E92 Psychiatry, Privatisation, Psychotherapy, the DSM & Trump (with Professor Allen Frances)

Allen Frances is an American psychiatrist and psychotherapist. He is currently Professor Emeritus of the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine. He is best known for serving as chair of the task force overseeing the development of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).  Frances is the founding editor of two well-known psychiatric journals: the Journal of Personality Disorders and the Journal of Psychiatric Practice. He is also the author of Saving Normal (2013) and Twilight of American Sanity : A Psychiatrist Analyzes the Age of Trump (2017).

Interviewed by Dr. Alex Curmi, consultant psychiatrist. 

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Transcript

Welcome back to the podcast. My name is Alex. I'm a consultant psychiatrist. Today I'm joined in conversation with Professor Alan Francis, an American psychiatrist. He's the former chair of the psychiatric department at Duke University and the former chair of the DSM four task force. Today, we have a wide ranging conversation about what attracted him to psychiatry, how he's seen psychiatry change across his career, the DSM, the Diagnostic and Statistical Manual of Mental Disorders, including his work as the chair of the task force for DSM four and his concerns about the latest version of the DSM, the DSM five. His views on psychiatric diagnosis, his concerns about the overprescription of medication, as well as the underfunding of outpatient treatment for people with severe mental health conditions. We discuss why the UK should not follow the US in privatising mental healthcare. The importance of the biopsychosocial model, how psychotherapy works, and how different schools of thought within psychotherapy should be integrated. And we even discuss the candidacy of former American President Donald Trump and what his popularity may reflect about modern culture. Thank you for listening and we hope you enjoyed today's conversation. Professor Alan Francis, thank you so much for joining me today. My pleasure. You have such a wealth of experience in psychiatry and psychotherapy or involvement in the DSM. There's a lot that I'd like to talk to you about, but first, could you give us a flavor of what what attracted you to working in psychiatry and mental health? Well, I was not very good at the rest of medicine. And, uh, psychiatry always came fairly easy to me. I think that I was interested in myself, interested in what makes people tick. And probably most of all, that I felt like a better person when I was with patients than I was in any other aspect of my life, so that I, I learned a great deal about the world, about people, about myself, and, um, feel very grateful to the patients who I was able to get to know well during during my career. How has psychiatry changed across your career? Do you think it's changed remarkably in terms of how much we know about the brain, how much we understand about behavior? And, uh, there's been a very exciting scientific revolution at the same time. It's, um, pretty much deteriorated. And how we treat patients. Especially in the United States. There was a movement when I began psychiatry, a great excitement about community psychiatry, about taking people, um, who were imprisoned in these horrible state psychiatric hospitals and giving them a new chance in life. That was the availability of new medicines. The community psychiatry movement promised to, um, allow people to be citizens, allowed people to work, allow people to live in the community. And it was a very effective model that was pioneered in the United States in the 60s and 70s. Unfortunately, the Reagan administration and austerity government cut the funding that was supporting the movement from terrible inpatient hospitals to very viable community mental health centers that cut the funding. And since then, for the last 45 years, there's been tremendous neglect of the mentally ill in the United States that the states saved money from closing hospitals. But instead of spending that money on community treatment for mental illness, it went to prisons and it went to cutting taxes as a result in the United States. We may be the worst country in the world to have a severe mental illness that the neglected patients have wound up on the streets. We have a tremendous homelessness problem. That's partly due to a lack of housing, but about one third of the homeless are people with mental illness. We have, um, 300,000 mentally ill people in prisons, so the neglect of the mentally ill makes them much sicker than they would otherwise be and leads to this terrible problem of homelessness and needless imprisonment. So I'm very, um, discouraged about the way psychiatry has developed in that it's not the fault of the field so much. It's the fault of the the politics of the society that the most vulnerable people within it are also the most neglected. Yes. And I think we're seeing a similar trend in the UK, although I don't think it's gotten quite as bad in the US. But similar to what you're describing, there is a strong trend to towards deinstitutionalization with the advent of effective pharmacological treatments. But of course, you can only do that if we have, as you say, very well funded community teams that are able to provide adequate outpatient support for patients with. Let's be frank. Serious chronic mental health conditions quite often, or even just severe psychological problems. But there is this trend towards austerity, which I think has left a lot of people wanting, and certainly in my visits to the state. I've seen the problem that that that you've described. Yeah. The the concept of severe mental illness is an interesting one. Um, it's not something that happens in a vacuum. So that the severely ill in the United States, a much more severely ill than the severely ill in the Nordic countries, or Trieste, which has had the model community psychiatry program stressed in Italy. If people are treated well, if they're given a place to live, if they're given easy access to treatment, if they're given opportunities to work, they do very well. If you treat the mentally ill early and well, they do not sink into the kind of horrible situations that we see on the streets of American cities or the American prisons. If you neglect the mentally ill, they become a tremendous social problem, much more expensive to imprison someone than to have a community mental mental health center. They also become a tremendous societal problem. Um, many of our cities are flooded with people who could do very well if they had been treated reasonably, but become much sicker because they're not. And the dangers in England is the efforts to privatize