Good evening, everyone, and welcome to warwicks. On behalf of four weeks, i want to thank you for your support. Last year, what celebrated 135 years is the oldest continuously family owned bookstore in the u. S. Thank you very much. Hopefully next year we will have our 126th year. What weeks warwicks is pleased to introduce andrew saul who will discuss his book. He will be in conversation with dr. David lehman. Andrew school skull received his phd from Princeton University and is currently distinguished professor of sociology emeritus at the university of california san diego. In 2015, he received the roy porter medal for lifetime contribution to the history of medicine. In 2016, the eric ralston award of a lifetime contribution to the history of psychiatry. His previous books include madness and civilization, hysteria the disturbing history, and madhouse a tragic tale of mega mania and modern medicine. He has contributed to many previous documentaries many pbs documentaries. He blogs for and has written for the atlantic, scientific american, paris review, wall street journal, and the nation among many others. Dr. David lehman received his medical degree from Washington University st. Louis medical school and completed his psychiatry residency at university of california san diego. He is chief of cognitive disorders clinic at the v. A. Medical center in san diego and medical director of the inpatient unit. He is heavily involved in education at the university of california san diego ethical school and the Residency Training program. In addition, he is the associate director for the third year clerkship and the court nadir of the fourthyear medical student psychiatry sub internship. Please give a very warm welcome to andrew scull with david lehman. Dr. Lehman i did not realize warwicks was that ancient and i am very pleased. We are grateful to have the advantage of a place like this. I am pleased to be with you tonight. The book that i just completed i first envisioned in the early 1980s. It would have been a different book had i published it back then. I had spent my early part of my career looking at the emergence of psychiatry and the rise of the asylum in victorian england. Before i publish that book, because i was tired of it, my doctoral thesis, but i went around doing interviews and people said isnt the shutting down of asylums a good thing . I said i have been buried in the 19th century, i dont know. I knew how much money and intellectual capital had been invested in the idea that the Mental Hospital was the solution to Mental Illness. I thought that would be in interesting topic and more convenient to my colleagues who regarded victorian england as strange. I wrote the book on deins on deinstitutionalization. It is not right it was not quite all that it seemed. I like to think it was a wish and book a precient book, the people who live with Mental Illness and watch that has resold whats that has resulted into. I did books that spanned history and i started to work on the 20th century. The period i was initially working on was 1920s and 1930s which was a period of extraordinary experimentation. Mental patients were shut up, locked away and their voices were stifled. Anything that had to say was a product of Mental Illness. That meant given the desperation at the time that they were vulnerable. The title occurred to me when i was a student in london. I always had this project and madness in civilization in my head. I wanted to put american psychiatry in a long historical context. How did it come to be . How did it evolve as the hopes that we could cure Mental Illness start to decline into hopelessness toward the end of the 19th century were psychiatrists and the culture dismissed mentally ill people as degenerates . As people who were no longer fully human and had to be locked away lest they breed and produce more of their kind. It was one that was imbued with dozens of helplessness. One of the things we did, california was the leader in the u. S. We started involuntarily sterilizing the mental ill. California did not stop doing that until about 1960. That legislation was the model for the nazis in germany. They produced compulsory sterilization but lacking the restraints of our political system. They exterminated en masse and then decided these people were useless teachers and so they kill them useless eaters so they kill them. It was there the technology of the gas chamber was developed. About 250,000 patients were killed at the test at the behest of top german psychologists. Psychologists who were not satisfied with just being housekeepers, running in the asylum and keeping the population under wraps, they wanted to be healers. They looked for various ways to intervene. Unfortunately, that produced some terrible results. At this point i will shut up for a few minutes and let david talk about those middle chapters first of all, let me thank you for inviting me. You have been training me since i was a resident in psychiatry. And probably more than anyone else, introduced me to the unpalatable nature of the history of psychiatry. That unpalatable history has had a dramatic and in the end very positive effect on my psychiatric career. And i would think it sad and perhaps horribly amiss if a resident were to graduate from a Psychiatry Program and really not be familiar with these warnings that you do so well and in such a devastating and horrifying manner reporting on the history of psychiatry. I think one of the things that is very important to understand is there was a strain in my discipline and among some renegades in the 1960s to dismiss Mental Illness, to claim it was a myth or a matter of social labels. And that has never been my point of view. I have seen it close up with close friends, one whom committed suicide after postpartum depression. I am not in any sense antipsychiatry, but i am very much somebody who thinks we need to face up straightforwardly