The Taproot Podcast - Part 6 - A Psychohistory of American Psychology: Please DO NOT Mangle, Spindle or Mutilate Me

Episode Date: April 29, 2026

In July 1979, Jimmy Carter went to Camp David for ten days and came back with the strangest speech a sitting American president has ever given. Officially it was about energy. Functionally it was about the soul. Eighteen months later, Ronald Reagan won forty-four states by promising the opposite, and American psychology received its marching orders for the next forty years. This episode traces how the apparatus got built. From Mario Savio's "put your bodies upon the gears" speech in 1964 to the dispersal of the counterculture into yuppies, Silicon Valley engineers, Lockheed contractors, oil-patch roughnecks, and the back-to-the-land movement that eventually curdled into the survivalist pipeline. From David Rosenhan's fraudulent 1973 study "On Being Sane in Insane Places" to Robert Spitzer's typewriter parties at Columbia, where two new psychiatric disorders could be drafted between cups of coffee. From the Feighner Criteria and the St. Louis Group to the Medicare Resource-Based Relative Value Scale and the RUC, the secret AMA committee that sets the prices of every medical procedure in the country while the nation tells itself it has a free market. From the academic capture of CBT and the manualization of what could be measured to Allen Frances spending his retirement trying to take back what he had built. At the heart of it sits the bet the field made and lost. For thirty years, American psychiatry wagered its entire diagnostic edifice on the assumption that biological validation was imminent, that the genes and the imaging and the neurotransmitter chemistry would arrive in time to retroactively justify the DSM. Twenty billion dollars later, NIMH director Thomas Insel posted a blog three weeks before the DSM-5 shipped admitting the categories were not scientifically valid. He later told Wired he had funded a lot of cool papers and not moved the needle on suicide, hospitalization, or recovery for tens of millions of Americans. The cathedral had been built on a foundation that turned out not to exist, and the surrounding infrastructure had become too entangled with it to demolish. This is the story of how a profession built to listen to suffering became a wall that suffering speaks into. Diagnosis as checkbox, payment as procedural code, research as citation farming, and the Sherman Antitrust Act ensuring that the only people who could fix any of it, the frontline clinicians, are forbidden by federal law from organizing the way that would give them leverage.

in their old machines. You haunt the space between breath on machines. Hey guys, it's Joel, and welcome back to psychotherapy on the couch, a psychohistory of American psychology. What psychology can see, what it can't see, and why it has trouble telling the difference. Welcome to episode six. Do not fold, spindle, or mutilate.

In the summer of 1979, Jimmy Carter went to Camp David for 10 days, and he canceled a, scheduled energy speech. He called in pollsters and pastors and economists and ordinary citizens, and he listened to them, included a lot of those conversations in the speech he would give. And what he came back with was one of the weirder speeches that a sitting American president has ever attempted. You know, officially it was about the energy crisis, but functionally it was about the soul. And Carter said that the country was in a crisis of confidence. He said it was a

crisis that you could see in the growing doubt about the meaning of our own lives and in the loss of unity and purpose for our nation. And he said, too many of us now tend to worship self-indulgence and consumption. Human identity is no longer defined by what one does, but what one owns. And he said that piling up material goods cannot fulfill the emptiness of life, which when we have no confidence or purpose. And this was a sitting president essentially doing depth psychology. the country. He was naming in 79 exactly the wound that we traced in the last episode, or the most recent iteration of it, the collapse of the mythology, the void left behind, and the way that Americans were trying to fill that void with consumption that could not

possibly ever fill it. You know, hungry ghosts in the Buddhist sense is what he was accusing the country of becoming. And he was trying to do for the country what a good therapist does for a patient, and he was trying to put words to what the patient could feel but couldn't say. The press called it the malaise speech, even though Carter never used the word malaise in the speech, and it really killed his presidency. Asking America to have a different relationship to the hero myth or to consumption is one that you can't do and has never been done since. And because Americans did not want a therapist, they wanted a father who could tell them everything was going to be fine, and especially that everything was going to be fine if they just kept doing what they'd done before. And so 18 months later, Ronald Reagan stood on stage and gave the opposite speech.

