, the Italians were fighting in World War I on the side of the British and the Americans and the French. They captured an Italian soldier who had malaria. Malaria was endemic in those years in Italy. And they brought him to him, and he extracted the malarial blood and injected it into a series of patients with GPI, with general paralysis of the insane, and claimed it cured them. We know from later on when he fessed up that those claims were wildly exaggerated, but they were widely accepted, and malarial treatment spread to Britain, it spread to Germany, it spread to the United States. Sometimes it was vials of malarial blood, but very often mental hospitals had actual colonies of malarial mosquitoes. So imagine you're a mental patient, and you're put in a straitjacket, and you're put in a room, and you can't move, and mosquitoes are buzzing around, and they bite you, and then you develop malaria.

Yes, in 1937, he got a Nobel Prize. Because this was a condition that was invariably fatal. And the claim was that somehow the malarial fever worked. Now, there are two possible ways. Von Jauregg thought it stimulated the immune system to attack whatever it was, was causing the insanity. But the other possibility was the following: When you have the malarial parasite in a test tube and you heat the test tube to about 105, 106 degrees, it dies. So the idea potentially was you were sort of burning the parasites out of the brain with this agent. And because people were pretty unsophisticated about statistics and because the idea of a controlled trial had not yet come to pass, this treatment was used extensively for a couple of decades. What caused it to stop, and you talk about the progress of science, was the discovery of penicillin, which was a real magic bullet. So once you had penicillin, you weren't going to continue treating people with malaria, so it died away. But it was the first such treatment, and here's the other way this feeds into the narrative of these desperate remedies that develop in this period between the mid-teens and, say, 1950. The discovery of the syphilitic origins of general paralysis of the insane occurred at a time when medicine had undergone a profound transformation. In the late 19th century, the work of Louis Pasteur, who was a chemist, not an MD, and the work of Robert Koch in Germany had uncovered the origins of a variety of diseases and suggested that bacteria were the reason why people sickened. And that led, of course, to a whole series of public health triumphs, because initially it didn't lead to antibiotics. But for a lot of these diseases, even viral diseases like rabies, you could develop a vaccine. And the vaccines were phenomenally effective. And so that was one way in which the new germ theory of disease transformed medicine and tied it into the laboratory and into science in a new way. And the other was the adaptation of Pasteur's theories by a British surgeon named Lister, who previously when pus developed post-surgery, people had thought that was a good sign. Lister said, 'No, I don't think so. This is actually these nasty germs causing this, and so we're going to do antiseptic surgery.' So he sprayed carbolic acid on the wounds to try to kill the microbes. Most of his colleagues thought he was nuts. Thought he was just, this is ridiculous, these microorganisms. You couldn't even see them, you know? Well, you could with a... But Lister prevailed. And eventually we moved from antiseptic surgery to aseptic surgery, which is what we have now, where you try to have a sterilized set of instruments in a sterilized environment, so you don't infect things, right?

