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This is KZSU Stanford. Welcome to entitled opinions. My name is Robert Harrison.
And we're coming to you from the Stanford campus.
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For the ancient Greeks there was something divine about madness.
Mania was the highest form of poetic inspiration.
Dionysus, the most dangerous but also the most sublime of gods.
During the Christian Middle Ages, madness was associated with a demonic,
and if they bothered to treat it at all, it was through forms of exorcism,
more or less horrific, more or less inhuman from our enlightened standards.
With the rise of modern medical science, madness was seen as an illness.
The fools of Europe were rounded up, taken off their ships, and shut up in psychiatric wards,
in what Michel Foucault called "The Great Internment."
As for the 20th century, it brought many changes in the
classifications and treatments of mental diseases, and it's that unfinished story we're going to talk about today.
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Studies have shown that overcrowding among rats and primates leads to stress,
and that stress leads to faulty cognition and dysfunctional behavior.
This is bad news for those who conduct such experiments, that is to say for human beings.
For a human civilization advances on its path to nowhere, our habitats get more and more overcrowded,
and we all get more and more stressed out.
This in turn leads to more and more neurospeenia and neurosis.
It seems that every week a new psychic pathology comes into existence,
one that no one had ever heard of before.
Troubled NFL running back Rickey Williams recently went on the Oprah show,
and declared that he suffered from acute shyness when he was an adolescent.
It turns out that some pharmaceutical companies paid him heaps of money to make that public confession,
because it seems they have just the drug to treat that condition, which they're now calling "chines disorder."
You'd think we have enough real pathologies without having to invent new imaginary ones.
Everyone knows that capitalism was constantly engender new desires by inventing the products that will satisfy them.
But is it not crazy to contrive new, non-existent medical conditions so as to market their putative cures?
When sometimes wonders whether our entire civilization is going and saying even as we speak,
and we along with it without our realizing it.
I don't believe in universal standards of normality.
The norms for what counts as normal change from century to century and from culture to culture,
what is important is that there be a general agreement about those norms.
For in the absence of such agreement we all go mad even when we're sane.
Nietzsche put it best when he wrote, "The greatest danger that always hovered over humanity and still hovers over it is the eruption of madness,
which means the eruption of arbitrariness in feeling, seeing, and hearing.
The enjoyment of the mind's lack of discipline, the joy in human unreason.
Not truth and certainty are the opposite of the world of the mad man,
but the universality and universal binding force of a faith in some the non-arbitrary character of judgments."
And man's greatest labor so far has been to reach agreement about very many things and to submit to a law of agreement,
regardless of whether these things are true or false.
This is the discipline of the mind that mankind has received,
but the contrary impulses are still so powerful that at bottom we cannot speak of the future of mankind with much confidence.
Gay science section 76.
Those words were written over 120 years ago by someone who shortly after he wrote them,
underwent a mental collapse in the streets of Turin and never recovered his sanity until the day he died on August 25, 1900,
at the dawn of a new century which would be the most insane century in human history to date.
What's frightening about our age is that this great labor of man to reach agreement about many things and to submit to a law of agreement,
that this millennia effort may now be failing to maintain its hard one discipline of the Western mind,
and that as a consequence, the contrary impulses to this discipline,
which Nietzsche associated with the arbitrary character of judgments, may be turning the world into a madhouse.
What's frightening about the age is that there is no longer any general agreement that submission to a law of agreement is necessary.
Or better, it seems as if we are cut up in a worldwide squabble about which kind of law of agreement we should all agree upon before the whole damn ward goes up in flames.
But I had better stop fantastically about the psychic health of our civilization at large, otherwise, the guest who joins me in the studio today might start doubting my own soundness of mind.
His name is Stuart Agress from the Department of Psychiatry here at Stanford.
Dr. Agress was one of the early leaders in the field of behavior therapy and is one of the founders of behavioral medicine.
After working on Phobia as a model for psychotherapy research at the University of Vermont in the 1960s,
he moved on to the University of Mississippi in 1969, where he served as chairman of the Department of Psychiatry before coming to Stanford in 1973.
His most recent research revolves around eating disorders, of which he is one of the world's leading experts.
We will be talking to him today about the history of psychiatry in general, as well as his own areas of expertise.
Stuart, welcome to the program.
Thank you, Robert.
