quarantines beach. and so, it was really sort of a historian's motive i guess where i started to say i'm not sure that we totally understand the story because we haven't been looking at the right sources. then of course once i got into it i was like look at the parallels. there could be real lessons for it today. [applause]

squatting in a diner for internetwork is even harder that's why we are providing lower income students access to affordable internet, so homework can just be homework. connect to compete. >> along with of these television companies supporting c-span2 as a public service. >> good evening everyone, and welcome. thank you all very much for coming. on behalf, i want to thank you for your support. just an aside last year we

celebrated 125 years as the oldest continuously family-owned bookstore in the united states, so thank you very much. hopefully next year we will have our 126th year. this evening, warwick's is pleased to welcome andrew, who will discuss his newest book desperate remedies, psychiatry's turbulent quest to cure mental illness and he will be in conversation with doctor david lewman. andrew received his ba from oxford university and his phd from princeton university and is currently the distinguished professor of sociology emeritus at the university of california san diego. in 2015, he received the roy porter medal for contribution to

the history of medicine. in 2016, the award for lifetime contributions to the history of psychiatry. his previous books include madness and civilization, hysteria, the disturbing history and madhouse, a tragic tale of megalomania and modern medicine. he's contributed to many documentaries including the pbs series mysteries of mental illness and also the lobotomized. he blogs for psychiatry today and matt in america and he's written for the atlantic, scientific american, paris review, "the wall street journal" and the nation among many others.

doctor david lehman received his medical degree from washington university st. louis medical school and completed his psychiatry residency at the university of california san diego. he was currently chief of cognitive disorders clinic at the va medical center in san diego as well as the medical director of the inpatient unit. doctor lehman is also heavily involved in education at the university of california san diego medical school and the residency training program and he is the recipient of teaching awards in both departments. in addition, he is the associate director for the third year medical student psychiatry clerkship and the coordinator of the fourth-year medical student psychiatry internships. so, please let's give a very

warm welcome to andrew with david lehman. [applause] >> thank you very much for that introduction. it's a pleasure to be here. i hadn't realized that warwick's is quite that ancient. that's quite a remarkable accomplishment and i am so pleased that we have a bookstore with this quality in our iecommunity. there are a few places these days lehman sad to say. so, i am very pleased to be with you tonight. the book that i've just completed i first envisioned if you can believe in the 1980s. it would have been a very different book had i published it back then. i spend my early part of my career looking at the rise, the emergence of psychiatry and the rise of the asylum in victorian

england. before i published that book because i was tired of it as my doctoral thesis, when i went around to interview, people asked what about the shutting down of the asylums don't you think that is a good thing and why is that happening. i thought i don't know, but i thought that it is a big surprise. i knew how much money and intellectual capital there had been invested in the idea that the mental hospital was the solution to mental illness. so anyway, i thought that would be an interesting topic and one continual to my colleagues that regarded people in victorian england is a bit strange. so i wrote a book on the institutionalization very early in the mid-70s when it was still being hailed as a grand reform. and my book suggested that

perhaps all is not quite as it seems. in many ways i like to think that it was a prissy end book. it was a book that anticipated what we live with today. of the abandonment really of people with serious mental illness and the problems that has resulted in. so, later on i moved into the 18th century then i did some books that expand across regions of history and i started to work on the 20th century. the period that i was originally working on was the 1920s and 30s which was a period of extraordinary extermination of psychiatry. mental patients were in a sense locked away and their voices were stifled and many in any event anything they had to say was seen as a product of the mental illness. so, that meant given the

desperation of the times that they were very vulnerable and the upshot was a series of interventions, some of which i discuss in this book. some at the beginning desperate remedies as a title that occurred in about 1981 when i was at the institute in london. but as time went on, i wrote many other books and i went back and forth. i always had this project which wasan a true exercise in the bak of my head. finally i said to myself i had to write these things but i wanted to put american psychiatry at a very long historical context. wheren did it come from, how did it come to be, how did he evolve in the 19th century as the initial utopian hopes that we could cure mental illness begin to subside into a climate of