mourning in America. America is a shining city on a hill. The government is not the solution to our problem. The government is the problem. Where Carter's speech had been an attempt at integration, you know, it said there's something that is wrong, the wrongness isn't us, and we have to look at it together. Healing is possible if we do that and a community and meaning with a solution. Reagan's speech was an act of repression. It said, there's nothing wrong with us. The wrongness is in them, bureaucrats, Russians, the welfare queens, the regulators, and if we just get rid of them, we will be fine. They're the reason that you feel this way. And one speech named the wound and the other named a scapegoat, but the scapegoat was infinitely more appealing, and the country chose to scapegoat and a 44 state landslide.

And I want to spend a minute on why that happened, because it wasn't a political event, or I'm not talking about this as a political argument. It was a generational absorption. To understand how psychology got its marching orders in 1980, which were building towards, you have to understand what happened to the people who decided a decade earlier that they would no longer be these potential loud voices against what Reagan was selling, or a voice selling something else, so that there could have been a conversation. In 64, there were students at Berkeley that held up signs at a free speech protest that said, I am a UC student. Please do not fold, bend, spindle, or mutilate me. They also had that on T-shirts. And the punch card,

the IBM punch card, which you used to program the earliest computers. You couldn't really input code, so you had to basically punch it into a card, like a grid, and that was the language that it spoke. If you got one dot wrong, the whole program didn't work, he had to start over. So if you had 300 of these in a stack, they were incredibly valuable. And if it was something that was, you know, a banking record or your student card that you were registering for classes or, you know, entering your social security number, you had to make sure it was right. And if it was bent or mutilated or put on a spindle, which, you know, people did,

cards in those times, then it wouldn't work. And it had to be a stiff, stocky card that the machine could scan quickly. And the IBM card had those instructions printed on the top margin. And the instructions warned the machine operator needed you to not damage this card because the card was data and the data was the person. Because the data was the person at Berkeley in 64. The mass influx of students had meant that there was a new kind of bureaucracy that needed to happen. There were giant movements that were too big to manage with traditional bureaucracy, with traditional structures. We now needed to atomize them into data. And this was how kids registered for classes. It was how they got their grades. It was how they communicated with the system that no longer had a person

that they could speak to. And it pissed them off. You know, the Berkeley kids held up these signs making, you know, themselves into the card, being like, I'm the one that you shouldn't utilize. Don't make me respect this card. It's not better than me. And so there were rallies and there where students strikes because the students refused to be treated like data or to treat computers and bureaucracy is more important than themselves. You know, the same thing that a lot of Carter voters or black, uh, not Carter voters were angry about when Reagan said, hey, bureaucracy is the bad guy. And they said, hell yeah. This is a world of increasing bureaucracy. These students sit on the steps as, you know, lefties. And they said, you will not mutilate us. You will not

turn us into data. And we are, uh, demanding. humans to interact with. Human system, not machine systems. But we're a bunch of raw materials that don't mean to have any process upon us. Don't mean to be made into any product. Don't mean to end up being bought by some clients of the university. Be they the government, be they industry, be they organized labor, be they anyone for human beings. Separation of the machine becomes so odious. Makes you so sick at heart that you can't take part. You can't even pass.

massively take part. And you've got to put your bodies upon the gears and upon the wheels, upon the levers, upon all the apparatus, and you've got to make it stop. And you've got to indicate to the people who run it, to the people who own it, that unless you're free, the machine will be prevented from working at all. So as Savio is saying there, you know, this was a demand. It was a moral demand to put your body on the gears of the apparatus, on the levers, on the wheels, and stop the machine if the machine will not stop being odious to you. And it's one of the most extraordinary things any American student has said into a microphone, you know, and it's one of the least