Some bits, yes. There haven't been the dramatic breakthroughs that I think everybody in the field would hope for. And there's some debate about how powerful what we have done is, and I think it's reasonable to debate that and to also acknowledge that there is important progress, limited as it is. Now you have 25% of the admits to a mental hospital actually suffering from an infectious disease. Medicine in general has now tied its fortunes to the laboratory. The idea that disease is caused by bacteria, we can't yet see viruses. It is a very powerful one and that notion that disease is caused by bacterial infection acquires great momentum but it hasn't touched psychiatry so medicine now has interventions that work and sometimes quite dramatically. You know the first patient given diphtheria vaccine. Diphtheria causes a leather-like membrane to grow over your throat and you die choking to death. And if you have a child and you watch that child die like that, you will never be over it. So when you had something that warded that off, that improved medicine's image dramatically and improved its financial prospects dramatically particularly as medical training became reformed and more involved with science. So that hasn't applied to psychiatry until syphilis comes along. Now we have the model that an infectious agent can cause people's minds to go amok. So the very person who invents the basic distinction between kinds of psychoses we still use today, schizophrenia and bipolar disorder, Emil Kraepelin begins to think, 'You know there may be something infectious about the mental illnesses we're treating.' And one of the people he trains is a young psychiatrist from the United States named Henry Cotton who's also been trained by Adolf Meyer who is the leading American psychiatrist of the first forty years of the twentieth century. And when he comes back from Germany having spent a year there, Meyer secures him a position as head of the New Jersey State Mental Hospital at Trenton and Cotton is an ambitious reforming man. He wants to bring psychiatry back to medicine. He also wants to chuck out all the old stuff. He doesn't want chains in his hospital. He doesn't want, if he can help it, straight jackets. So that goes away. But nothing seems to change fundamentally. He still isn't curing patients. And then he comes across this idea of focal sepsis. The idea that low-grade infections can lurk in the body and what they do is release toxins into the bloodstream and the lymph. And hey, imagine if those toxins get to the brain. What's it going to do? It's going to poison the brain and the brain is then going to act up. So we don't have antibiotics. So what are we going to do about this? Well we can perhaps locate the bacterial infection and then we can get rid of it. We can engage in what he calls surgical bacteriology. So the first obvious target here is teeth. Your teeth look close to your brain. They're often infected. That infection often goes untreated for a time. So we pull a lot of teeth. Patients don't get better. Maybe the theory's wrong. No. Tonsils, well they're getting infected so we'll remove them. Still don't get better. Well they're swallowing the bacteria so we remove stomachs and we move spleens and we remove colons. And we claim to be curing eighty percent of our patients. And rich patients come from all over America to be treated with this novel treatment.

Cotton gives a series of lectures at Princeton. There were not

Some lectures which are given by Nobel Prize winners. There's a very prestigious series. It's published by Oxford University Press and Princeton University Press. The New York Times hails it as a great breakthrough. And in reality, 45% of the people who get the abdominal surgery die within a year.

Yep. He's cutting out stomachs. He says—there's this passage in one of his papers where he says, 'Stomachs are like cement mixers on a construction site and could be dispensed with.' When you think, oh my God, if you were released from Trenton and you had no teeth, people immediately knew you were an ex-patient because the word had spread. And this goes on for—starting in 1916, Cotton drops dead of a heart attack in 1933, but he's succeeded by three people he's trained. They drop the abdominal surgery. They use colonic irrigation, but the teeth and the tonsils keep being pulled. I interviewed the dentist who had come to the hospital in 1916 and must have pulled several hundred thousand teeth. And he retired in 1960, which was when that finally stopped. And he was convinced Cotton should have won the Nobel Prize for this. Oh, well.

It's extraordinary. So obviously, many of the interventions I'm talking about are very powerful interventions conducted by people in white coats and stethoscopes and scalpels.

Yes, powerful as well in terms of placebo effect. Look, what I am going to do to you, and yes, it's gonna hurt and it's very intimate, but it's going to make you better. So that's always—this is a problem that persists in contemporary psychiatry, trying to figure out how much of the improvement we're seeing is the placebo effect and how much of it is the active effect of whatever we're doing.

Yes.

Yes!

It's placebo effect that comes from both the patient who wants to be better—and wants to believe this is gonna make them—and from the person conducting. And it's easy to deceive yourself, to see what you want to see. So anyway, that was one episode. We talk about triumphs of medicine, so let me talk about one of the real triumphs of 20th century medicine, which is interesting to refer to because it wasn't a cure, just like psychiatric drugs aren't a cure for mental illness. It was a symptomatic treatment but it transformed lives, and that was discovery of insulin in the 1920s. Previously, particularly what we now call type one or juvenile diabetes was a death sentence. You got it and whatever you did, you tried various quack remedies, you tried diet, you tried all sorts of things. The inevitable thing was it killed you. And then came insulin. Now insulin doesn't mean you're cured of your diabetes, but what it means is you can live a relatively normal life and your lifespan is greatly expanded. So by any measure you have to say that's dramatic progress.