hopelessness, a period towards the end of the 19th century where psychiatrists into the culture at large dismissed mentally ill people as degenerates, as people that have suffered evolution in the rivers were no longer fully human and needed to be locked away lest they breed and produce more of their kind. and that was the state at the end of the 19th century very heavily biological account but one that had the sense of hopelessness. california was the leader in the united states if we started in voluntarily sterilizing the mentally ill. in california they didn't stop doing that until about 1960, so it's a very long history. and that legislation was the model for the nazis in germany

and they produced a compulsory sterilization lacking the restraints of our political system. they exterminated on that and then they decided that these people were as they called them useless eaters and so they killed them. the final solution was first started on mental patients. it was there that the technology of the gas chamber was developed about a quarter million patients were killed with the active participation of leaving german psychiatrists and that was one possible response. but in other respects, psychiatrists who were not satisfied with just being boarding housekeepers running in asylum and keeping the population under wraps, they wanted to be healers and so they looked for various ways to

intervene and unfortunately, that produced some pretty terrible results and i think at this point i will shut up for a few minutes and let david, who i know, to talk about those metal chapters where i talk about that experimentation as i call it. 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 i think very positive affect on my psychiatric career.

i would think it is sad and horribly ms if a resident were to graduate from a psychiatry program andfr really not be familiar with these warnings that you do so well in such devastating and horrifying manner reporting on the history of psychiatry. >> one of the things that is important to understand as there was a strain in my discipline and among some renegade psychiatrists like thomas in the 1960s to dismiss that mental illness and claim thatll it wasa myth or that it was all a matter of social labels and that's never been my point of view. i understand how deeply distressing and disturbing and disruptive mental illness is in people's lives. i've seen it close up with friends one of whom committed

suicide after postpartum depression. so, i am not in any sense anti-psychiatry but i am very much somebody who thinks we need to face up straightforwardly to the truth of what we can and can't do, what we understand, but we don't understand. the limitations of our knowledge, the kind of things that in the present we really ought to be doing and not. and so, while the book is heavily critical in many ways of psychiatry, it's not meant to be, and i'm glad to say, the critics 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's gone wrong and ways in it has made progress in the last 50 or 70 years. that the limits of that in the moment and the ways in which i

think the national institute of mental health has been captured by the mental illness. as we concentrate on genetics. the upshot of that for patients that are sick has been basically nothing. you think that is me speaking as an outsider. running from 22 when he stepped down said you know over the last period i spent a lot of money about $20 billion and he said we've funded some really cool science and genetics. the payoff for patients has been zero and he was being too kind. if you look at people with

serious mental illness, some of you 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. it's not purely psychiatry is the result of public policy. but it's a sobering reminder that we have a very long way to go. designed as an abstraction of the brain and the brain is by far the most complex organ in the body. the question psychiatry asks than other branches of medicine

what is consciousness is the most difficult question science is a proposed so i don't think it should be a surprise that psychiatry has not come up witho many answers very quickly. the decade of the brain when we made all kinds of promises that haven't yet been delivered but what i would say is i see no reasonno why science given the time cannot address these difficult questions in psychiatry the same way that it's addressed in other branches of medicine. it's not going to happen in the next decade. but i don't see why it cannot happen.

>> i guess but i would add is that it seems to me that the distinction is often made between the biological and social. the economy. our brainsns are very much the joint product of the brain we are born with and the brain that develops over those years and the patents that develop within our very much a product of the culturally end of the social environment in which that brain matures and that person matures. one of the problems i have, i am not trying to say there shouldn't be neuroscientific research and there shouldn't be research into genetics although so far that has proven to be something of a dead end. what i would like to see his research as well that deals with the other dimensions of 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 to provide suitable housing and social support for people with serious mental illness. i think it seemed biological psychiatry was the way to go and you mentioned in your locale the rockefellers institute struggled with this question what should they fund given all this money 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 the bet on the exciting stuff rather than the less fun

and exciting questions of how you house people and address loneliness and minimize the suffering associated with the human condition. >> i would agree what many people may not realize and this is why it is important i think to have the historical perspective is before the second r,world war there was essentialy no federal involvement in mental illness rather than running one hospital in dc. there was no federal funding of research but alone psychiatric and the major actor in that was in fact the rockefeller foundation, which made the rather brave and unorthodox decision in the early 1930s that it was going to fund psychiatry is the least developed part of medicine and the one where it thought it could make the most difference. it did to spread quite widely.