I would like to begin Stuart by quoting a sentence from an encyclopedia entry on psychiatry and see if you agree with it.
The sentence is the following, the clinical application of psychiatry is intended to bridge the social world and those who are mentally ill.
I guess it's the bridging of the social world that worries me a little bit.
I think perhaps we might start with thinking about how we think about psychabatic disorders in general.
There are several models, if you like. One model is that we have discrete psychotic disorders, quite discrete from each other, and from what we might call normality.
Another model, so we would have it that we have an overlapping set of disorders.
For both models, people might argue that we have a sort of a number stretching from mental disorder all the way through normality.
Of course, the problem is we really don't have enough data to decide which of these various models is correct.
But I must say one could argue quite logically that in fact there is a number of disorders from various severe to something close to what many of us might experience as quite normal.
And of course, there's a setting of mental disorder that we have to think about.
For example, let's take a very simple example.
We have say a person who has a fear of heights, but they live in the prairies, in a small town, and there's no building more than two stories high.
No bother.
But let's say if that person moved to a big city to take a job and found that the job was on the 20th floor of a skyscraper.
Now, this person might struggle to work for a day or two, but my guess is they would be overcome overwhelmed with anxiety.
So in one circumstance they have no mental disorder, and in the other, they're now almost incapacitated, can't work, and so on.
So setting is another factor that we have to think about.
Does that imply that there are mental disorders which preexist circumstances that they're internal or intrinsic to certain personalities?
Yes, I don't know about certain personalities. I'd say people.
Certainly.
In general, right. Yes.
I think it's quite clear that we have some kind of pre-disposition towards a mental disorder, but this predisposition, whatever it might be, genetic, let's for the moments, go back to genetics as the basic predisposition, perhaps.
But that genetic predisposition has to interact in some way with environment, some kind of stress, some kind of repeated stresses, some kind of nasty experiences, and so on.
And given that may flourish into a mental disorder, on the other hand, people that don't get that kind of stress, but have the same predisposition may never develop the same mental disorder.
Do you believe that something like fear of heights could have a genetic basis?
Oh, I think fears, like heights, snakes, small rodents, like mice, all those clearly are inborn fears, and they're protective.
For example, if you put a baby on a glass, on a table, but then it goes over a glass, and it's crawling, it will instinctively stop when it sees the height coming up as it won't fall.
Similarly, those kind of ordinary fears probably protect us as children from all sorts of nasty things.
Well, usually I would try to build up to the big metaphysical questions toward the end of an hour, but let me jump right into it because your suggestion makes me wonder whether the importance of circumstance as unleashing or rendering a
maybe latent mental disorders manifest. Do you believe we are living in a in an age where our lived environments, our cities, our globalized world is changing the lived world in such, to such an extent that maybe all many of us who are otherwise would be normal are experiencing mental pathologies that we would not
experience otherwise. I don't think so. I think the age of anxiety has been proclaimed over and over again through the centuries, and in many ways I think today we're in an extraordinary lucky circumstance.
I mean we have good water, good food, good housing, good education for huge numbers of people for which this wasn't available years ago.
So I think if anything we're probably in a reasonably good circumstance, now you did bring up of course in your prelude to the show, the question of crowding, and that is a real finding.
Now we don't know what density for humans will bring along a stressful situation that we just don't know.
Well, I suppose you could say that we have good water, we have better education, we have less penure in our system, but I was reading in preparation for the show that at the beginning of the
there were only a few thousand people who were in a silence in Europe all of Europe. At the end of the century there were hundreds and hundreds of thousands and of course now in the 20th century there may well be millions.
So there how does one account for this demographic exponential growth in the people who seem to suffer from mental disorders? Is this just that they were not diagnosed earlier or we didn't have the luxury to treat them?
Or is there an effective increase in what we call today mental disorder?
We don't really know from back then. My guess is back then most mentally ill people were cared for in the family.
So after all we had essentially mostly a rural society and those rural societies looked after people in the home generation and the one, no a silence or not very many, a silence to send such people too.
The family basically took the stress as you know in England for example in the UK, Bethlehem the famous mental hospital which later became bedlamps and gave much entertainment to the onlookers was founded in the 14th century but it was a very small asylum and even when it was bedlimate to remain a quite small place.
