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 phe