medical care in England, um, fostered in part by American chains, hospital, mental hospital chains who lobby in England to undercut the NHS, which provides wonderful service under very straitened economic circumstances. To privatise it in a way that I think would lead to disastrous neglect of the most vulnerable people. When you privatize mental health, what happens is that the most expensive patients are left out of the system. That the met, the people who have more severe mental illnesses are more expensive to treat. In a privatized system, you give excessive care to people who don't need it. So the people who are worried well get too much care because they can afford it. The people who desperately need help, who should be a public responsibility, fall through the cracks and wind up in prisons or homeless. So the NHS is kind of a protection and hopefully with a new government, a protection that will become stronger and better supported is the protection from the kind of privatized health care in America, which leads to a non system, leads to overtreatment of the worried well and under treatment of the really sick. And do you think that that trend of overtreatment of the worried will on the treatment of the really sick. Is that a trend that also follows when physical health care is privatized? Of course, the um, in order to provide the people with severe mental illness, died 20 years earlier than the rest of the population. So one of the risk factors, one of the strongest risk factors for an early death, is having a severe mental illness. So adequate treatment for the severely ill requires very close collaboration between primary care and mental health services. And this can only be done in a system that has a sense of public responsibility for the most vulnerable. If you privatize the system, you upload the amount of treatment for people who can afford it and have insurance. They can afford it. And actually they wind up getting too much treatment. If people have too good insurance, they get medication they don't need. And at the same time, in the system of privatized health, mental health care, the people desperately need help, wind up homeless or wind up in prison. Is it fundamentally a problem of incentives that once healthcare is privatized, the incentives are just changed from? You know, because I guess when a system is public, like the NHS, the incentive is how do we treat the most people for the least amount of money? There's a there's a trend towards efficiency. Whereas in a private system, yes, efficiency is also good. But then fundamental incentives around profit are introduced which warps the, the, the mechanics of the system. Is is it that simple or is it more complicated than I'm making it out to be? It's really very simple. It's a political and economic question. The sense of social responsibility that privatized systems of medical care put profit first and patients last. Public systems of mental and medical care put patients first and profit less. The average per year cost for overall medical care in the US is $12,000 per capita. In the UK, it's under 5000, so the NHS is spending a little bit more than a third as much per person on medical care, on every medical outcome. Forget mental health, but in every medical outcome, the UK does better than the United States. So there's this feeling of desperation in the UK because the NHS is way, overworked. Way underfunded. Hard to recruit people to it, but the actual care given is far superior to the care given in the United States, even though it costs only a bit more than one third as much. And part of that is that the system in the United States is obscenely profitable, encourages excessive treatment for people who don't need it because it's profitable. The most profitable, profitable group to treat are people who have excellent health insurance or can pay out of profit for procedures they don't need. That's that's the best population from a profit perspective, from a public perspective. You don't want to do low value, expensive care. You want to provide the care that's needed for the population, the high value care. So it's almost antithetical to good. But it's really not just mental health, good mental health and also physical health care that the profit motive be reduced to a minimum and that the public health distribution of funds were the most needed be the highest priority. So Britain improves, the NHS suffers not because the model is bad, it's because it's way underfunded. The US suffers because it's overfunded in the wrong ways. Yes, that's overfunded and the funds are directed towards the wrong cohort and not just directed to the wrong cohorts, but doing excessive procedures that are profitable because they're profitable, many of which are not helpful for patients. Low value care is wonderful for the profiteers and terrible for the patients. Do you worry about things like the, say, the overprescription of antidepressants? Do you think antidepressants are overprescribed? Well, they're way over prescribed every problem the US has. Other countries, including the UK, have, but to much less a degree, we are the model for overtreatment of of the mildly ill and the worried. Well, in the US about 20% of patients get a psychotropic medication. Think about that. 1 in 5 people's regularly taking a psychotropic medication. Uh, the antidepressants and women, over 40, a quarter of them are on antidepressants. The reason for this is the lack of, um, primary care doctors having time to to get to know their patients. So the average primary care visit in the United States is about 10 or 15 minutes. 80% of psychiatric drugs in the US are prescribed by primary care doctors. GPS prescribe 80% of all medications, including 80% of antidepressants. They often have only 15 minutes to see a patient, including writing up the record. The easiest way to get a patient out of the office quickly is to prescribe medication. If you know the patient, if you understand that most people presenting with emotional distress in primary care have a fairly transient problem, it's often related to an external stressor related to a medical illness. The best way of dealing with it will be normalization advice psychotherapy. But when these things are unavailable, when there's no time for the GP to get to know the patient, when there's no psychotherapy available as a referral, the easiest thing to do is to write a script. Now, once the patient gets the antidepressant prescription, most people will feel better in a couple of weeks anyway, because most people see the doctor on the worst day of their life, or one of the worst days of their life, they get better through expectation regression to the mean support. But if they've been put on the medicine they didn't