to the truth of what we can i cannot do, what we understand, what we dont understand, the limitations or knowledge, the kinds of things that in the present we really ought to be doing and are not. And so while the book is heavily critical in many ways of psychiatry, it is not meant to be, and im glad to say the critics who have responded to it so far have not seen it as, an attack on the field but more an attempt to analyze ways in which it has gone wrong, ways in which it has made some limited progress and at the last 50, 70 years. The limits of that at the moment and the ways in which i think has been captured by very monochromatic view of Mental Illness so we concentrate on genetics, we concentrate on neuroscience. The upshot of that for patients who are actually sick has basically been nothing. You think that is me speaking as the outsider, so i will just say, and so he ran i am in h from 2002 happen 22015, when he stepped down, said, you know over the last period, i spent a lot of money, about 20 billion and we funded some really cool neuroscience and really cool genetics and the payoff for patients has been zero. He was being too kind. If you look to people with serious Mental Illness, someone in the audience will know, the Life Expectancy of those people is 15 to 25 years less than the rest of us and that gap is growing, not diminishing. That is not purely psychiatrys fault, it is the result of Public Policy. But it is a sobering reminder that we have a long way to go. The way i think about it is this way, those comments, psychiatry is concerned with the mind. The mind is an abstraction of the brain and the brain is by far the most complex organ in the body. The questions psychiatry asks are vastly orders of magnitude more difficult than other branches of medicine. , and, what is consciousness is among the most difficult question that science has ever posed. So i dont think it should be a surprise that psychiatry has not come up with many answers very quickly. It will take time. As you point out in the book in the 1990s there was some irrational exuberance, the decade of the brain when we made all kinds of promises that have not yet been delivered. But from my perspective, what i was say to thomas is i see no reason why science, given the time to not address, is very, very difficult questions in psychiatry going the same way i in other branches of medicine. It is not going to happen in the next decade. But i dont see why it cannot happen. What i would add is it seems to me the distinction that is often made between the biological and the social is false dichotomy. Our brains are very plastic organs. They are very much the joint product of the brain we are born with and the brain that develops over those years and patents that develop within the brain are very much a product of the social and the cultural environment in which that brain matures and that person matures. One of the problems i have, im not trying to say there should not be Neuroscientific Research and should not be research into genetics, although so far that has proved to be something of a dead end. What i would like to see is research as well that deals with the other die mentions a Mental Illness and as a clinician, you are only too well aware of that. We have we need research on how best to give families some relief. We need research on how we provide suitable housing and social support for people with serious Mental Illness. Nimh has largely neglected that for two decades now. Yeah, but i think it seemed that biological psychiatry was the way to go and you mention in your book how the Rockefeller Institute really struggled with this question what should they fund and who should they trust in terms of recommendations . There were so many advances that were happening so quickly with medical technology at the time that it seemed reasonable to place a bet on the sexy, exciting stuff rather than the quotidian, less fun and exciting questions of how you address loneliness and how you minimize the suffering associated with the human condition. I would agree, what many people may not realize, why it is important i think to have a Historical Perspective is that before the second world war, there was essentially no federal involvement other than running one Mental Hospital in d. C. With no federal funding of medical research, let alone psychiatric research. The major actor filling that gap was in fact the rockefeller foundation, which made the rather brave and unorthodox decision on it early 1930s that it was going to find psychiatry as a least developed part of medicine and the one where it thought it could make the most difference. And it did spread its net quite widely. Some of the directions it spent money, quite reasonable. Others, and a delight of later developments, seemed rather problematic. For example, rockefeller founded funded the german nazi psychiatrists and continued to do that right up until the break of world war ii. And was heavily involved. On the other hand, rockefeller also provided funds to try to rescue many psychoanalysts who were jewish from the nazis and bring them to america, and that proved to be a very difficult exercise. But it about doubled the number of psychoanalysts here and one of the preconditions for something that happened in america after the war which really had no counter anywhere else im aware of other than buenos aires, and that was the emergence and dominance for a period of about a quarter century of psychoanalysis in american psychiatry. Understand that in 1950, there were a halfmillion people in americas Mental Hospitals and that continued to grow for another four or five years. Those psychiatrists august the could not practice psychoanalysis obviously could not practice psychoanalysis. It was in that environment the drugs revolution emerged, sort of the psychoanalysts. But if you look to academic psychiatry, if you looked to the high status growth