But insulin is something our bodies produce, we hope, unless we're really seriously diabetic. Those of us with Type Two diabetes, our bodies resist insulin and we have to resort to other ways of trying to cope. But if you get too much insulin, it makes you unconscious, and that's how another one of these desperate remedies came along. A man named Sakel working in a German clinic for drug addicts—they were using putting people under mild comas to help them through the withdrawal symptoms once they got over their addiction. So he was familiar with that. And when he moved to Austria, he decided he'd try this as a treatment for schizophrenia. And so he put people into comas, sometimes comas that would last hours, days. They would be revived by giving them glucose, usually intravenously, sometimes not. During the time they were in comas, they often seized, had seizures. He saw that as a therapeutic sign. And he claimed that this Insulin Coma Treatment cured eighty percent of his—eighty percent tends to come up again and again in these treatments as a sort of percentage that you cure. And he was invited to New York and demonstrated this at the Harlem Valley Mental Hospital. It spread. This was starting in 1933. The visit to America was, I believe, 1936, and Sakel ended up settling here. He had a very lucrative private practice in New York, and when he died he left his partner, I think, an estate of about two million dollars, which in the early sixties was a very substantial amount of money that he'd earned from practice, right? So insulin coma therapy was widely adopted. What kept it from being a large scale thing was it required an enormous amount of nursing and medical attention, 'cause people were literally hovering on the brink of life and death. They could go into a permanent coma, they could just die. So their vital signs had to be monitored. They had to be brought around very quickly if need be. And there's some evidence that the treatment killed brain cells. And when Sakel was told that, he said, 'Yes, that's probably true. They're killing the schizophrenic brain cells.' That's just nonsense, of course. That's just nonsense, but that's his rationale. Insulin comas weren't subjected to a randomized controlled trial until the 1950s. And when they were subjected to a controlled trial, they failed it, and so it died out. And that's, I guess, scientific progress again in a way, but it took a long time. One of the people who received insulin coma therapy—have you seen the film A Beautiful Mind? He did receive insulin coma therapy. Ironically, actually at Trenton State Hospital where Cotton had been, so John Nash received insulin comas, and they were going to lobotomize him, and they didn't, but he was at risk of that.

Yes, that's right. Performed on John Nash, one of the great minds of the 20th century.

And Nash clearly did become delusional, but that was one of the treatments he was subjected to, and well represented, actually, in the film of A Beautiful Mind. So I mentioned seizures. Also in Austria-Hungary in this period, another psychiatrist decided that you couldn't be both schizophrenic and epileptic. That there was somehow an antagonism between the two. So if you had epilepsy, you didn't have schizophrenia. If you had schizophrenia, you couldn't have epilepsy. I should say at the outset, that's not true, but that's what he believed. So then, the logical next step was, 'Well, if we could create an artificial epileptic seizure, maybe we would drive out the schizophrenia.' So, what to do? He first tries injecting camphor, a natural substance. Natural substances aren't necessarily benign substances. That caused abscesses, and it wasn't very effective. He sought an alternative, and he settled on something that was called Cardiazol or Metrazol, depended which side of the Atlantic you were on. And injecting that into a patient usually caused a seizure, a big seizure like a grand mal seizure, where your body arcs back, your legs contract dramatically.

And you ended up, yes, with fractures of vertebrae, fractures of the hip socket. Because when muscles in the thigh contract that badly, what happens? The thigh bone is driven into the socket at such a rate that it fractures, right? So these were among the complications that Metrazol produced. More than that, he himself conceded that between the injection and the seizure, the patient felt as though he were on—or she was on the brink of death. Now imagine, pretend you're a mental patient. You're brought in in a straitjacket, a man in a white coat with a big hypodermic injects something into you. You feel as though you're gonna die. And maybe that lingers for two, three, ten minutes, and then you seize, with those possible fractures following.