quoted, you know, at least in the mainstream, you know, cybernatics and some other, you know, historians use it. But it is a spiritual ancestor, you know, that moment of many things that happened to psychotherapy and other American systems after that date. It was about the mainframe being an enemy, the machine as enemy, and the whole apparatus of bureaucratic rationality that had gotten into the country after Vietnam because of Vietnam, the amount of processing and the amount of scale that these systems had to have. Because it was these students noticing that after Vietnam scaled the military to become a system that required machine logic, that that machine logic was being brought home,

and the entire country was now being treated in the same way that this military apparatus that had been created to run Vietnam and the DoD forever onward would be turned to end word and we would run the country that way. We would not treat everyone like a soldier, but we would start to treat everybody like a product and like a cog in the machine the same way that the military had. You know, and the summer of love collapsed in 67 with, you know, there was the death of the hippie parade in Height Ashbury that was this sort of a parody of, you know, the hippies dying off. Heroin was coming in after Vietnam. A lot of these people were getting hooked on harder drugs. And, you know, and it was now, you know, the needle instead of psychedelics.

and, you know, dirtweed. And, you know, Manson, Charles Manson happened in 69. Altamont happened three months later. The weather underground, they went militant. And then that movement went nowhere and largely didn't have a symbol to rebel against after Vietnam. So they turned themselves in and they got acquitted because the government had been collecting information on them illegally, basically, with Quintel Pro. And, you know, Nixon is reelected in a landslide in 72. The oil embargo hit in 73.

stagflation, 18% interest rates. You know, your commune did not have health insurance for your kid anymore. It wasn't fun. And you had a kid now because it had been a decade and you were tired. So nobody put their body on the gears. The bodies went into the gears, one after another, and the gears kept turning. And after a few years, nobody could even remember what the gears were supposed to grind to a halt for. And nobody could feel them.

There was a mass dissociation. And so when the hippies dispersed, you know what happened to the hippies it's it's actually documented demographically pretty well you know the largest group of them they didn't just go one place but the biggest group became yuppies they were these young urban professionals like the kind of thing they got made fun of in like you know mid-80s movies and they cut their hair and they got mortgages and they entered the formal labor force and they kept the social liberalism but they lost the economic radicalism and you know jerry rubin you know the yippie who'd been arrested in chicago you know

know, at the convention, was hosting this business network in salons, like, you know, at Studio 54 by 1980, and the commune became the condo. And the demand for personal liberation got seamlessly absorbed into the demand for personal economic freedom, which was what Reagan's pitch was. That's why it worked. And smaller groups, you know, the ones that Stuart Brand had called the new communalists, they took their cybernetic theories and their copies of the whole Earth catalog, and they went to Silicon Valley. And the... same people who had held up those punch card signs in Berkeley at 64 went on to reimagine the computer is the opposite of what they had protested. The computer was no longer the mainframe,

crushing the individual. The computer was the personal microcomputer liberating the individual. And the network was no longer IBM. The network was the W-E-L, which brand launched in 1985 is one of the first online communities. These, they were basically list serves, you know, or if you're not as old as me, they were like forums. The forum is like the closest thing. There were these bulletin board systems that you would log on to and basically post stuff and talk to people out of the country,

but you had to pick one to subscribe to and pay for. And, you know, the distance between the Grateful Dead and early Google is remarkably short. And a lot of people, the same people, walked in that pathway. And both believed that the network's inherently leveled power structures. But they were wrong about that. in ways that we're still paying for.

Because those hippie communes, a lot of the language that was used to sell bulletin boards and systems and these early networked computers, it was the same network, it was the same language of the commune, except you could do it from your basement when your kids were asleep. And, you know, you had to spend about the cost of a helicopter to get one until the price came down. But it was something that was familiar to the culture.

It didn't feel different, but it was different. And a lot of these people who went into cybernetics and, you know, sold their, you know, whole earth catalog, but had learned all of this, you know, kind of great engineering stuff, went to work at Lockheed. And that sounds like a joke, but, I mean, you can look at these demo shifts. Like many of the countercultures participants had advanced degrees in physics and engineering, because they were into ecology, essentially. And when the draft ended, when the moral stigma softened, the defense industry offered the most complex technical problem in the world to solve and the most money to solve it. And it didn't really care about your politics. You didn't have to make that distinction. You know, the Skunk Works division that built the SR 71 Blackbird and the F-1-17, you know, stealth fighter.