of psychiatry on an outpatient basis, that was heavily psychoanalytic. And that was not just a matter of the profession. The whole of american culture, especially high culture, but also popular culture, was saturated with psychoanalytic ideas. Freud was seen as the equivalent of darwin. We sort of raise a smile these days but intellectuals in all disciplines, the humanities of social sciences particularly, flocked to freudian ideas. Look at the movie spellbound, one of offered hitchcocks films i think 1948, and you will see it is propaganda for psychiatry. It begins so there is that where people sought meaning in madness, tried to understand it on a psychological level, tried to treat it, and some american analysts went so far as to say that could treat schizophrenia with psychoanalysis. Which freud himself had not thought possible. So it was really i cant stress other than washington using [laughter] davids alma mater. Other than that, virtually every other department was headed by somebody who was either a psychoanalyst or sympathetic to psychoanalysis. And the best recruits to the profession went that way. That is where the rewards were. That is where the best patients were, those who had money and also were more interesting than the ones stuck on the backboards at the state hospital. So it is curious in a way that the thing that marked a room revolution in psychiatry emerged not there and not in the university, but the Mental Hospitals, which is where the drugs, the antipsychotics, particularly thorazine and its copycat drugs, first emerged. What happened for many years is like a building being destroyed by termites, the structure looks solid. The psychoanalysts thought, we are in the saddle. With remarkable rapidity, that shifted. And we can date it is precisely in 1980, fueled by problems that had emerged about psychiatric diagnoses, the fact psychiatrists could not agree what was wrong, there was a sustained effort to create a diagnostic system that at least was reliable which meant doctor here a doctor there look at the same patient, they would produce the same diagnosis. And it was an approach that was a theoretical by its nature but in fact underneath that, fueled by hostility to psychoanalysis and help to serve as the death mail for that branch of the profession. I think it is a complicated question. Psychiatrists the generation who trained in the 1960s, psychoanalytic ideas. I know david can speak to that. If i have anything to do about it, they do. I have lots to criticize about psychoanalytic psychiatry, but it is important to recognize that whatever the flaws in their doctrine and their ideas, whatever their flaws in the rigidity that produced in so many practitioners that in many ways they sowed the seeds of their own demise through the rigidity and esoterica. But they were and are the humanists in this story. And rather than sort of recorr ecting or redirecting some of the rigidity, they ended up throwing out the baby with the bathwater, wholesale of replacement of dynamic psychiatry with biological psychiatry. As troy gaspers would have pointed out decades previously, that would be a deadend. So far biological psychiatry is only part of the answer. And that needs to be recognized and is not always recognized. That is something i would concur with. I have my own quarrels with the rigidity of freud is him but it did give patients voice and that was very important. That is really lost now. It is interesting, there was a study done in the 1960s of what happens of psychiatric practice were like at that point. Outside the institution, the average length of time somebody spent when they went to consult a psychiatrist was between 45 minutes and an hour. Over the typical 55 minute hour. That meant there was a lot of exploration in the patient where now partly because of managed care, partly because of the pressures of the Insurance Companies, partly the need psychiatry is not the best paid of medical specialties it has sort of become a pill mill. You see the psychiatrist for 10 minutes and that is barely time to really penetrate. It may be different but a lot of research has suggested that. There is a real decline on the profession part of delivering psychotherapy as well as the psychopharmacology the profession is come to terms on. Indeed, one of the stories is the emergence of other professions in the psychiatric and psychological realms. So very many particularly patients with other kinds of disorders and up with clinical psychologists and clinical social workers getting some of this psychotherapy they dont get when they go and see their md. This is an unpleasant topic. [laughter] these are economic forces that are driving this rather than theoretical forces, rather than ideas about what is possibly the best way to treat Mental Illness. And so in my mind, i separate out the mistakes made for theoretical, scientific, or ideological reasons from just the sheer Market Forces that every industry is going to respond to, producing either favorable or unfavorable results because of those incentives. I mean, what are the things that happen when the Mental Hospitals indeed out emptied out, and it was mixed as my history shows, but there have been a long tradition of Mental Illness, unlike physical illness and this country, being a state responsibility, being something that was funded publicly. There was a very strong public psychiatric wing to the profession. It was obliterated, really. The profession did not protest, i would say some did, but not enough people protested about what was happening. But what was going on was not the product of the psychiatrists deciding this was the way forward. It really was the other forces that you were talking about, conscious Public Policy choices, pressures from the insurance industry, the availability over technology in the form of the drugs that looked like conventional medicine and could be dispensed pretty quickly. And