some of the directions in which it is spend money and others in the light of later developments seemed rather problematic. rockefeller funded the german nazi psychiatrist sand continued to do so up until the outbreak of world war ii. it was heavily involved. on i the other hand, rockefeller also provided funds to try to rescue many psychoanalysts and bring them to america and that proved to be a very difficult exercise but it about doubled the number of psychoanalysts and was one of the preconditions for something that happened in america afterer the war which he no counterpart anywhere else that i am aware of other than buenos aires andos that was the emergence and predominance for the period of about a quarter

century of the psychoanalysis in american psychiatry. understand that in 1950 there were half a million people in america in mental hospitals and that continued to grow for another four or five years. of those psychiatrists obviously couldn't practice the psychoanalysis and indeed, it was in that environment thatat e drugs revolution and emerged sort of behind the backs of the psychoanalysts. if you look at the academic psychiatry, if you look to the high status growth of psychiatry on an outpatient basis, that was heavily psychoanalytic and not just a matter of the profession. the whole of the american culture especially high culture but also popular culture was subrogated with these ideas. it was the equivalent of

copernicus. it sort of raises a smile these days but intellectuals of all instances particularly flock to the idea. looking at the movie spellbound one of alfred hitchcock's movies and i think 1948 and you will see its propaganda for psychiatry begins so there is that interregnum where people sought meaning in madness, tried to understand it on a psychological level. freud himself hadn't thought it was i can't stress it other than washington

st. louis. [laughter] every other department was headed up by somebody that was either a psychoanalyst or sympathetic to psychoanalysts and the best recruit went that way that's where the rewards were and the best patients were. the thing that marked the real revolution in psychiatry emerged not there or in the universities but in the mental hospitals, which is where the drugs and the antipsychotics in particular that of the copycat drugs first emerged. what happened for many years is like a building that is being mauled away by termites.

the structure looks solid and the psychoanalysts thought we are in the saddle and then with remarkable rapidity is shifted. it was fueled by problems that had emerged about a psychiatric diagnosis and the fact they couldn't agree in a different case what was wrong. there was a sustained asset to create a diagnostic system that at least was reliable which meant you've got to here and hear andhear looked at there sat that would produce the same diagnosis and it was an approach that was theoretical by its nature butin in fact underneath that it was fueled by hostility to the psychoanalysis and helped tos serve as the death knell fr the branch of the profession, and i think that is a complicated question.

psychiatrists of the generation who w trained in the 60s will have all encountered psychoanalytic radios. nowadays i don't know. david can speak to that. >> if i have anything to do about it, they do. but i have lots to criticize about the psychoanalytic psychiatry. but it's important to recognize that whatever the flaws in their doctrine and their ideas, whatever the flaws in the rigidity that is produced in so many that you bring out that in many ways they sow the seeds of their own demise through their rigidity. but they were and are the humanists in this story and rather than sort of free

correcting or redirecting some of the rigidity they ended up throwing out wholesale replacement of the psychodynamic cycle psychiatry with biological psychiatry. and as carl would have pointed out, decades previously that would be a dead-end. so far, biological psychiatry is only a part of the answer and that needs to be recognized and is and always. >> that is something i would concur with. i have my own quarrels with the rigidity but it did entail listening to patients and giving the patient is a voice. that was important and that is lost now. it's interesting there was a study done in the 60s what the patents of the psychiatric practices were like at that point and outside of the

institution, the average length of time somebody spent when they went to consult a psychiatrist was between 45 minutes and an hour, almost the typical psychoanalytic. so that meant there was a lot of exploration, whereas now partly because of managed to carry out the pressures of the insurance companies and partly the need to psychiatry is the best paid of medicall specialties it's sort f become a pill mill. you see the psychiatrist for ten minutes and that's very time. now it may be different in your aclinics, but a lot of research has suggested that. there's a decline on the professions part of delivering

psychotherapy as well as the pharmacology they've come to terms with and one of the stories in the book is the emergence i of other professions in the psychological realm so very many particularly patients with other kinds of disorders end up with clinical psychologists getting some of the psychotherapy they don't get when they go see their medical doctor. >> this is an unpleasant topic. >> 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. in my mindep i separate the mistakes made for theoretical

scientific or audiological reasons from just s the sheer market forces that every industry is going toha respond , producing either favorable or unfavorable results because of those in incentives. >> one of the things that happened when they emptied out there had been mental illness unlike physical illness in this country being a state responsibility, being something that was funded publicly. there was a very strong public psychiatric wing to the t profession. it was obliterated and it wasn't the profession didn't detest. some did but not enough people.