They needed these brilliant minds. And, you know, their hair came off and the white coat went on. And the same people who had organized the teachings against the war were by the mid-80s, you know, working on propulsion systems for weapon systems, having compartmentalized the work into something that they could live with. So when you see a candidate like RFK where it's like people who have, you know, people who have. like him are like usually like working in huntsville for like a military contractor or a rocket company but then they also like are super into like vitamins and they like like like high tech but they also like view themselves as like agrarian and natural and against the system that is the last vestiges of these guys you know others you know probably the smallest group it's still a pretty big chunk they went to work in

the oil fields in 1973 the embargo created these massive labor demand you know for this domestic oil extraction because it wasn't coming from other countries. We've got to get it here. And so the oil patch paid really well if you didn't have one of these technical degrees or you weren't particularly gifted a STEM field. And it didn't require any corporate polish. It stuck, you know, your sort of a badass rogue, rambler, a lone, every man, hardworking, you know, individual.

It fit that archetype pretty well. And so there's kind of funny stories. where, you know, a lot of these people are watching basically like hippies, either put their hair under a baseball cap or cut it off and switch the tie-dye for plaid or put the platt over the tie-dye and start working these oil rigs. And, you know, you call the place where you link basically like an oil extractor. Like you call it a joint, they're huge, these huge machines. And so there was like a joke in these towns where they were like, yeah, the hippies heard

that we have 50-foot joints. You know, it's the tool, anyway, but you don't have to, the, the, the joint is a tool pusher. But, you know, it was this kind of joke that these towns were now being populated by, you know, in these sort of rural, a lot of times, conservative communities that had seen themselves, you know, against the hippie movement, were now being populated by them, and they couldn't really tell themselves apart from them. And the generation that had celebrated the first Earth Day became the labor force of the fossil fuel regime.

But none of these things, the point of this is that none of these things, of these things felt like a contradiction. They were pretty natural evolution. Um, because none of these guys understood systems pretty well. I mean, very well at all. And, you know, we have the benefit of hindsight. Um, but this just felt like the next thing. It didn't feel like a different thing. And many of these other people, you know, kind of the fourth that's left, they went to the woods. They became these back to the land movements. Um, and a lot of times they were rebelling against the excesses of the cities. You know, they didn't like the hard drugs.

They didn't like the heroin. And so they sort of became like conservative hippies. A lot of the back to the landers were either very religious or socially conservative. You know, in the Ozarks alone, there's 2,000 migrants that arrive there. And most of them are white. Most of them are under 30. Most of them have undergraduate degrees. And they buy these 90 acre parcels with year-round springs for under $20,000.

And, you know, if you had to know how to do that, you know, kind of ecology stuff, not the STEM knowledge, and maybe not the ability to work on an oil rig, that was a pretty good deal. And so the story gets kind of dark there because that back to the land movement made these kind of weird outcomes. You know, one stream became modern organic farming. Something like woof, if you ever thought about organizing or, you know, going to volunteer at the World Organization of Organic Farmers when you were in college, you know, in between a year or something.

And, you know, but after the farm crisis of the 80s and there's decades of rural, you know, isolation. It kind of curdled into this weird survivalist pipeline. And that's why, like, now, you know, you associate conspiracy theories with generally the right wing, where in the 90s, when I was growing up, you know, Alex Jones and a lot of these guys, they were seen as, you know, these kind of hold out against the government communities. They were all seen as left wing. They were seen as sort of like extreme liberals because those core tenets of distrust, deep distrust of government, desire for autonomy, rejects. of industrial capitalism, self-reliance.

They turned out to be ideologically, you know, pretty fluid. There was a lot of rural desperation mixed with, you know, whatever is left over from the roaring 60s. And so some former hippies evolved into these fierce anti-government survivalists and basically started, you know, kind of sovereign citizen-type movements. And researchers now call that the kind of crunchy to alt-right pipeline. But that's sort of the formula for what we have now. And, you know, when I was a kid, those guys were seen as left wing. You know, they were the ones, you know, talking about UFOs and the JFK assassination and everything.