the Insurance Companies were not willing to pay decently for other kinds of care, and they still are not. Yeah, unfortunately, that is the place that we find ourselves in right now. I think that one has to recognize if youre going to promote improved treatment for the severely mentally ill, youre going to have to recognize it is phenomenally expensive. I think your book comments when the asylums were open, it was the single biggest line item on the budgets of most states. That is jawdropping. And that was crappy care. That was snake pit care. So you can imagine the cost that would be involved in providing beautiful stateoftheart care for the severely mentally ill. And he brings up it brings up a very difficult question that most people do not want to look in the face, which is, should people with severe Mental Illness who are marginalized and do not vote get the majority of the resources that otherwise are going to people with Mental Illness but not asylumlevel Mental Illness . I think that is i think one of the other things that i would say that is not confined to the history review here at the last 200 years or so but extends much through all of recorded history that im aware of, Mental Illness is something that it constantly is associated with fear and rejection. And so this is a population, as david said, they dont vote so in that sense the politicians are not going to be responsive to them, but much of the problems are kind of hidden away. I think one of the things i saw in the years of the institutionalization, a lot of the burn originally fell on the families where they were still intact, and particularly on women who are often pulled out of the workforce to care fulltime for the patient, eventually crumbled under that strain very often. It is just too much. Those families who are very reluctant to make a lot of noise , and the reason for that is obvious. They did not want people to know that in their domestic bliss, there actually was Something Else happening. It is amazing how when you become aware of this problem, people sometimes will open up and you realize what they have been going through. When that breaks down, in fact so called welfare reform has been worse, harder for them to get social supports. States have not replaced the moneys they used to for the most part to been on the Mental Hospitals. In new york state in 1950, it was 30 of the state budget was the Mental Hospitals. Extraordinary number. So what we see as a result, we see the worst of it, i mean, living in california whether you are downtown San Francisco, l. A. , san diego, the problem of homelessness which is not only a problem of Mental Illness but a subset, an important subset is in Effect People with serious psychiatric problems who just cycle from the flophouse to the jail with an occasional stop of in the Psychiatrist Office to get a prescription and then back into the cycle all over again. It is a dismal part of life in a country as rich as ours, and that is what we face. I would suspect you and i differ politically this issue. When i read the book, one of the things that jumps out at me is how many of the devastatingly bad ideas were promoted by progressive ideas. So much of psychiatry involved unscrupulous people. But more of it was wellmeaning people who did hugely unscrupulous things. Jawdropping. In the name of the ends justify the means. They were so enamored with their do goodism ideas that they lost the boundaries of western civilizations ideas. I think eugenics is an example of that and deinstitutionalization is an example of that and so i do worry quite a bit that the idea that if we just sit down and come up with yet another program to help the severely mentally ill and spend a lot of money on it, that that will then be the panacea. I have my doubts and i see these patients in the emergency room on riegler bases that i know the solution is going to be much more difficult and challenging than convincing the state of california to spend more money. I dont disagree at all, david, actually. One of the great messages i think of the book is psychiatry would take to heart the hippocratic injunction first do no harm. That jumping into enthusiasm and refusing to see the evidence that runs contrary to ones enthusiasm and thinking you have a magic wand that will solve the problem, that is repeatedly happened over the last 200 years. The results have almost been uniformly disastrous. Indeed, some of these people were perhaps many of them were absolutely sincere in their belief that they had discovered the royal road to intervening. One of the figures in this book who also is in my book madhouse is a gentleman named henry kotten who ran the new jersey state asylum in trenton from about 1908 until he died suddenly in 1933. Kotten decided, it is an idea he may have picked up from arguably the third major figure of times, that Mental Illness was the result of infections lurking under the body that were poisoning the brain. A. About a era, the only solution was to surgically eliminate them. This first targets were teeth. A lot of people had run into. You pull those, put and then and then pull tonsils. The people did not get better, instead of thinking im on the wrong track, you have to have other areas of infections in the body and kotten starts eliminating stomachs and spleens and another pattern, women are disproportionately targeted for some reason. We can talk about what i think some of the reasons were but trust me, 65 , 70 of patients were female who operated on. When i say he was sincere, he decided any teeth were a potential menace and so he had his wifes teeth and his two children steve prophylactically removed. Then one of his sons seem to be masterbating, he removed part of his colon. When he fell mentally ill under pressures of an investigation into him, he went to hot springs, arkansas, and had his own teeth pulled. So he believed what he was doing but what he was