need on that first visit. They'll attribute the improvement to the medicine, not to time or expectation, or the fact that most things get better on their own. And once on the medication, they'll often stay on it. An unnecessary medication for years and years and years, sometimes lifetime. It's also very hard to stop a medication that most psychotropic medications have, withdrawal syndromes that the withdrawal syndrome is often not discussed fully at the beginning. Patients often stop abruptly. You need to de prescribe slowly under supervision. If you stop abruptly, you're very likely to have withdrawal symptoms. It's very easy to confuse those withdrawal symptoms with the initial problems that you started with, and to think that you're having a relapse, and therefore you must be on the medication that the medication was doing something useful. It may have been a completely useful, useless medication. Often is a completely useless medication that wasn't needed at the beginning. But once you started, unless you get off it very, very slowly, unless the prescription is done carefully and patiently, the relapse, the withdrawal symptoms will be misinterpreted as relapse and people will stay on medicines they don't need. So the major message in this more time to get to know patients. Less quick writing and prescriptions. More training of doctors and have a deeper scribe. So it shouldn't be so easy to prescribe. There should be ways in which you don't have to prescribe medicine to get the patient out of your office, and there should be much more training amongst doctors and much more awareness amongst patients about the risks of rapid withdrawal and the likelihood that there'll be withdrawal symptoms that will be confused with relapse. Yes, I'm very often shocked at how often I see patients who have been on antidepressants for sometimes years at a time, despite the fact that if you simply ask them, has this benefited you at all? They will say, no, not really, or I don't think so. It's almost like they've never even thought about it. And one of the things I would advise is that if you even initiate an antidepressant or any psychiatric medication, you regularly check in with the patient as to whether it's benefiting you or whether other side effects and for whatever reason, again, perhaps because of systemic or structural problems, this doesn't seem to happen. It's routinely discussed in the media and in popular culture that antidepressants are just like it's it's routinely opined that it's they're not effective. Do you think rather than them being not so effective, the problem is simply that they're being prescribed to to wider cohort. And if we were simply more careful and judicious about when we prescribe antidepressants, actually there'd be a much more effective treatment per capita. Well, effectiveness is a relative concept. So if you're treating a very mild population, people who don't have severe symptoms, there's a very high placebo response rate. And so the antidepressants may have a 70% effectiveness. But the placebo response rate may be 50%. The extra added value of the antidepressant is only a fraction of people who feel better after taking the pill, because so much of the effectiveness comes from the placebo. If you're treating more severe patients, the antidepressant effect may only be 50%, but the placebo response rates under 10%. So that may feel, oh, it's not working for everyone. It certainly doesn't. But it may be very helpful, essential for half the population. So I think the antidepressants are very psychiatric. Medicines in general are very effective for the few and necessary essential for the few, but they become more harmful than helpful when they're overused for the many. And I think you're exactly right that targeting people with severe problems, they people with severe depression definitely will need either antidepressants or ect. Psychotherapy itself does not help. It's a very useful adjunct for patients, especially as they get better. But there is not a psychotherapy that's very effective for very severe depression. On the other hand, medications not really necessary for milder depressions. So the algorithm should be that for mild to moderate depressions, psychotherapy and time would be the first intervention with medications being reserved only as a last resort if psychotherapy and time are not sufficiently effective. On the other hand, for severe depressions, psychotherapy may be adjunctive helpful, but most people with severe depressions are going to also require either medication or ECT. I think that's a great way of thinking about it and moving on to psychotherapy. One of the problems I've found practicing in the community, in the NHS is that it's very difficult to get patients to psychotherapy. They need, for example, you might be treating someone with borderline personality disorder, for which the gold standard psychotherapy is dialectical behavior therapy. But again, so under-funded it's so hard to get someone into the correct program. What's that like in the States? Is psychotherapy easier to access? What's the situation? The situation in the United States is that for people who have money, psychotherapy is fairly easy to access. For people who don't have money, it's impossible. And the money might be direct out of pocket, um, payments. Or it may be having insurance that covers, uh, and even the people have insurance. It's often difficult to access that insurance. There is supposed to be parity between medical and mental health problems as far as insurance companies work work. But there are barriers placed to using insurance and mental health that make it difficult, so that there is a chronic feeling here, as well as in England and in many countries, that it's difficult for the patient or for the GP to access psychotherapy. And part of the problem is it's not just a clinical issue, it's an economic issue. It's really stupid. Economically to put someone on an antidepressant that's going to require maybe years and years and years and years of treatment that they don't need. And it's not just the expense of the medication. It's also the expense of all the doctor visits, the complications of the medication. Psychotherapy is often very effective. And brief doses, brief psychotherapies, very useful, very cost effective. So sometimes the equation is it's impossible to get psychotherapy for ten sessions, which will be very effective and very inexpensive in the long run. Very easy to get medication for ten years or longer. That's very expensive in the long run. And as a society, we're investing in the wrong place. We should have psychotherapy and that psychotherapy can be done by GPS. So GPS are very effective psychotherapists when they're given time and training to