It's violent and hard to witness and is very unpredictable. So it's used, but people are not very happy, and that's how we get electroconvulsive therapy, electroshock, as it's first called. Two Italian psychiatrists, Cerletti and Bini, experiment with electricity, and they first experiment on dogs. And they make a mistake initially. They have an electrode on the head, an electrode on the anus. The electric current passes through the body, it stops the heart, the dogs die. So that seems a dead end. And then somebody says to them, 'You know, you should go to the Rome slaughterhouse and see the pigs being slaughtered, 'cause you'll learn something very interesting.' So they go, and the pigs are dangling by their hind legs, and as they come by, two electrodes cross their head. Electroshock, they convulse, they're unconscious, their throats are slit and pork arrives. So, they try that on dogs, and current passing through the brain, it turns out, doesn't kill them. So they decide to try it out. They pick up a transient homeless person at the Rome train station and they bring him in. And they try it, and at first they don't use enough current. And nothing very much happens. And they're very white-faced, they're quite worried off in the corner. We have descriptions of this, and they're talking, 'What should we do?' 'Well, we'll up the current.' And the patient hears that and says, 'No, another one, that's deadly.' They do it anyway, and he convulses. Another grand mal seizure, with the same problems of spinal fractures and hip fractures and so on. Not universally, obviously, but often enough. And he stops breathing. You can imagine the scene. And then he spontaneously starts breathing again, and when he comes around, he's in contact with reality. They got this miracle cure, and it's very easy to administer, cheap, doesn't involve injecting things into people's bodies. So that quickly spreads across the Atlantic and other parts of Europe. And ECT becomes a very widely used intervention. Couple of things to say about this. It turns out it's not very useful for schizophrenia. Remember the connection between seizures and schizophrenia that was originally posited, but it seems to work in cases of depression, suicidal depression particularly.

Yes, if we fast forward, we're looking at in some respects a different animal for reasons I'll explain.

Yeah, so we're talking about unmodified ECT, which rules the roost really well into the 1950s, and some places even into the 1960s. And so it is associated with all the problems of fractures that we've talked about. It's also associated with memory problems. People often lose memory. There's some dispute about how serious that is, but it's pretty widely recognized that's one of the prices you're going to pay for that treatment. The thing is, for mental hospitals in the '40s and '50s, ECT was much more used as a device to control people's behavior, than as a therapeutic intervention. It was quite punitive, seen as such. Patients didn't want to repeat, and so they sort of controlled themselves a bit. But yes, we don't know why it, quote, 'works,' but more recent work starting in probably the 1990s—and I'm going to get in trouble with some people for saying this because you mentioned patients and psychiatrists who swear by ECT. There are others who swear at it. Partly because of the memory problems I alluded to, and partly because of claims that it may cause brain damage. Passing an electric current through the brain is possible. What changed ECT a bit, quite a bit actually, was giving muscle relaxants so that people didn't thrash about, and the fractures were largely a thing of the past. When you introduce these muscle relaxers, originally they used curare, but then they used other, more modern drugs to paralyze the muscles temporarily. The problem is, that would also paralyze your breathing muscles, so that's not too good. So it became a more complicated procedure because you needed anesthesiologists, breathing support, and so forth during the procedure. But you did eliminate the fractures. It still was a very widely disdained practice, I think, particularly when they had drugs available. The thinking was that, well, we'd sooner use those, but the drugs turn out to be only partially effective, and pretty ineffective very often for suicidal cases or in cases of extreme melancholia. Now, a couple of things to say: Very often, ECT has to be repeated at intervals, as a kind of maintenance therapy. So it hasn't cured things, but it temporarily alleviates the symptoms, and the temporary may be fairly lengthy, but nonetheless, very often things will recur. The memory problems can be quite severe. The worries about brain damage are, I think, certainly things we have to be very cautious about. And when we talk about treatment-resistant depression, that's an interesting concept to me. What it means is those are the patients who don't respond to drugs. They may not have a different disease, but the drugs don't work for them, hence treatment resistant. And the numbers of psychiatrists who are willing to give ECT are rather small, and in many states it's hedged around with lots of legal restrictions. In California, for example, ECT now almost can't be given to involuntarily confined patients 'cause you have to volunteer for it. So it's unusual in that most medical procedures aren't hedged about by legal constraints like that. And there clearly is a very powerful group of people, some of them psychiatrists, many of them ex-patients, many of them other people who just are suspicious of modern medicine and science, who form a group who are very powerfully opposed to ECT. So although it's fair to say there are trials now that seem to provide decent evidence that for some patients this works and that those patients are deeply distressed before the treatment, it's also still a controversial treatment, I think it's fair to say.