Yeah we really don't know whether mental illness has increased now there have been studies in this century where people take retrospective histories that is go back and ask people about their mental illnesses and it does seem from those studies that things like depression, anxiety, eating disorders are increasing that is people who are in the same place.
People who are younger or in the younger decades than people that have less have more of them than in people of the older decades now.
This of course could also just be due to memory and remembering badly I mean can I really remember 56 years ago whether I had a depression or not?
Probably not and so will be less frequent remembrance in the older age than in younger people and that may be what it's about.
On the other hand for eating disorders we really do have some quite reasonable data that we have really had quite exponential growth in the last 20 years or so even though eating disorders stretch back into antiquity.
I want to speak about eating disorders a bit later but first can you've had quite an experience over the last few decades of how psychiatry has evolved so maybe we could talk about the therapeutic side of this equation leaving aside for the moment about what counts as a mental disorder whether there are vested interests.
Like the pharmaceutical companies to contrive mental disorders in order to market their products and so forth.
Can you tell our listeners what when you were for example in medical school and going to psychiatric wards and so forth what was the scene like and how much has it changed since then?
Quite dramatically. As a medical student of course we were taken off on a trip often to the closed the closed psychiatric wards of these mental hospitals large, brick institutions often of course outside the city and it was quite a frightening experience.
So we came in through these rather long dark corridors and an attendant would open the door and of course out of the door would try to pour all the inmates who were quite
like, I think quite peculiarly.
Anyway we were shoved inside and then the attendant pushed everyone away and locked the door.
Now the terrible thing is that in the 1930s, so this was in the 50s, in the 1930s there was a mental hospital in England that unlocked all the doors and threw away.
And well no one escaped. They would wander outside and they'd always wander back.
And so you wonder you see how much of the disorder shown by inmates was not only their mental disorder, their psychiatric disorder, but was also the disorder of institutionalization of being locked up, of having no reasonable sort of interchange with anyone.
Social isolation basically and being locked up. Well if you were locked up what would you do you'd try and run out the door at the first opportunity.
So a great deal of it was institutionalization. As we got rid of these institutions in the 50s, 60s and 70s those institutions were closed for better or worse I may say.
Now these institutions being what psychiatric wards?
"Secondary hospital hospitals and wards" What began to happen in the 40s really and even before that we saw psychiatric wards opening in general hospitals.
Not these institutions often the country are often the suburbs of big cities but in general hospitals.
And now we've found out that we could actually manage almost every psychiatric disorder on a ward.
Of course there might have to be a section of the ward that was locked for very disturbed people until we got them under control.
But going back to you know my residency in psychiatry we really had very few therapies.
In fact the first therapies that we had in the first year my residency were basically insulin treatment where insulin shock treatment and electro shock treatment those were the two big ones.
Plus of course psychoanalytic psychotherapy.
Now very quickly were they effective at all? Shock treatment was certainly effective was.
Insulin therapy it may have never been any good controlled studies of it really.
But very quickly in my second year of residency the first antidepressant came along as well as the first anticycotic.
The first anticycotic of course came from the anti-toburculable wards where they found out that I was an I as it an anti-toburcula agent made the patients rather cheerful.
So this was the very first molecule that was used as an antidepressant and given some success this pharmaceutical companies quickly came along with more effective molecules more effective antidepressants.
Same with anti-psychotics they were first used to lower temperatures in the operating theatre.
But they were found to work on psychosis and again the pharmaceutical companies spun off a whole lot of molecules over the years are making them more effective less side effects and so on.
Well two questions the anti-psychiatry movements of this period where they as connected to what you were saying that people were shut up in these in these wards.
And that this was a problem inherent to the institutions just as much as it was with the mental disorders.
So for example the idea that people were being driven mad within the walls of the...
No I see the problem I mean the anti asylum movement really goes back into the 19th century and here were people reformers who saw the terrible conditions.
Much worse than I described the terrible conditions in many institutions in the late 1700s 1800s and so on and actually really did try to reform things by building better institutions by having more space and so on and so forth.
In fact in the early 1800s I think mental institutions were probably much better because for example in America we had a fairly homogenous population at that time.
So far enough and the inmates were from the same kind of classes and there was often occupations like farming and so on and so forth.
It's often been called the age of moral therapy and interesting term actually.