doing was an absolute scientific travesty. It wasnt unique to him. He was praised when he went to london in 1927 as psychiatrys lister who had introduced antiseptic surgery. And that by the most prominent figures in british medicine. Walter freeman was sincere. He was a moral monster and my eyes. He lobotomized kids as young as four. And boasted their brains could tolerate more damage. And when i took part in the pbs documentary, i think you can still see it online which is about his career, it is too sympathetic in my view to freeman but nonetheless two of his children took part but so did one of his last lobotomy patients, named howard who was lobotomized at 11 after his parents marriage broke up and his new stepmother decided he was acting out too much and needed to have his brain operated on. Theres a lot of sincerity. Sincerity does not cut it in my book. Yes, very often the asylum experiment, it was small, intimate institutions. And the early years, they did. They had charismatic heads. But to do it with the hordes of patients who flooded into state hospitals, that just was not possible. I dont inc. We are that far apart i dont think were that far apart. It is weird to note two of the nobel prizes given out in psychiatry were given out to really horrific treatments. The nobel prize for injecting mentally ill patients would likely general creases of the insane with malaria. Malaria was used as a treatment for tertiary syphilis. And then the great portuguese neurosurgeon got the nobel prize for the invention of the prefrontal lobotomy. Close i should add that was 14 years after the first lobotomy. So one might have thought there been time to accumulate enough contrary evidence. But no. There really wasnt. Into the 1950s, the operation continued in some instances even into the 60s. There were a couple of enthusiasts in england and yale as well. The other thing to bear in mind is these were not necessarily patients visited on the poorest. We often think, oh, well, the extremity would have taken place the experimentation would have taken place on the most vulnerable. But in fact, perhaps the most famous case of botched lobotomy they were all botched as far as im concerned but one of the worst outcomes was rosemary kennedy, jack kennedy sister, whose father had her lobotomized in the early 1940s. She could barely walk. She was incontinent. She had to be trained to speak again. She was locked away in the Kennedy Family kept her out of sight and out of mind. I dont think ever visited. Again, the earliest lobotomy patients were all outpatients. They were people with money. They came because they heard about this miracle cure. They volunteered for it. The institute of living in hartford, connecticut what was and probably is a rather prominent private psychiatric facility. It was the first Mental Hospital to build a special surgical suite to perform lobotomys. The maclean, which is probably still the most expensive Psychiatric Hospital in the country, also lobotomized a substantial number of his patients, particularly women. The narrative is very complicated. I think Mental Illness brings with it a great deal of honor ability, enormous amount of vulnerability, enormous amount of suffering. It is, as one of my fellow strains, often a very solitary nightmarish place to be. Then for everyone around them, just profoundly disruptive and disturbing and threatening. I would like to highlight the word desperate in the title of your book. This is an eight amash to dr. Ebright band who i had the Great Fortune of having here today. He is emeritus psychiatrist here in san diego who has trained hundreds and hundreds of psychiatrists over his career. What is so important to learn and psychiatric training is the experience of desperation that you have. You have patients that are suffering in the most horrible ways. Some of them are violent. When we have one violent patient in our unit, that is very disruptive. I think about asylums with hundreds of violent, disruptive patients with no thorazine. What could you do . It is very scary to go to work being afraid you might be assaulted. That is very real. That is not an excuse in anyway for putting an ice fit in somebodys brain but unfortunately, it helps me understand how people got to such a desperate place. And what the doctor has told me is when you feel that desperation, then a part of your brain should be turning off and saying, oh, i know what happens next. So whatever i think im going to do next, im going to observe and maybe get a Second Opinion and spend some time thinking about before i run off and try and save the world. I think that is very right. It is precisely the desperation which is the desperation felt by the patient. Felt by the family, the therapist. Do something. That sometimes doing something is worse than not doing anything at all. And that is a history we see again and again. It is the desperation that makes it possible for people to conceive a bright idea that takes you down a rabbit hole and persuades families and patients to accompany them down the rabbit hole. Yes, the title is meant to have multiple meetings meanings. It is just such it is hard to avoid despair when i was writing the book. So depressing. Your conclusion youre like, yes, the drugs are better than not having the drugs but the drugs for some people are positively they create and those that is as bad or worse than the disease they are treating. As i look at modern psychopharmacology, i see patients falling into three groups. Part of the problem for psychiatrists is we dont know in advance when a patient resents i should not say we. They dont know. I dont like to pretend the expertise absolutely dont have. But they dont know which groups somebody is going to fall into. For some of the patients, antidepressants and antipsychotics to radical difference in a positive direction. They transform someone who is raving, hallucinating. They that down, possible