do it. Uh, many, many of the people won't need to be referred to. Someone else. If the GP could just spend a half hour instead of 10 or 15 minutes, they might be able to do the watchful waiting to get the patient feeling. This is a problem now, but let's see how it looks in a month. We'll follow this up closely. If GP's had more time with each patient and got to know the patients better, they wouldn't have the reflex of prescribing so quickly to get the patient out of the office so that they can see the next patient. Let's talk about the DSM. You were involved on the task force for the DSM four. For the uninitiated, what is the DSM and why is it so important in psychiatry? Well, I think the DSM is is, um, very helpful as a clinical guide that without having explicit criteria for making diagnoses, different clinicians seeing the same patient will come to different conclusions about what the problem is that the diagnosis is way too subjective unless people are working off the same page about what symptoms must be present to make which diagnosis. It's very helpful in differential diagnosis that the with every patient, the first thought should be is there a medical problem causing this, especially in elderly patients? The second thought should be is medication side effect causing these symptoms or drug use causing these symptoms. And then the third level is to figure out which among the various disorders best fits the symptom pattern that's described in the DSM. So it's a very useful manual. The problem is that it was both oversold and overbought, that when the DSM became popular in the 1980s, 1980 with DSM three, the feeling was that these criteria might lead to a deep understanding of psychiatric disorders, that if we had a reliable system of diagnosis and at that point we just got the availability of imaging tools. We were just beginning to get the availability of genetic tools and molecular biology. So in the 1980s, there was a tremendous excitement in the field that we had a reliable, more or less reliable diagnostic system. We have all of these neuroscience tools. Pretty soon we'll understand what causes mental illness. And once we understand what causes it, it shouldn't be very far to figure out better ways of treating. Turned out not to be like that. The mental illness is far more complicated than people imagined. The brain is the most complicated thing in the known universe. There are 86 billion neurons. Each neuron has a thousand or more connections to other neurons. There are several hundred trillion different synapses in the brain. And the studies that we've done so far have just been a very tiny fraction of understanding all of the complexity of mental illness. We still do not have a biological marker for any psychiatric condition. We still do not understand the causality of any psychiatric condition. We don't understand how the medicines work, so that the excitement that the DSM would lead to a clear understanding of disorder and much better treatments is not worked out. On the other hand, the people and so people who worship the DSM, I don't trust people who worship the DSM. It's not a Bible. These are constructs. They're useful constructs, but they have to be applied with clinical judgment and common sense. The people who criticize DSM and don't know it are equally, I think, misled because it is a very useful way of categorizing symptoms of understanding the differential diagnosis and of planning treatment, and also maybe predicting course. So the DSM is a useful system if used cautiously, carefully and, um, not, uh, rushing to judgment. It's a harmful system when people worship it and apply it too quickly and without thoughtfulness. It's also, I think, equally harmful for people to say, oh, I don't do DSM diagnosis, I don't need to. I just use my own gut feeling or my own subjective judgment, or attribute all problems to one cause. Uh, the only model in psychiatry that makes any sense is a biopsychosocial model that takes into account that every presentation is likely to have some biological contribution, some psychological contribution, some social contribution that these interacting complex ways, and you need to think about each patient in terms of each of these factors in order to be develop a good formulation and a good treatment plan that anyone who thinks that mental illness is simple is always wrong. The one thing we can say with absolute certainty in mental illness that all reductionist, simple models of mental illness, whether it's mental illness is a chemical imbalance or mental illness, is a result of all mental illness result of childhood trauma. Every model that's simple will always be wrong, because people are much more complicated and the brain does not reveal its secrets quickly. Yeah, and the brain really exists at the interface of all those forces. You mentioned the biological, the social, the psychological. Everything is coming together and affecting each other in ways that are dynamic and very hard to to grasp. Quite counterintuitive, really, for a lot of people to grasp. And to what extent are you transparent with your patients about the diagnostic systems we use, about the fact that they're constructs? And to what extent are you transparent about the fact that we don't know. There's a lot of mystery to how our medications work. Yeah, I think for most every patient, transparency is the best policy. I think there are some people who are experiencing tremendous stress and for whom, at that moment, hearing that the limitations of the field may be just an added stress. And so you're not going to push forward with everyone in revealing all of the uncertainties. But I think by and large, the we should expect our patients to be honest with us and we should be honest with them. And I think there is a tremendous amount. We do know, I think the, the, um, it's unfair to the patient and unrealistic to make believe we understand the disorders in great detail in terms of their causation, But we do know a lot about course, we do know a tremendous amount about how symptoms lumped together. We know a lot about treatment planning. And so I think that the diagnosis for many patients is a relief. Previously, they may have felt uniquely damned and misunderstood. Uh, having a diagnosis helps you to put things in perspective that previously were so confusing. The fact that we understand a lot about the different problems and what are the best treatments, and that we can usually offer a variety of different options and then negotiate with the individual what they think is best for them. Amongst the options. I think that makes for a powerful therapeutic relationship, and we should all understand that the therapeutic relationship is absolutely essential. It's the curative