But what happened of course is in England I think with the age of industrialization where the rural population flooded into the cities and in America the great age of immigration
where now we have a mix of immigrants pouring into the country.
The mental hospitals became overcrowded, they were often crowded with people who couldn't speak English as patients and the whole thing I think began to deteriorate into the kind of situation that I saw when I was a medical student.
The anti psychiatry movement was often much more targeted for example here in California in Berkeley actually passed an ordinance banning the use of electroshock therapy rather novel audience or ordinance banning a medical procedure that actually have been shown in control of these two work.
Is that also the electroconvulsive thing is that what electroshock is like it's the same thing. I think there was a lot of objection to that somehow just the idea of it.
Just the idea of inducing an epileptic fit exactly and now of course that's all blocked off with an ascetics.
So the introduction of medication was a big revolution in the treatment of mental illness.
It was an enormous revolution. Yes, it was not liked by some people these many psychoanalysts so it has a sort of assault on people as a very incorrect approach to the handling of mental illness but that kind of drifted by over a few years and became quite accepted.
Well there are still psychoanalysts or people sympathetic to psychoanalysis who are still very suspicious of the medicalization of conditions which sometimes are not pathological at all and that are part of what used to be quite normal evolution in a person's for example in that a less than shyness.
It was never a disorder but if you pathologize it and medicalize it and treat it with medication on all of a sudden there might be grounds for objecting to the attention deficit disorders and so forth.
I think there is, I personally not being an expert one way or another worry because I guess I'm old enough to be still part of a generation where you used to take medication as a last resort not as a first resort.
Absolutely, me too.
I think this is a problem with professions, isn't it? I mean the army, the law, medicine as the three professions are forever wanting to expand.
Which we see that historically we see it right now. Army is getting bigger. Lawyers like more litigation and physicians like more things to treat.
And I think many of us feel very uncomfortable including myself with many of the extensions that we see and perhaps the misinterpretations of behaviors and symptoms that might otherwise be quite normal and I think this is particularly noticeable in children in children of course children's behaviors all over the place half the time.
It's very easy to get a diagnosis of one thing or another. Perhaps too easy I think at times.
That's not to say that treating some children's disorders isn't a good thing and that it works.
But I think many would agree it's been over-expanded in a number of areas.
Well, there's what I hear about behavioral therapy. I think first of all that it would be almost hostile to medical therapy because with a pill you just are so prejudiced in favor of a biochemical etiology that you circumvent entirely the behavioral day-to-day patterns of existence.
You take a mental disorder out of the sphere of the existential and into the biochemical.
Is -- am I misperceiving it?
No, you don't miss receiving it at all. In fact, many behaviorists if you'd like to call them that I don't think is a very good term for them would in fact agree that much many behaviors have been over-medicalized into medical syndrome.
I personally don't -- being Scottish, I don't quite see this distinction. For example, whenever we behave, whatever we do, lift a finger.
That signal goes all the way through and affects our brain and therefore all kinds of things are firing off.
And so we very often forget the behavior behaving affects the brain and that therefore changing behavior in a particular way also affects the brain and affects brain chemistry.
And we've got some very early demonstrations of just that fact in fact.
Well, you're one of the founders of this behavioral therapy in the field of psychiatry.
And I mean, I think that behavior -- changing behavior might change the brain, but I think the medical side of psychiatry is says, well, let's just change the brain and to hell with the -- or let's hope that by changing the brain we can change the behavior.
But I actually -- my sympathies are on your side because I guess I was nourished on existentialism and I'm still an existentialist to the degree where much more than we want to admit is under the governance of the human will.
Now, I know that first psychiatrist that might be a little bit anathema that a great deal of mental disorders might be under the governance of the human will.
And that if you change your behavior through an act of will, you might be able to get out of your neurosis or your pathology.
Now, there are certain aggravated forms of mental disorder which obviously are medical.
But I think there's a sympathy between this existentialist doctrine and a kind of more behavioral approach.
No, I think you're right.
Of course, when we first started with behavior therapy, that's just attempting to change behavior often by altering things in the environment, providing feedback to people about the behavior changes.
Can you give us an example?
Well, like you told me before on air that women who could not cross El Camino, what a fascinating.
Right, exactly. It's an agrophobic. Someone who is almost housebound.