contact with what the rest of us like to call reality. And theres a group of patients in the middle. With all medical treatments, there is no free lunch. There are always side effects. Things we dont want that come with the things we do. With psychiatric medications, though side effects often are very severe, sometimes lifelong once you have contracted them. With the middle group of patients, they are expressing the side effects more than the first group us oak of, trying to weigh the benefit the drug perhaps produces against the problems it creates. Then you have another group of patients who just dont respond. If they get anything, they get the side effects. That is not what it is supposed to be about. Any damages of this problem really. And the die mentions of this problem are really very great. A lot of the Research Done on drugs is been funded by the Drug Companies. Unfortunate, deeply contaminated by that. It looks like evidencebased medicine. It is biased because they suppress the data they dont like and they cook the books. In 2005, there was a very large study called katie which appeared in the new england journal of medicine led by Jeffrey Lieberman was recently forced to step down after he made some rather unfortunate public remarks. But what that study showed, it looked at any original antipsychotic. One is the first generation along with one from the 1950s. And three socalled atypical modern drugs. Is it is the old drug inferior to the current drug and how well do these work . The answers on both fronts were not very reassuring. The new drugs did not perform better than the old drugs. They cost a lot more money because they were patented. They were not better. That different side effect profile but it was equally as serious. The other thing i found striking reading that study, depending on which drug there were four in the trial between 67 and 82 of the patients dropped out either because the drug was not working or they could not stand the side effects. So we dont have psychiatric penicillin. We have pills that help some people. If, god for bid, i had a relative who needed psychiatric care, i would not stand in the way of a trial a careful trial of drug treatment but i would be very aware the odds were mixed about whether it was going to work in that particular case. I would be delighted if it did, but not surprised if it didnt. What do you think, david . I am big pro forma. I dont know if it is unexpected given this discussion, but i would be so sad to think of a career in psychiatry without the benefits of modern chemistry that the pharmaceutical companies have provided. Lord knows they have been naughty at times in their marketing styles, brushing things under the rug. Its true. Big pharma has really provided the possibility of relief for so many patients. I am so thankful for that. On the other hand, and i agree with that i mean, i do not dissent. It is very important to understand that we have had some progress and that progress in many ways have been tied to the drugs ability to reach a substantial number of people suffering, but by no means all. But the others had thing is, as you know, big pharma has pulled out. They are no longer looking for new treatments, improved drugs. Partly the reputation over the naughtiness david was talking about that i discovered in the book, but more than that, they could not see a way to make a profit. There was no obvious new avenue to explore. There are some flybynight operations done using ketamine and psychedelic treatments. There are some people advocating for deep brain stimulation as a solution to depression as though we know where depression resides in the brain. We dont. So there are those things but the companies that for 60 years . There were heavily involved in the process of doing research on possible pharmacological treatments have gone away. They have disbanded their departments. They have stopped. They found other areas of medicine are more profitable. Research follows profit in our system. It is not an ultra stick phenomenon altruistic phenomenon. A might be if there was public funding, but there is not enough of that around. That is another facet of our contemporary situation that unless you are somebody who just like the scientologist dismisses psychiatric medications as poisons that have no therapeutic value, you cannot see that as a positive development for all the bad things the Drug Companies did along the way. Should we take questions . I would love to if there are some questions. You talked about the issue of the homelessness and mentally ill. Indeed when you read the current voter pamphlet, think Anyone Running from the board of equalization to governor to anything you can think of, director of finance, they all make reference and i wish to solve the problems of the homeless. Can you share your thoughts about what possibly might be effective . Well, i dont think anybody has a good solution to that particular problem. Simply throwing money at it isnt going to resolve it. San francisco spends on average i think 35,000 per head a year. Anybody who spends time in that city as i do realizes they aint getting much value for their money. It is a mess. One of the issues, and it is when we sort of skirted around, back in the days of the old Mental Hospital, most people got into the Mental Hospital forcibly, so to speak. If necessary, the cops showed up and took them. So there was compulsion and they could not leave. Even if they wanted to. These days that whole situation is very tricky and it is one of those political minefields currently there are some new ideas about this which potentially involve some degree of compulsion and civil libertarians are up in arms about that. And i get that having seen what it was like when people were shut up, as i said, in both senses of the term. It is very dangerous situation. On the other hand, many of those people are very resistant and getting