what was going on was not the product of the psychiatrist deciding this was the way forward. it really was those other forces that you were talking about, conscious public policy choices, pressures from the insurancere industries. see availability of the technology in the form of the drugs that looks like conventional medicine and could be dispensed withd pretty quicky and the insurance companies were not willing to pay decently for the other kind of care and still aren't. >> unfortunately that is the place that we find ourselves in right now. i think that one has to recognize if you are going to promote improved treatment for the severely mentally ill, you're going to have to recognize it's phenomenally

expensive.ll i think your book comments that when they were open it was the single biggest line item on the budgets of most states. that is jaw-dropping and that was bad care. that was snake pit care so you can imagine the cost that would begin evolved for providing beautiful state-of-the-art care for the severely and mentally ill. and it brings up a very difficult question that most people don't want to look in the face which is shown to people sh severe mental illness or who are marginalized and do not to vote get the majority of the resources that are otherwise going to people with mental illness but not asylum level mental illness.

in the last 200 years or so it extends to all of the recorded history that i am aware of. mental illness is something that constantly is associated with stigma and fear and rejection. so this is a population as david said they don't devote us with the politicians aren't going to be responsive to them but much ofob the problems are kind of hidden away. i think one of the things i saw in the years at the institutionalization a wad of the burden originally fell onti families when they were still intact and particularly on women whowo were often pulled out of e workforce to care full-time for

ntthe patient eventually familis crumble under the strain very often. it's just too much. those families were very reluctant to make a lot of noise. the reason for that is obvious. they didn't want people to know that in their domestic list there was something else happening. it's amazing how when you become aware of this problem sometimes people will open up and you realize what they've been going through. when that breaks down and infect a so-called welfare reform has listened to the situation for many, it is harder for them to give social support. states have not replaced the money that they use to for the most part spend. new york state in 1950 it was

30% of s the state budget. an extraordinary number. so, what we see as a result we see the worst of it living here in california there you are in downtown san francisco, la, san diego. the problem of homelessness blwhich is not only a problem wh mentalnt illness, but a subset, important subset is infect people with serious psychiatric problems who just cycle from the gutter to the flophouse to the jail with an occasional stop off in an office to get a prescription and back into the cycle all over again. but that is what we face. >> i would suspect you and i differ politically on 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 well manning people that did hugely unscrupulous things, jaw-dropping in the name of the ends justify the means. they weree so enamored with thr ideas that they lost the boundaries of western civilizations. i think of the deinstitutionalization as an example of that. i do worry quite a bit that the

idea if we just sit down and come up with yet another program to help the severely end the 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 a regular basis and i know that the solution is going to be much more b difficult and subtle and challenging than convincing the state of california to spend more money. >> i don't disagree at all. one of the messages in the book is that psychiatry ought to take to heart first do no harm, jumping into enthusiasm refusing to see the evidence that is contrary to one's enthusiasm and thinking you have a magic wand that will solve the problem that

has repeatedly happened over the last 200 years into the resultss were almost being uniformly disastrous. indeed, someso of these people perhaps many of them were absolutely sincere in their beliefs that they had discovered the road to intervening. one of the figures inn this bok is a gentle man named henry that ran the new jersey state asylum from about 1908 until he died suddenly in 1933. he decided it was an idea that he may well have picked up arguably fromrg the major figure of times that mental illness was the result of infections that were poisoning the brain and in

that era the only solution to that was to surgically eliminate them so you started in the first targets were a lot of people had rotten teeth. tonsils were another thing. so tonsillectomy's. but when people don't get better instead of thinking perhaps i'm on the wrong track here, you start saying there have to be other areas of infection in the body and called and starts eliminating spleens and uterus is and another patent that occurs again and again, women disproportionately are targeted forte some reason. but trust me 65, 75% of the patients were females who were operated on. when i say cotton was sincere, he decided any were a potential

menace. he believed what he was doing but what he was doing was an absolute scientific travesty and it wasn't unique to him. he was praised when he went to london in 27 as psychiatry's lister, that by the most prominent figures in british medicine so they were sincere. walter freeman was a sincere.