agent in most psychotherapies. It's very powerful curative agent even with medications that the active. Aspect. The chemical aspect of the pill is only a very small part of what helps the individual. Doctors were prescribing dangerous things for the most part the patients. For for 4000 years, the history of medicine has usually been doctors prescribing either completely inactive treatments or harmful treatments. And yet doctors were always held in high esteem, despite the fact that they offered little or actually were hurting the patients. Bleeding patients, which went on for 4000 years, was a bad idea. Purging patients. Terrible idea. Giving patients heavy metals. We were actually poisoning patients for thousands of years. And yet patients came to doctors for help. Why is that? The power of the therapeutic relationship? The power of placebo was so strong that even the doctors were doing harmful treatments. Patients felt better. And I think that at this point we have effective treatments for the first time. Um, there were some effective treatments before modern psychiatry, but basically we have effective treatments now. They're not perfect, but most of them have a fairly good benefit harm ratio. We have effective treatments, but we shouldn't make medicine. We shouldn't make psychiatry. We shouldn't make psychotherapy some sort of rote by the manual prescribed the pill activity. The relationship is essential to healing in every doctor patient relationship and every therapist patient relationship. And I assume the the value of the therapeutic relationship in its its benefit in psychotherapy and other health care interactions. That's been well studied. Right. And like large, well validated studies. Is that correct? Well, it's really fascinating. The, um, there's a paper that every psychotherapist should read written by Rosenzweig in 1936, and he developed the concept of the dodo effect based on Alice in Wonderland, the Nelson Wonderland. The dodo bird has a race, and in this race, all who run win a medal. Everyone who runs win a medal. And he predicted, Rosenzweig predicted, that that's exactly what would happen with psychotherapy, he predicted, and he had no studies at that point to confirm this. It was just his intuition that the therapeutic relationship would be so powerful that different forms of psychotherapy, even though they had different jargon, different rationales that they would have about equal results and the literature. Since then, thousands and thousands and thousands of studies has demonstrated that when you compare two types of psychotherapy, both of which have a reasonable rationale with well-trained clinicians, in that type of psychotherapy, you almost always get high scores that the there may be for certain problems, certain techniques will be more useful than others, uh, for agoraphobia and phobias in general. exposure therapy is will have to be part of the treatment. There may be certain personality problems where psychodynamic techniques have some advantage, but by and large the focus should be on the relationship, on helping to promote corrective emotional experiences, on helping to create benign cycles to substitute for the previous vicious cycles they have often characterized. What do you mean by a benign cycle? Very often. If you can promote a small change in a person's life, that will result in positive, amplified feedback towards a happier future. Relationships and behaviors. Whereas patients, when they come to us, are often stuck in vicious cycles that they behave in such a way. Personality disorder is the classic cure, where people with personality disorder have an expectation of the world and behave in a way that has the world confirmed their worst expectation. And if you can begin to get outside of the rut of your personality, of your symptoms, if you can begin to behave differently, sometimes even very small behavioral changes will result in dramatic life changes because it leads to the world treating you in a different way. You get out of the rut of being, um, if you feel like you're going to be rejected, you act in a way that you get rejected because you lack the confidence to to try things differently. If you change your behaviors just a little bit, maybe be a little more assertive in things, um, you can feel that, oh, my world is opened up. I can do more than I thought I could do get positive responses, get new relationships. Then you try more and more and more. So slight changes for the better or slight changes for the worse sometimes have dramatic impacts in the person's life. And we should be promoting in psychotherapy is a relationship that encourages the patients to see the world differently, to act differently in the world, to expect more of the world and to expect more of themselves. And often even tiny changes result in a great deal of change. This leads to a topic near and dear to me that we shouldn't have all these separate schools of psychotherapy. It makes no sense for someone to feel, oh, I am just a psychodynamic therapist. I am just a cognitive therapist. I'm just a behavior therapist. Different patients need different things, and the same patient needs different things at different points in the treatment. And I think if we integrated therapy and had people trained so that they didn't regard the different schools as mutually contradictory, if we got rid of the jargon that separate schools, we'd realized that there is an essential unitary psychotherapy, and people should be trained in that rather than in a particular narrow way of if you have a narrow range of techniques available to you, then you're a hammer looking for nails. It should be that the patient leads the way their needs, their interests, their preferences, rather than therapists applying the same kind of therapy to every patient. Yes, I agree with you, and I've often thought that when I've been looking at all the different schools of psychotherapy and what I felt was kind of the unnecessary conflict in between them, and ultimately, ultimately, I've landed on the idea that it's the job of the therapist to try and figure out what the client needs at that point in time, whether that's a more psychodynamic approach or a more cognitive behavioral approach or whatever else the patient needs. Um, it shouldn't be the job of the client to try and fit in to the, the, the, the modality that the therapist has trained in, no matter how much, no matter how invested they are in that modality. I've seen lots of the best therapists in different schools work. And, um, the remarkable thing is that they're very much alike, that the training programs tend to be narrow, but the people who apply that therapy first, or even developed at first, tend to be very broad. And so if you take the best