And I'll give you a case that I remember from Vermont when we were really doing experiments with this kind of thing.
And so, here's this woman, she's failed every therapy known to psychiatry at that point.
Drugs, everything else, and we just took her all off all the drugs.
And so then what we did was to simply get her to walk as far as she could outside the back door of the hospital.
Of course, she could only take about a step or two, came back in, and we praised her for what she did.
And next time she could walk a little bit further, she continued to get reinforcement, and very soon she was walking quite a long way with this continued kind of reinforcement, and then we stopped the reinforcement that is stopped praising her.
And the walking simply deteriorated. So here we were able to make symptoms come and go away.
We started praising her again and giving her a proper schedule of reinforcement after Skinner's pigeons and the casinos, at Las Vegas.
They use Skinner's paradigms to reinforce behaviour.
And pretty soon she was walking downtown, and we just generalised that to various circumstances, and she was pretty free.
So here we've just taken a very simple approach of positive reinforcement to enhance a particular behaviour that she needed to enhance.
With no need of medication.
With no need of medication at all. Exactly.
Your area of now with eating disorders that you've spent a lot of time on, is it the same sort of thing that you try to do when you're dealing with things like anorexia and obesity?
Well, let's leave our bestie out for the moment. Let's just stay with eating disorders for a minute. Yes. Yes, absolutely. Well, for the moment, for anorexia nervosa, there is not a, at this point, there is not a single study that would suggest any medication is going to be very useful.
Indeed, a few years back, I think one would say there was no treatment that had been shown to be particularly useful.
Now, I think the situation is a little bit better.
And what we're trying to do now is to concentrate largely on the adolescent anorexic, the young anorexic, which is much more valuable to treatment, and who lives in a controlled environment.
That environment is called the family. And my colleague, Dr. Locke, a pediatrics guitarist, and I have been doing some very interesting work in adapting a family treatment that was first talked about and researched in London, adapting it really to the American scene.
And it's basically what happens is that we get the parents to take charge of the child's feeding and to refeed the child.
In the second session, for example, we bring the whole family in, we are soon to bring a meal with them.
And of course, everyone and all the children come, everyone, and they all get nice big servings except the patient.
And of course, the patient gets a few lettuce leaves and a bit of tomato.
Well, one could ask the parents, "Well, how is she going to put on weight with that amount of food?"
And in that session, what we try and do is get to have the parents get the anorexic to eat one more bite than she wants to eat.
We then coach the parents in subsequent sessions in giving the patient plenty of food, ensuring that the patient begins to eat more and more.
What happens is the patient loses weight and rexics always keeps them weight, handy that they can lose.
Loses weight, but then begins to put on weight.
And in fact, after six months therapy, 12 to 14 sessions, they're getting close to normal weight.
And after a one-year follow-up, they're right back at normal weight.
We've done a five-year follow-up now. Really very good maintenance of normal weight.
Of course, anorexics have other problems. They often have obsessive compulsive disorder, anxiety, disorders, depression.
All these may need treating along the way in other ways, often perhaps by medication.
For the anorexia, it looks as though this refeeding program, family refeeding program is very good.
We've got some nice control data on that now. And that's looking fine.
The real problem anorexia and abosa is when it becomes chronic.
The patient's narrow, their social interest down, narrow all their interest down, their thinking changes, such as it becomes narrowed.
And of course, they're very, very underweight, which in turn, stars the brain of nutrition.
And so the brain isn't working very well, so many of them are not working very well. It's very difficult to do therapy.
And right now, we're doing some very early studies on trying to change these thinking patterns ahead of therapy to see whether that'll help.
I have no idea whether it is going to be helpful or not.
The program, the therapy that you just described, depends. It sounds like upon the anorexic being with his or her family.
Absolutely. And what happens when they go up to college and graduate school and no longer have that person to give them the extra value?
Right. Once they remove themselves from the controlled environment of the family, there is no one to bring pressure on them to eat.
And therapy is just terribly, terribly difficult. In fact, no control study has shown any efficacy in treating the adult more chronic anorexic.
I just wanted to say that some don't get better. 34% do get better and over time more get better. Often they go for anorexia to bulimia, to a subclinical variant of bulimia, and maybe over the years, to being rather thin people by having no eating disorder.
That may take 10, 15, 20 years. Meanwhile, of course, anorexia nervosa is the most lethal of any psychiatric disorder.