treatment. The texture of life in our cities is being undermined by their presence. So i think politicians are responding to the fact when i wrote my first book about it, is that these people were largely being returned to the poorest, most deprived areas of the city. That is where the social services such as they were were and those people had no political voice. They had no political clout. They could not protest. But what has happened as the numbers have multiplied is they are everywhere. We used to be able we used to be able to shut our eyes to what was going on unless you are in the biz. And now it is inescapable and it is provoking a backlash even in cities that think of themselves as progressive like San Francisco. I think San Francisco dont get me started. That city is in a really strange place. I dont know, do you have anything to add, david . My perspective is that psychiatrists are not the people to solve the housing problem. I think economists would be a much better place to start. And so Many Mental Health practitioners who weigh in on this question have absolutely no training in economics, which to me seems bordering on fraudulent. And i think Milton Friedman had a lot to say on the issues of supply demand. And if you dont have enough supply, how do you trust it. It may maybe a way to start would be to look at those questions. I agree substantially there. I think new b is him in california and the overload of regulation which is really stymied supply of housing level that is needed contributed. By no means all the people you see in the street are people who are mentally ill8 drug addicted or alcoholic. Many of them are people who literally can no longer afford a roof over their heads. Anybody who has watched what happens to california housing crisis, it is no surprise you wonder how anybody with an ordinary job manages to put a roof over their heads my feed and clothe themselves and their kids, and have any margin beyond that. It just gets worse and worse. And it is, it is a supply demand problem. If you have millions of people and you dont build enough houses, you are going to face exactly that problem. Not always what is going on in england, for example, in london, the housing is big brought up by corrupt money. It is russian, chinese, arab, dirty money from all of the world. And many of those houses sit empty. They are a parking place for illgotten gains. I think in new york theres a bit of that phenomenon. Here, not so much. Here we really have created a problem for ourselves. And it is also peoples expectations. Houses just get bigger and bigger, they get more more complicated and expensive. And what that loses sight of is for ordinary people, that is not something they could ever afford or even they need a decent place to live and we dont have i agree with you, that is not a psychiatric problem. Not at all. In fact, the institutionalization problem is created problem that some ways is psychiatric and psychiatry tries to cope with, but it is the product of much larger social movements and social forces. And so to look to psychiatry to solve those problems seems to me a category mistake. Great way to put it, category mistake. You made reference to psychedelic [indiscernible] is this our new desperate remedy . It is a little early to tell but it has some of the signs of it. Yes, it does. I was reading a couple of papers this afternoon just before i came down about the emergence of a number of huge startups, billiondollar companies, who are investing in this thing. Once that genie is out of the bottle, it is going to be very hard to put back. I look at things like there has been this revival of interest in lsd, magic mushrooms, blah blah blah. Same thing with ketamine. Ketamine, yeah, changes mood. We know that. For years it was a pretty drug, it was special k. It also produces hallucinations, can produce damage to the bladder. It has a lot of potential once it is given some sort of license, there will be Unscrupulous Companies and people who will set up shop. And i have been hearing about this infusion, people who are given infusions for other medical things saying, heres a great source of new revenue. Unregulated yes, i do think both of those things have the potential to be a new desperate remedy. People used to always say to me when i talk about henry kotten, it couldnt happen now. Well, it would not happen exactly that way, but it could happen. You could have some damaging remedy take hold and then be out of control and hard to stop. And you see figures like michael pullen, for example, who has become a cult figure because of his very interesting writings on the food chain, now touting this it sounds like Timothy Leary reborn. And it is very dangerous. I do worry about exactly those developments very much so. Do you have any idea compares to canada or europe with regard to the treatment of the mentally ill . And so forth . Especially with socialized medicine, are they worse off than us . Better than us . I am most familiar with the english situation. I know little bit about things in europe and i was just there. Homelessness was somewhat less visible in london in the last time i visited and i was a little surprise. Out of the blue, a british psychiatrist i know whos is a member of the house of lords, elaine murphy, wrote to me and said, you know, one of the artifacts of the covid epidemic was the government swept those people off the streets because they saw them as reservoirs of infection for covid. So they move them to Sheltered Housing in a hurry. But says now they are leaking back out. So on the whole, i argue that one of the things that really drove deinstitutionalization were states were able to move patients off the state budget and under the federal budget. Medicare prompted a flood of people, old people being moved out of the asylum and into Nursing Homes and boarding care homes. When ssi came in, which provided some support regardless