cognitive take, Aaron Beck. As a therapist, he was not very dissimilar from the best behavior therapists. He was not very dissimilar from the best psychodynamic therapists, that he was able to feature the patient center stage on the patient, and he would say, and do the Becks Don't Train in the manual for Cognitive Behavioral Therapy, the manual for Cognitive Behaviors on the committee that, um, funded the early studies, and, uh, CBT and then, uh, dialectic behavior therapy and we required for research funding that the therapy manuals so that it could, you could know what was being done and it could be standardized. And so CBT was manual ized for the research purposes of getting funding. The manuals can be useful as a basic sort of training, but it's not the way the back Institute focuses on training cognitive behavioral therapists. No cognitive behavioral therapists should think they're doing adequate treatment by following a manual. You have to be following the patient. And if you're working on the manual, rather than understanding the patient, you will always be behind them, ahead of them, or saying things that make no sense to them. So we need, I think the hope of the future for psychotherapy is to try to. Right now there are about 50 different alphabetically named therapies CBT, CBT, bunch of of name therapies. Founders are constantly creating new types of therapy. And I think this is bad for the field. It's limited therapists to thinking, oh, this is the one right way of doing things. It's ruined their flexibility and dealing with patients. It's narrowed their ways of understanding people. And I think psychotherapy, none of the techniques is mutually exclusive, and none of them is sufficient by itself so that a trained, a well trained and experienced psychotherapist should feel that they are applying all the techniques. Depending on the needs of the patient at that particular moment. Yes, it's kind of a question of incentives like we were talking about before. If you're so caught up by how well are you sticking to your training manual, or maybe in the case of something like psychoanalysis, how rigidly are you adhering to the ideology that you were trained in? That takes away bandwidth from what should be the North star of how you're working, which is how can I improve the quality of life of this, of this client? And if you stick to that, what you find is you want more tools, you don't want less tools. And actually the rigidity is the very kind of thing we're trying to extinguish in our clients. Yeah. I've noticed that the, um, over the course of the years, I've seen dozens and dozens of excellent natural psychotherapists. A lot of what makes a therapist good is inborn and early nurture, um, people who have warmth, who have the ability to understand people, natural empathy. I've seen them ruined as therapists because of close adhesion to one or another school, that they become too mechanical, too inflexible. They worry too much about what should I be doing at this moment, rather than allowing their natural intuition and empathy to guide them? So I've always told people I supervise don't apply anything we say today to your next session with the patient. Because we work hard to use this for the next session. You'll always be a week behind. Always be with the person in the room that your best teacher in psychotherapy will be your patient. Following your patient and following your own internal reactions to the patient. Certainly that can be educated through technical training, but it shouldn't be destroyed by technical training. Yes. Getting back to the DSM again, you've worked on the DSM task force for DSM for. Something I've always wanted to know is how is the DSM written exactly? To what extent is it the result of research? To what extent is it the sort of collective wisdom of a few chosen clinicians? And what's the actual process of how it's like how people sit down and write it? It's changed over time. Um, the DSM three was an innovative approach that for the first time provided criteria to the diagnostic system. DSM one and DSM two were completely unreliable. There was a study that I was partly involved in that compared British psychiatrists with American psychiatrists in the early 70s, 60s, late 60s and early 70s that showed that showing the same videotape the British psychiatrist diagnosed mood disorder, the American psychiatrist diagnosed schizophrenia, and the impetus for DSM three criteria was the realization that unless you had a reliable system of diagnosis, you couldn't have research and you couldn't have any systematic way of recommending treatment because people weren't diagnosing the patients the same way. There was no research with DSM three. And so what we did then was people gathered in the room. Uh, the person who was the leader, Bob Spitzer, was a very charismatic individual. There would be shouting and screaming in the room about the criteria, very little research to support anything. And he would be sitting with the computer trying to put together a set of criteria based on the different opinions in the room. But it was very much who was the loudest? Who was the most persistent, uh, that determined the criteria. There's nothing sacred about the DSM criteria. They were informed by a lot of clinical experience, but there's they were developed through a very, um, strange and chaotic process of consensus. Um, I took over DSM four. I was very concerned about making changes. Because the system was expanding the purview of psychiatry and including milder and milder forms of symptoms, so that people who previously were diagnosed as normal were now being included as having mental disorder. And I also felt that the lack of stability in the system over time would reduce its usability and its clinical utility. So we tried to do DSM four in a way that would have as few changes as possible. We told people at the beginning that unless you can prove through data, existing studies and data sets that had not been analyzed yet and in field trials, unless you prove that a change was absolutely necessary, we're not going to make that change. Even with this very conservative attitude. And it was so conservative that we had 94 suggestions for new diagnoses and we accepted only two. Asperger's as a kind of milder form of classic autism and bipolar two as a form of bipolar disorder that did not have full blown manic episodes. Both of these changes seem to make sense. Both of these changes tested well in field trials that they would have a small but useful effect. Both of these changes wounded up to be fairly disastrous. So that even though we were that careful and that conservative, we allowed two changes that made sense at the time but led to, uh, false overdiagnosis. Um, autistic