Yes, yes.

I think lots of people upset. So if we talk about drugs, there'll be two kinds of people who will be upset, those who think the drugs are more powerful than they are or who have been successfully treated by the drugs and go, 'Well, it worked for me, so, you know, stop criticizing it 'cause it really is an effective treatment.' And then on the other side of the coin, there are those who either the drug treatment has been used and it's failed, or they're being left with terrible side effects that don't go away, or they're part of a general group of people that unfortunately is of a growing number these days who are so suspicious of medical science and of the drug companies that no amount of evidence will sway them. They are convinced that, you know, the drug treatments are poisonous. The Scientologists being a very extreme example of that, who they have a whole museum in Los Angeles and the title is Psychiatry Industry of Death. And then if you think about all the resistance, for example, that has surfaced to vaccination in contemporary US and how the trust in vaccination has been destroyed for a substantial number of people, it's very difficult to convince them that they're mistaken.

A general distrust, exactly.

That's one of my great worries about our contemporary situation, that we're only—we're less than a year in. After four years of this, first of all, the degree of mistrust will have grown exponentially, and once trust is lost, it's very hard to recover. Secondly, the science itself is being destroyed. Clinical trials that were midway through were aborted, so that knowledge has been lost. You would have to start from square one, and that's years of work. Scientists aren't being trained because funding has been cut. Scientists with successful careers no longer have the funding necessary to do their work, and it takes at least six or seven years to train a scientist at the beginning of their career. And so if you have four years with nobody being trained, you're talking about a decade being lost, and what's lost is invisible—because it's counterfactuals. We don't know what that science will lead to or what that medical treatment might lead to, and very many times they fail. That's the nature of science. It's the nature of medicine and medical research that not every bright idea we have is going to eventuate in a breakthrough. It would be really simple and wonderful if that opposite were the case. But the reality is we have to go down lots of blind alleys, we have to try lots of different things, and we have to take years to move from the laboratory to practical application. And when we eliminate a whole segment of that, and when on top of that we diminish people's trust—in science, that's a really, I think, a profoundly devastating thing that probably given my advanced age, I won't live to see the consequences of, but my children and grandchildren will. It really is something cultural that you've got to build up trust. And it can be destroyed very easily. So one of the things, to go back to the very first question you asked me about, is psychiatry in crisis? Well, genetics was supposed to provide a clear picture of the origins of various mental diseases 'cause they do seem to run in families. So the expectation was once we decoded the human genome and we could examine bits and pieces of it, that we would very quickly find a Mendelian gene or set of genes for schizophrenia, let us say. Hasn't happened. We now use genome-wide association studies, that is throwing everything in the kitchen soup into the picture, and then without any preconditions and seeing what relates to what. And if we use three hundred small variations in the genome, we can account for about ten percent of schizophrenia. That's not very powerful. Beyond that, what psychiatric genetics has tended to throw up is something that undermines the distinctions that we've made based on symptomatology. So if you look, there is a great deal of overlap in the kinds of genetic abnormalities that heighten the susceptibility to bipolar disorder or schizophrenia or autism. There's a lot of overlap there. What that suggests is these aren't distinctive entities in the way that, you know... Schizophrenia, as my friend Robin Murray, a British psychiatrist, has to say, 'It really seems to be the extreme end of psychosis, the most serious.' But it's sort of on a continuum, you know. And so if psychiatry has to say in ten years, as some leading psychiatrists are speculating, that there's no such thing as schizophrenia, there's no such thing as bipolar disorder, that will tend, I suspect, to have pretty bad effects on people's trust—in psychiatry, and yet that's where the science may lead them. So it's a complicated picture, but this issue of trust and its absence is vital, I think, in looking at not just what we're talking about today, but across a whole spectrum of things, even outside the medical realm altogether. If you lose trust in institutions, trust in science, trust in history. So I think more humility and less arrogance, more willingness to confess the limits of what we can do, more awareness of the dangers of enthusiasm, more skepticism when we're told something is a breakthrough. One of the things I worry about is the tendency of science journalism and medical journalism to hype things and then when the hype turns out to be just that, that undermines trust. You know? So be cautious when things come along—don't be so sure that it represents a breakthrough. I'm very worried at the moment. I see Ketamine and psychedelics being propounded as a miracle cure for depression, and the evidence for that is enormously weak is the best way to put it. And I've seen this movie before too many times. You know? I mentioned that 80% cure for Cotton's work, 80% cure for insulin coma therapy, 80% cure for the early asylums. This is overblown rhetoric, and the reality is usually progress comes in small steps. Sometimes it comes in big steps. Penicillin, I think was a huge step. I was lucky enough to grow up in the era when penicillin and other antibiotics became widely available. They hadn't been overused by then. And so if I had a strep throat, I had something that got rid of it right away. I didn't run the risk of heart valve damage, which in previous times would've been the case. So you know, once in a while you do have these dramatic shifts, and maybe AI will help us in that regard, but maybe it won't. It's another potential double-edged sword.