Is that right? Yes. People die from organ failure, of course, from the nutritional problems, and people also die from suicide. But half the deaths are suicide, half from medical complications.
So it's to be taken very seriously. It's to be taken extremely seriously, yes.
Can I ask about the gender proportions among anorexics? Well, it's about 10 to 1 on the females. Is there any explanation for that?
No, they're tall. I don't think we have a good explanation for that. The same obtains in bulimia nervosa, which has been cheating and purging.
But does not obtain in binge eating disorder, which is just straight binge eating, which usually leads to weight gain.
There, it's about three women to every two men. So there, the proportion changes.
Is there a role that's played, obviously, by the media culture, for it to explain this disproportionate among the females where there are models of female beauty, which, let's face it, they're all of them anorexic.
And these are the models of emulation that... Well, all of them thin. Some of them are anorexic. What's the difference? How would I know not being a psychiatrist, whether one of my students is anorexic or just thin?
Well, it's very difficult in this. You really get to know the person and can really assess them. Clearly, first of all, it depends on weight.
And we usually begin to classify anorexia when they've lost 15% below body weight.
But that's accompanied by a whole lot of other things, extraordinary concern about their body. A misperception of their body as plump when it isn't plump at all.
And a continual thinking about food and how to avoid food and how to get sinner and how to lose weight and how to overemphasize all that cluster of behaviors that determine anorexia and a VOSA.
But are they not 15% below some of them? Some of them have anorexic, of course, and develop anorexia. But when you develop anorexia, you probably can't go on working as a model.
And as you know, one or two have collapsed and one who had been at the odd death of models who have anorexia. So, danger is disorder.
My colleague and friend who's been on the show more than once of Renee Sherard has very famous for his theory of memetic, the memetic behavior among human beings where it's really others that set the examples and that through imitation, all sorts of things, even our desires are determined through what we perceive others as desiring and so forth.
And I remember hearing him talk about eating disorders as having a strong memetic contagion about them simply because it's imitative. Is there anything in your research that might lend credence to that?
Not a great deal. I think if we take anorexic into the genetic loading for that, it's really quite high.
So, I think we have to say that of the more ovolveating disorders, anorexia, novosa and buliminovosa look as though they have a fair amount of genetic loading.
So, I don't think there's a lot of my memetic stuff there. However, oddly enough, I have an odd anecdote that backs up this supposition.
And in one of my various stops across the country, there was a girl's college, women's college.
And this was before buliminovosa was common at all. And it looked as though one girl was bulimic and very quickly, buliminovosa swept through all the dormitories.
Now, was it buliminovosa? Really? Or was it a memetic buliminovosa? Or was it because it went away just as quickly as it had started? And I think probably the probably is a certain amount of mimetic things in terms of peer relationships at school, peer relationships at college and so on.
But I think the determinants are probably much earlier in life. Our own studies where we looked longer, Juneally, from birth, forwards to about 11 years and then other colleagues have looked in adolescence, really find that parental influences, including father's influence, interestingly, are really important, particularly parents who are worried about the
their own weight and shape. This tends to get carried over into worries about their daughter's weight and shape, which tends to get expressed quite early at the office.
And then begin to die at the end of the day. And then the daughter's weight and shape is very important.
And then the daughter's weight and shape is very important. And then the daughter's weight and shape is very important.
And then begin to die at. And this then puts them at risk for bulimia. It doesn't mean they're going to get it, but it puts them at risk.
Now, does the media play into this? The media is much blamed for some of these things. We actually did a controlled study where we exposed adolescent girls, either to receive for free fashion magazines or nice magazines like the Economist.
That's boring stuff, I guess. What we found actually was this, but it was only the girls who had high concerns about their weight and shape that in fact were influenced by the fashion magazines.
And so there was a predisposing factor there. And then the fashion magazines reinforces them, re-enforced it, yes.
So I don't think we can blame the media too much.
Well, to go back to some more general issues about psychiatry and therapy and treatment.
I'd like to raise a question of the so-called talking to your studies and began your career when I guess psychoanalysis was still at powerhouse in psychiatry.
And you have seen it over the decades, lose ground, more and more ground, more and more ground to the point where I heard you say on a previous occasion when you were talking about this, that is really shrunk down almost to from the clinical point of view to nothingness.