disorder used to be 1 in 2000. We expected it to be maybe 1 in 700 with our change. Instead, it's become 1 in 38 in the population. So there's been this tremendous explosion of the diagnosis of autistic disorder that we didn't anticipate. And that was caused by mostly by the fact that school services were offered to people who had autistic disorder not offered without the diagnosis. And any time there's a reward for DSM diagnosis, it skyrockets. Uh, bipolar two used to be a bipolar disorder, used to be about one sixth of all mood disorder. Adding bipolar two. It became a very popular diagnosis. It was advertised by the drug companies and it became one third of all mood disorder. So the lesson to me was, you need to be very careful in making any change, because the road to hell is the road to diagnostic. Hell is paved with good intentions and has harmful unintended consequences. And it's very hard to predict how what you change in the system, how that will be used, often misused by the outside world when there's a reward to be given to getting a diagnosis. DSM five went the opposite way that it was, um, open to changes. ICD 11 similarly very, um, loose criteria for making changes. And so lots of things have been included that I think have done more harm than good. Can you give any examples? Yeah, I think that in each case there's a rationale. But the harmful unintended consequences are worse than the benefits of prolonged grief. So there are some individuals who continue to grieve beyond what might be considered the expiration date for grief, and have grief in a severe way beyond what might be seen as the usual response to losing a loved one. And this has been made into a psychiatric disorder. The problem with this is that every time you introduce something, it's so easy to misuse, so that in the previous world someone had prolonged grief, they would be diagnosed as having major depressive disorder. And they would be seen as having a mental disorder that needed treatment. The trouble with adding prolonged grief is that it takes now makes it easy to include, as mentally ill people who are having what should be conceived as normal grief reactions, that there's no expiration date on grief that's universal, that the price we have is mammals, and loving is what we miss people, especially when it's a loss of a child, when it's a traumatic loss and unexpected loss. Grief is often not fit into a tidy, you know, you X number of months. And if you're still grieving, that means it's a mental disorder that for some people, losing a child will be something they think about every single day of their lives for the rest of their lives that we pathologize normal grieving when we introduce prolonged grief as a mental disorder. So I think it would have been much better to keep the old system that if someone has the symptoms of major depression after losing a loved one, you treat it as major depression, but you're not pathologize in trying to capture some people who might have been missed in the previous system, some people who might have been false negatives. You create a whole world of false positives. Internet disorder. There certainly are people who are so driven to be gaming, especially that they lose track of the rest of their life. They stay in their rooms, they don't go to school. They don't work. It's definitely a problem, especially a problem in Korea, Japan, but increasingly a problem in other countries as well. So the idea of having something that would sort of officially recognized gaming disorder makes great sense for the few people for whom it really is a severely impairing problem. However, when you introduce something like gaming disorder, it gets spread to everyone. And so we have, you know, how many people now are not on the screens many hours a day. How many people, uh, you know, wake up at night or in the morning? The first thing they do is check their, their, their screens. So it be something that is has become kind of a universal is now can be misused as a mental disorder. So I think it's very important that we be careful. The systems are made by experts. And experts in any area know tremendous amount about their area, but don't know about how they what they see and what they can find useful will be misused outside the narrow confines of their research clinics, and something that may be a very useful, innovative diagnosis for someone working with highly selected patients, very carefully evaluated by extensive staff in a research clinic, will be a disaster if it's applied in primary care. Most diagnosis is done in primary care. Yes. We're almost out of time, and we don't normally get political on this show. But given the current times, uh, the US election is coming up. Two days ago, Biden decided to abandon his candidacy. You've written a book about the the the first Trump presidency called Twilight of American Sanity. What do you think in light of the fact that he may indeed become president president again? What do people need to understand culturally about Trump's popularity, or perhaps psychologically about Trump's popularity? Trump's popularity will forever puzzle me that I've known about him. I guess for six, almost 55 years, he's always seemed like a crook. He's always acted like a crook. He's always been exploitive. He's always lied. Um, he's a despicable human being. And, um, in this current term, that if he should win this election. And now I now have some hope, he won't. But if he should win this election, American democracy is tremendously at risk. This is not just a campaign slogan. It's an actual fact that the people around him have developed a program, project 2025, that would destroy American democracy and the people. The president doesn't rule by himself. It's the people around him who control the government. They have identified 2500 human, 2500 people who would be in his administration, who would be trying to implement this anti-democratic, um, authoritarian, almost fascistic plan. And I really have great fears that should Trump win this election, that will be the last fair election in the United States that that severe that they will rig future elections so that they will not lose future elections and that they will be able to end American democracy. I don't think that I'm exaggerating this. I really believe that this is a risk. And the Trump administration, the two existential risks to humanity now are the most severe are climate change. and AI replacement, and the Trump administration will open up both. So they've already made tremendous promises to the fossil fuel industry and to Silicon Valley that neither will be regulated. So humanity is self destructively driving us towards a irrevocable tipping point in climate change. And there's a real risk that I will