he lobotomized kids as young as four. when i took place in the documentary i think you can still see it online. it's too sympathetic in my view. so did one of his last patients who was lobotomized at 11 after his parents marriage broke up and they decided he was acting out and needed to have his brain operated on. a lot of sincerity doesn't cut it in my book and yes very often the asylum experiment when it was launched it was in the institutions all i do think in the early years they did a lot

of good and had charismatic dedicated staff but to try to do that on a routine basis i don't think that we are that far apart. >> it's weird to note that the two of the nobel prizes given out in psychiatry were given out to horrific treatment. the nobel prize for injecting mentally ill patients with likely general praises of the insane with malaria that was used as a treatment. then of course the great portuguese neurosurgeon and the prize for the prefrontal

lobotomy. i should add that was 14 years after so one might have thought the time to accumulate by then but there really wasn't. and into the 50s the operation continued in some instances even into the 60s there were a couple in england and at yale as well. the other thing to bear in mind is these were not necessarily patients visited on the poorest. we think the experimentation would have taken place on the most vulnerable, but in fact perhaps the most famous case of a botched lobotomy, of course they were all botched as far as

i'm concerned about one of the worst was jack kennedy's sister whose father had her lobotomized by free men and walks in the 1940s and she could barely walk. sheha had to be trained to speak again and the kennedy family kept her out of sight and out of mind. i don't think they ever visited. so and again the earliest patients were all outpatients. they came because they heard about this miracle cure they volunteered f for it. the institute of living in hartford connecticut as one was and probably still is rather prominent psychiatric facilities. it was the first mental hospital to build a special surgical suite to perform.

and also lobotomized a substantial number of the patients particularly. the narrative is very t complicated. it brings with it a great deal of vulnerability and enormous amount of suffering. it is as a psychiatrist once put it the reflections in the most social often very solitary nightmare place to be and for everyone around it is profoundly disruptive and disturbing and threatening. i would like to highlight the word desperate in the title of your book and this is an oma's. i have the good fortune of having today and emeritus

psychiatrist here at the san diego whose trained hundreds and hundreds of psychiatrists over his career. what is so important to learn and psychiatric training is the experience of desperation. you have patients that are suffering in the most horrible ways. some of them are violent. when we have one violent patient in the psychiatric unit that's very disruptive. i think about asylums with hundreds of violent disruptive patients. it's very scary to go to work being afraid you might to be assaulted. that's very real. that's not an excuse in any way for putting an ice pick in somebody's brain.

but unfortunately, it helps me understand how people got to suches a desperate place. what he taught me is when you feel that desperation a part of your brain should be turning on and saying i know what happens next so whatever i think i'm going to do next, i'm going to observe and maybe get a second opinion and spend some time thinking about before i run off and try to save the world. >> i think that's right. it's precisely the desperation felt by the patient, by the family, by the therapist to do something. sometimes doing something is worse than not doing anything at all. that is the history we see again and again the desperation that makes it possible for people to

conceive a bright idea that takes them down a rabbit hole and persuades families and patients. so it is to have multiple meanings, not just it's hard to avoid the despair when i was writing the book. my editor kept saying to me can't use a more positive things? things? this is so depressing. your conclusion, yes they are better than not having the drugs but the drugs for some people are positively. it's bad or worse than treating. when i look at the pharmacology i see patients falling into

three groups and part of the problem for psychiatrists suggesting ithi is that we don't know in advance, i shouldn't say we, they don't know. i don't like to pretend the' expertise. but they don't know what group somebody is going to fall into. >> . >> you are trying because they

are experiencing these more than the first group i spoke to. one way the benefit produces against the problem that creates. then you have another group of patients who just don't respond. with the side effects that's not quite what we are supposed to be about. and in 2005 and unfortunately it was deeply contaminated and it looks like evidence-based medicine that they could suppress the data and they cook the books but in 2005