of your work history, then the young people started to be moved out at the hospital. So it was possible here to move it is a shell game. Then as the feds cap back on some forms of welfare, that was not replaced and so the situation in some ways got worse. Britain, like most of europe, has a more developed welfare state than we ever did. But nonetheless, i will tell you talking with wellinformed and wellintentioned british psychiatrists whom i trust, psychiatry has i was got the short end of the stick. And even when the Health Service was funded rather better under tony blair, for a few of those new resources trickled into psychiatry. It was always the stepchild. As david was saying earlier, this is not a politically powerful constituency. There is nobody arguing for them. If we are seeing arguments now about homelessness, it is not because we have sympathy for the people in the street. It is because they are affecting our quality of life and we dont like it. That is the honest truth. So a little bit better because there is more developed set of social services, but in the last dozen years under first the coalition and the conservative government and now with brexit, things Public Services have been slashed in britain and theyre probably going to be slashed more because their economy is going down the toilet. It is hard to find things when you fund things. I think politically you have to understand if the productive part of the economy is not thriving, you cannot afford to do all these nice things you think you would like to do. As we move toward potential recession, it is a very worrisome time because i have seen ed, Mental Health budgets seen it. Mental Health Budgets are prime candidates to be cut. Texas cut its Mental Health budget for other prattling and at the last dreadful week, and they redirected it to the show game of were going to control the border because the feds are not doing it. And then there is a shooting and instead of saying that we have a problem with guns, it is blamed on Mental Illness. The problem is not that we have too many crazy people, it is that we have, in my view, absolutely crazy gun laws. And that i dont see any fix for. When you have 400 million guns out there, it is hard. But maybe you dont allow 18yearolds on their birthday to buy two high powered rifles, a munition, and body armor. Maybe have some sensible restriction that we dont do that rather than thoughts and prayers after the slaughter of the innocents. Sorry to be on a soapbox. That one really angers me. Mental illness being blamed what that does as well is exacerbates something i talked about earlier this evening, namely the stigma that attaches mentally people. Mental illness sometimes produces violence but i know is is it the case that everyone who is mentally ill turns violent. To the extent we encourage that equation, we make that population fearsome and not something we want to look away. Rather than deal humanely with. Any more questions . I have a question. This is a favorite topic of mine involving psychiatric history and the editor of the dsmiv has bemoaned the allowing the explosion of psychiatric diagnoses in dsmiv and expanding the dsmv. He fought a losing battle trying to prevent the dsmv from growing even bigger. Where do you stand on that . I think that all through the 200 years i have looked at the problem of what someone has called diagnostic can be seen. It happened in the asylum era, a lot of people got scooped up and probably could have been cope with in other ways, cope with, in other ways coped with in other ways. The dsm is the diagnostic and statistical manual. You have to have it to get insurance reimbursement and be diagnosed as mentally ill. Alan francis was the editor in chief of the fourth edition, he said he created an nightmare in respect to autism which exploded in numbers. That was a controversial thing to say. For parents with an difficult child with a difficult child, access to that diagnosis was actually something that they so ught because our educational advantage and things they have were not have gotten. When it was leaked that the tax force was considering changing the boundaries there was fears of backlash, it is easy to think this is all a the product of an realistic profession imperialistic profession. It is also public demand. Ill be thinking about the issue of, which has become a huge thing. A huge industry. Taking no stance on where Mental Illness came from, with ptsd, ptsd had a very clear ideology and it was not brain disease, it was a product of traumatic experience. That first emerged among Vietnam Veterans against the war. They allied themselves with two harvard psychiatrists who were sympathetic to them and they browbeat spitzer. Eventually they succeeded to a point. They wanted to call it postvietnam syndrome. He was not having any of that. It became posttraumatic stress disorder. Over time, it expanded in ways that makes sense to me intellectually. For example, women who have been victimized by rape and sexual assault. Very profound change in their identity and lives. People who after texas, right . Pretty soon, it was my College Student is upset by what he is being asked to read in class, we need trigger warnings. We are going to suffer from posttraumatic stress disorder. That sort creep is very dangerous. That sort of diagnostic crete eep is dangerous. What do you say . Ditto. Thank you all for being such a patient audience, i hope we have imparted something. I would like to thank david who i have known for a lot of years now. Thanks to steve and david. When i have had a student with either a Serious Problems of self or with family issues, that i needed that needed somebody, he is who i refer people to. I wish i knew more clinicians like david. Thank you both very much. This has been a very enlightening evening. The next time you write a book, i invite you back. Thank you all for coming. [applause] programs anytime