so outsmart us in the very near future that they may find humanity unnecessary. And the Trump administration has made explicit promises and is getting billions of dollars from the fossil fuel industry and Silicon Valley on the explicit promise that neither will be regulated, just the opposite of what humanity needs to be done that needs doing. So I think that this is a crucial time in American politics. I don't accept the idea that Trump is crazy or that he's delusional. I think he's dangerous. I think he's, uh, developed a an ability to fool tens of millions of Americans and to create a situation in which he can really destroy our country and go far in destroying the world. So I see this as a very crucial election. So the proposal you mentioned, what about it? What is proposed that would threaten American democracy specifically? Yeah, the major things are that the voting rules will be changed in such a way as people will be excluded from voting. That will make elections in the future much less fair, that the Justice Department will be politicized so that the Trump's enemies will become enemies of the people, that the regulatory capacity of the government to control the excesses of corporations will be eliminated. The abortion. There's a very strong possibility that there would be a national right now at state by state, so that in many states like California, where I live, abortions have increased dramatically because people are coming from other states that the pills that are necessary morning after pills are necessary are widely available in this new administration. It may be in the most extreme cases, um, like the vice presidential candidate, only the health of the mother would allow for medical intervention. And what this does is not only prevent abortion, but it prevents adequate medical care for women who are pregnant. Um, the gay rights will be another target. Um, the explicitness of the plan, I think it's about 800 pages. It's in great detail. Um. It's serious. Uh, it's been well thought out, and they have the personnel to implement it. This is a very dangerous time for the United States. It's a very dangerous time for our species. And what was the main thesis of your book, Twilight of American Sanity? Because my understanding is in that book you wrote about how Trump's rise is somehow a reflection of the culture. Could you expand on that a little? Yeah. And it's not just an American problem. I think that the elections in France and Italy and Hungary, the tendency, I think, amongst a very large number of people who are disadvantaged in this modern world, especially people in more rural areas or people where local industries have been, um, collapsed by globalization. So globalization was great for certain businesses. It's made for a tremendous inequality and wealth, but it's left many people very far behind. And the reaction has been to want someone to do something to make it better. And very often the niceties of democracy have disadvantaged people in such a way that they're willing to accept the idea of autocracy in order to get back to something that would make their lives more reasonable. The irony in the United States is that Trump represents the billionaire class. He represents all of the interests that have been aligned against the average person, and yet many average people are seeing him as some sort of savior who will help to return what they regard as a better previous age, and in the United States has been tied up with religion. So his promises about abortion, the Supreme Court appointments have allowed the religious right, which is extremist, nationalist, theocratic, to use him as a vehicle in order to gain control, even though that they are a very small portion of the American voting public, they've been able to gain control of our Supreme Court to have about equal say in our legislative chamber. And if Trump wins, the Supreme Court will forever be representing this point of view. It's already six three in favor of it. The congressional elections may no longer be as fair as they've been, and they haven't always been very fair in the past in some states. So it could very easily take this division of powers that checks and balances that have protected democracy in our country. And if you have a Trump authoritarian president who will influence the executive branch to become more dictatorial, if you have a Congress that's controlled by that party and the Supreme Court with lifetime appointments. This makes for a very volatile situation. The mystery in the book, which I tried to explain, is why so many people are taken in by Trump. And it is. It remains a great mystery. But the more that you understand the suffering that people are feeling with modernization, the more it is possible to see a charlatan like Trump becoming, um, a false prophet and a fake savior. Do you think the Democrats have anything to answer for in terms of straying from perhaps their previous commitments to to people who are disenfranchised, to those of us in our society who are worse off? Of course, I think that that's been the target that has allowed the Republican Party to disguise rational economic self-interest, that people will vote for a party that have tax cuts for the rich and reduce services for them, because somehow or other they feel that abortion is a more important issue, or immigration is a more important issue, that raising these false issues and seducing people into thinking that's what's important. Baiting and switching its vote against the, you know, the gays, vote against the borders, vote against women's rights. Don't worry about your economic self-interest. That's been the Republicans are terrible at governance, but excellent at propaganda. And there are good signs. So I think it's a good sign that the Labour Party was successful in Britain. And it's a very good sign that in Poland, which was sort of under a fascist, theocratic kind of government for more than a decade, that they've come back to democracy. There's some hope in these signs, but there's also a worldwide reaction against the, um, globalization, against the loss of income in many areas, the rural poverty across the world, so that it's a very dangerous time and we have to keep our focus on what really matters. And that's preserving democracy, preserving the climate and saving us from the Frankenstein of artificial intelligence. Well, it's hard to argue with that. On that optimistic note, we're out of time. Professor Alan Francis, it's been wonderful to speak to you. It's rare that I have a guest who is quite so almost encyclopedic in his knowledge. Thank you very much for coming on, and we'd love to have you back at some point in the future. I enjoyed it, and thanks for inviting me and good luck with your podcast.