there was a large study that appeared in the new england journal of medicine after he made unfortunate public remarks but what that study showed that looked at the original antipsychotic and said is it inferior to the currentt drug and how does this work? and the answers on both fronts or not very reassuring they cost a c lot more many and what i found striking readingnd that study between 6782 percent of

the patients dropped out in because the drug wasn't working or they could not stand the side effect. we don't havell psychiatric penicillin and if god for bid i had relatives who needed psychiatric care come i would not stand in the way they trial of drug treatment but i would be very aware that the odds were mixed if it would work and i would be delighted if it did not surprise dividend. what do you think quick. >> i am pro- big pharma i don't 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 not yet times in their marketing style. and brushing things under the rug. it is true. but big pharma has and i am so thankful fort. that. >> on the other hand is very important to understand that we have had some progress and in many ways that was tied to the drug's ability to reach a substantial number of people suffering they are no longer

looking for new treatments or improve drugs. partly their reputation combating that naughtiness they cannot see a way to make a profit and there was no obvious new avenue to explore with some flyso by night operations using ketamine and psychedelic treatments and there are some people for deep brain stimulation we know where it resides in the brain and we don't and those for six years were heavily involved in doing research have gone away.

they disbanded and found other areas of medicine where those have no therapeutic filer - - value. you can't see that for the job companies develop the way.

>> we both talked about the homeless and if you read the current voter pamphlet from that equalization to governor to anything you can think of of director of finance and with the troubles of the homeless can you share your thoughts p on what possibly might be effective? >> i don't think anybody has a good solution to that particular problem andne simply throwingt money at it will not resolve it. san francisco spends on$3 averagee $35000 per head period year in the band who spends time in that city is ideal

realizes they're not getting much value for their many. it is a mess. one of the issues that we have skirted around back in the days of the old mental hospital, most people got into mental hospital forcibly. they were certified as insane and if necessary the cops showed up. there was compulsion and they could not leave even if they wanted to. these days that whole situation is very tricky and it's one of the political minefields too have some ideas about this which potentially ofolved to some degree compulsion and the civil libertarians are up inn arms about that. and i get that having seen what it was like at the time

it is a very dangerous situation many are resistant to getting treatment and that texture of life in the city is undermined by their presence so i think politicians are responding to the fact the institutionalization that these people are largely being returned to the poorest mr. private areas of the city. but they're everywhere. and then to shut the eyes but

now it is inescapable provoking a backlash and san francisco's politics don't get me started. that is in a really strange place. do you have anything to add? >> my perspective is that psychiatrist are not the people to solve the housing problem. i think economist are 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 milton friedman has a lot to say on the issues of supply and demand may be a way to start the look at those questions i believe the had the overload of regulation which has stymied the supply of housing that the level that is needed and contributed that by no means the people that you see in the street are people who are mentally ill or drug addicted or alcoholic. many are those who literally cannot afford a roof over their heads. and anybody who has watched what happens to california housing prices is no surprise you wonder how anybody with an ordinary job manages to put a roof over their head and feed

and clothe themselves and their kids with any margin beyond that and it gets worse and worse with the supply and demand problem if you have millions of people and you don't build enough houses you will face that problem. not only what's going on in england its product by corrupt money it's russian and chinese and dirty money from all over the world and many of those houses sit empty a parking place for gotten gains so here not so much here we really have created a problem for ourselves. and also people's expectations as houses get bigger and bigger and that loses sight

for ordinary people is not something they could ever afford they need a decent place to live. i agree that is not a psychiatric problem is to show / and is creating problems that in some way they try to cope with but it's a product of much larger social movements and social forces. so to look to psychiatry to solve those problems is a category mistake. >> you made reference to psychedelics. >> it's a little early to tell but there are some signs and actually i was reading a

couple of peepers this afternoon before i came down about the emergence of the number of huge startups, billion-dollar companies that are investing. wants that genie is out of the bottle it's hard to put back. there has been this revival of lsd and magic mushrooms. the same with ketamine. changes the mood and we know that for years. it was a party drug. special k it also produces hallucinations and can damage the bladder but once it has given some sort of license there will be unscrupulous companies and people who will set up shop in people who are