Yes. We can add beyond the realm of science journalists. I think Science and Nature make choices about what they're gonna foreground, and they too have this tendency to look for things that make a big splash.

I think the editors, the major journals, that's what they're looking for. As, you know, I mean negative findings are very important in science. They're the things that help us avoid mistakes, but they're not the things that are going to get you published in the journal.

Having lots of scientists working on these problems in different sites and different places turns out to be very important, I think, as a check on enthusiasm, as a check on premature claims that turn out to be unfounded. And also because you're often partially right but you're not fully right and someone else following the same idea—is perhaps gonna be a little closer to the truth than you were. And so it's very helpful to have multi-centered things and not everything under one all-knowing thing. And that's a problem with funding agencies. The maverick scientist has a hard time—very often—getting a hearing. And we know of lots of examples of that in history where after the fact we go, 'Oh well yes, we should have supported that line of research, but we didn't.'

Yeah, Menlo Park. Yes.

Mental hospitals have had a very patchy and complicated history. He was working actually in a hospital for veterans. Those were largely created after the Second World War when there were very many more psychiatric casualties among American troops than even the First World War. The interesting thing is we all by osmosis know that in the First World War there was something called shell shock that afflicted the troops and that the military initially resisted recognizing and ultimately were forced to grasp. But in World War II, American psychiatric casualties among the troops were two to three times as high as in World War I, and that's an important part of the history of psychiatry. But the upshot of that was that post-war the VA was heavily involved in, first of all, paying to train psychiatrists and even psychologists, and then had in its mental hospital system a considerable involvement with psychiatric disorders. Kesey—Well, the book is different than the film is the first thing to say. Obviously, the film is heavily indebted to the book, but it changes various things.

Yes, I think that's right.

Yes. And you have a nurse figure in Nurse Ratched.

Louise Fletcher, I think is an equally powerful performance.

Psychiatry, yes. It's very interesting. I used to teach a class called Madness In The Movies, and I didn't just use... In fact, I used relatively few contemporary films and all among all the films from back then, the one almost everybody in the class had seen was One Flew Over the Cuckoo's Nest. So 18, 19, and 20-year-olds, in 2015, if I showed them Alfred Hitchcock's Spellbound, no chance they'd ever seen that, maybe one, because they were a class of people interested in film. But everybody had seen One Flew Over the Cuckoo's Nest.

I think One Flew Over the Cuckoo's Nest. I think oddly a very different film appeared at about the same time was I Never Promised You a Rose Garden, which is a much more sympathetic portrait of a different kind of psychiatry, a very Freudian psychiatrist, really about Frieda Fromm-Reichmann who worked at Chestnut Lodge in Maryland and treated schizophrenia with psychotherapy rather than with drugs or other forms of physical intervention. And that was a bestselling novel by a young girl who had been her patient with some fairly serious delusions and a very complicated family background, and again the film changed a lot of things in the novel. That's what films do. My book Madhouse at one point interested Hollywood, and one of the two principals said to me, 'I really like this story. It's got a great first act and a great second act, but where's the third act?' Meaning, 'Where's the happy ending?' And I had to say there wasn't any happy ending to that story. It was just rather grim.