Right, yes. And yet it's, well, would you like to say a few words about that?
Sure, absolutely. Yes, when I started at a resident, the only talking therapy, well, the only big one was in fact derived from Freudian psychoanalysis.
There were some other salivanian analysis and so on that looked more at the interpersonal thing and so on.
And basically what we practice of course was a very shrunken version of psychoanalysis, seeing a patient one sort twice a week, not the five hours a week on the couch sort of business.
But what happened was that extraordinary little research has been done and even today has been done into the efficacy of that kind of psychotherapy.
Or indeed into rationalising that kind of therapy, manualising it so that people can know how to do it.
It's really handed down by word very often rather than as a technology.
And we've got to understand that psychotherapy of any kind is really a technology.
Sure, it's a part of an art and it's a discipline.
It's a discipline, techniques, exactly procedures and so on.
But what happened of course because behaviour therapy came into existence in the, well, in the '50s and '60s and did studies,
the show that it worked for various disorders and that those studies have now gone on into very large studies.
The definitive therapies for many disorders have now become offshoots of those behavioural therapies.
Now let me say there now a lot more complicated than the example I gave you earlier on.
I mean and they are themselves highly specific and specified talking therapies that also aim to change behaviour.
So those therapies have really taken over psychoanalysis as kind of with and away, despite being very interesting and obviously interesting to literary types like yourself.
And maybe that's its future.
Well some people have said that people accuse psychoanalysis of not curing anything, a concuriscets of phrenia, a concurivist.
But the drugs that they only treat the symptoms, they don't cure the causes of it either.
But how many medical disorders do we kill?
Not too many, really.
So it's much the same.
Yeah psychoanalysis, but you do acknowledge that sometimes speaking can be very helpful for certain patients.
Absolutely, yes, right.
I mean actually the behaviour therapies have become in some ways very much talking therapies aiming to change, thinking and behaviour.
Rather more specifically though than the old psychodynamic psychotherapies, but of course it can be helpful.
Absolutely.
And indeed for example for the eating disorders all the controlled studies show that the behaviour therapies that we use are actually better than drugs.
They're more effective than drugs.
So they clearly are the first line of therapy.
I'm knowing the history of literature and some of the tragedies that we read and teach in the classrooms and I've just been teaching Virgil's Ania and seeing how the, that there's always this idea that one understands that certain behaviours are destructive and self-destructive.
And yet the fact of the matter is that there's nothing more difficult than to change people's behaviours.
It seems that we are very hardwired once we have certain behaviour patterns and even mentality patterns.
If we could change these things easily then history might be less of a nightmare than it has been.
Have you not found in your experience that it's something fiercely resistant when it comes to certain behavioural changes?
I remember for example in the AIDS threat was at its peak.
It was extremely difficult to get a lot of people to change their sexual behaviours despite the fact that death was a very, very real risk that they were falling into.
And so often even in Western society now there's a resurgence in these behaviours of putting people at more risk again.
Yes it's quite remarkable.
What is it about our behaviours that seem so stubbornly conservative and self-repetitive?
Well of course you could argue that sex is a very highly reinforcing activity and death is a long way away and we know full well from animal experiments and human experiments that immediately
that reinforces.
Well very much take precedence over delayed reinfolds.
But another example would be in a family when you have a couple of years and you know that one of,
we'll know that she's going to say exactly the wrong thing that is going to provoke it.
And with full cognizance of the nefarious consequences can't change the behaviour and then how many people are locked into patterns of behaviour that don't promote their own happiness.
Right, yes this is a sort of business of interactive behaviours.
I wouldn't be surprised that the husband doesn't say or do something maybe very small.
Small signal that triggers the impulse and the impulsive behaviour and that triggers the next one and off they go.
We see the same with children and parents and if we can, and it is very difficult to alter that dyadic kind of behaviour with parents and children as a bit easier because we can hopefully get the parent to change.
Yeah, well Stuart it's been a very fascinating discussion.
I want to thank you for coming on.
We've been speaking with Dr. Stuart Igrass from the Department of Psychiatry here at Stanford about the evolution of psychiatry or the last decades and 20th century and eating disorders and other things.
And please tune in next week we'll be with you again. Thanks again Stuart.
Not at all.
Delight.
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