giving infusions for other things here's a great source of revenue and unregulated. there we go we do think both of those have the potential and people always used to say to me that could happen now when i say not exactly that way. but it could happen. you could have a damaging remedy take hold then stop. the cult figure in the very interesting writings on the food chain sounds like timothy leary reborn it it's very

dangerous. very much so. >> with the regard of the treatment of the mentally ill and so forth. specially socialized medicine but homelessness was visible than the last time we visited in a little surprised and then out of the blue the psychiatrist i know that was a member of the house of lords said one off the artifacts of the covid epidemic swept the

people off the street because they saw them as a reservoir of infection in covid so they moved them but now they are leaking back out. so on the whole, i argue one of the things that drove the institutionalization were states are able to move patients off the state budget and onto the federal budget. medicare prompted a slide of old people moved out of the silent and when ssi came that provided some support regardless of the work history then the young people started to be moved out of the hospital. so it was possible. it's a shell game moving resources different. then as the feds cap back on welfare that was not replaced

so the situation got worse in some ways. britain, like most of europe have a more developed welfare state but talking with well-informed and well-intentioned british psychiatrist to my trust, it end ofgets the short the stick. it was better under tony blair. very few of those new resources trickles into psychiatry it was always the stepchild. nobody is arguing if we see that now about homelessness is not because we have sympathy for the people in the street but they are d affecting our quality of life and we don't like it. that is the honest truth is so a little bit better because

there iss more developed sense but in the last dozen years under the coalition and the conservative government and now with brexit public services have been slashed in britain and will be more because the economy is going down the toilet it's hard to find things and politically you have to understand the reproductive part of the economy is a thriving you cannot afford to do all the nice things that you would like to do and as we move toward potential recession it is a very worrisome time because i have seenhe it and mental health budgets are the prime candidates to be cut

texas cutdf their budget and they have redirected it to the show game of we will control the border because the feds are doing it. then there is a shooting and instead of saying we have a problem with guns, it is blamed a mental illness. but absolutely crazy gun laws. but maybe you don't allow 18 -year-olds on their birthday to buy two high powered rifles and 350 rounds of ammunition and body armor maybe there is a sensible restriction.

sorry that that one really angers me. mentalme illness blamed and what that does as well is exacerbates what i talked about earlier this evening which is the stigma. but by no means is this the case and then to encourage that equation. and then other than to our claim it tomo deal humanely with any more. >> last question. so with that psychiatric and the editor of has be moaned

allowing the expulsion psychiatric diagnosis and of course expanding and fought a losing battle and tried to prevent from growing even bigger. and then it happened in the asylum era. to be coping with and other ways. and yes i do think.

that creates the diagnosis to be diagnosed as mentally over several additions. the editor in chief of the fourth edition in later to create a nightmare with respect to autism which exploded in numbers. that was very controversial thing to say because for parents with a difficult child and sometimes that's putting it mildly, access to that diagnosis is something they sought because it brought the social support and things that otherwise we would not have gotten and when it was leaked the task force was considering changing the boundaries there was fierce backlash and it's

easy to think this is the imperialistic profession but also public demand. i will be thinking the next couplebo months which has become a huge industry the one exception of dsm-iii to be a theoretical. that was ptsd. that had a very clear ideology it was not a brain disease but the product of a traumatic experience. that first emerged among vietnam veterans and they allied themselves with two harvard psychiatrist who were sympathetic to them. and they browbeat spitzer and eventually they succeeded to appoint. but they wanted to call it

post- vietnam syndrome. but spitzer was not having any of that so as posttraumatic stress disorder. and overtime and what makes sense to me intellectually with women who were victimized by rape or sexual assault a very profound change in their identities like the aftermath of texas but pretty soon my college student is upset by what they are asked to read and we need trigger warnings and then if not we will suffer from ptsd. that diagnostic creep is very dangerous and there always will be people willing to pay

under because if we supply that publicly there will be even more. what do you say david quick. >> ditto. [laughter] thank you all for being such a patient audience hopefully we imparted something. and knowing from time to time and then to refer people to. i wish i knew more clinicians like david. >> this is been a very

enlightening evening in the next time you write a book i hope you comee back and thank you all very much for coming and enjoy the evening. [applause]