And that was seen as a lefty thing. Now it's largely, you know, not. And so the, and it'll come back around. I'm not picking on anybody. So, you know, the culture didn't really die. It dispersed. And the pattern of the dispersal tells you why Reagan won in a 44 state landslide and why the Efficiency Gospel found no or.

organized resistance in the field that should have, you know, resisted at the hardest. Because the counterculture was never, you know, really collectivist. It was hyper individualistically, we talked about before, Sam Bingley. You know, it rejected the communal obligations of the mid-century welfare state in favor of personal liberation. And once the left-wing political project collapsed in the mid-70s, the demand for personal liberation was absorbed wholesale by a political right that offered personal economic freedom as a substitute. And neoliberalism thrived. you know, precisely because it could absorb the hippies' hatred of bureaucracy in the state and repackaged it as free market deregulation, but they didn't feel like they were switching

sides or doing something different. You know, as Reagan would say, I didn't leave the Democratic Party. The Democrats left me. The Age of Aquarius did not defeat the establishment. It updated the establishment's operating software. And it's worth pointing out that, like, a lot of the, we view the hippies in retrospect as being very, like, left-leaning. a lot of these guys were not political

and they were not bright. Like if you want to look at kind of like the vibe of this time, probably one of the stupidest books ever written is Jonathan Seagull, or what is it? Jonathan Livingston Seagull. It's like a Seagull doing Buddhism and being like, oh, I'm ostracized by the flock because I want to fly high for the spirit of it to better myself,

but they want to fly low down and they want to pull me down and judge me, but then I will have a try, whatever. that culture is a whole lot of the vibe of this time. And so, you know, when Reagan's giving a speech about government being the problem, he's not saying something alien to the Berkeley generation. He was saying something that fit exactly inside the vocabulary that they had just spent a decade building. And speaking to the frustration that they're feeling about the bureaucracy,

when Savio gives that speech. You know, they had said that the machine was the enemy. And he said that government. was the enemy. And they said that institutions were oppressive. And they said that regulations were oppressive. And they said that you liberate yourself by breaking free of those things. And, you know, Reagan was saying that a free market would liberate you. It was free. Let the market decide how much you're worth. So the punch card kids didn't really march against Reagan in 1980 because Reagan was telling them in the language that they had written that their old

enemy was his old enemy, which wasn't, you know, quite true. But it was a lie in vocabulary that could no longer distinguish, you know, from the truth because the vocabulary was the same. You know, the semantics of these things felt very similar. But this is how the Overton windows shifts. Like, it's not really argument. It's vocabulary and exhaustion. And the people who built the vocabulary getting tired enough to let the next person come along and use it, you know, however they want, is generally how American culture works. That's why I'm spending so much time on these ideas in a psychotherapy podcast or what happened to psychotherapy podcast.

But this is the moment that American psychology gets its marching orders for the next 40 years. Because if the cultural project is now repression, the cultural project of psychology will also be repression. Or if it isn't, it's going to be at odds with the culture, but makes it hard for a, you know, bureaucracy to exist. that's codependent on the bureaucracy of the country. And so the country has decided not to look at what is wrong with it. The apparatus that was supposed to help us look at what is wrong

will be repurposed to help us not look. To manage symptoms, to restore function, to get us back to work. That's what therapy was supposed to do. And the apparatus complied, not because anyone planned it, but because the incentive structures realigned overnight and a profession that had been desperately seeking legitimacy for a century found itself offered a new kind of legitimacy. If it would just stop asking certain questions,

and it did stop asking those questions, it could go ahead and be treated like a serious adult at the table, or so they thought. And this episode is about what happened there. You know, like I say in the beginning of all these, what psychology can see, what it can't see, and why it struggles to tell the difference. You know, it's about the wall that the wound speaks into,

or ran into. It's about bureaucratic apparatus, the diagnostic manual, the billing code. the 15-minute session and the closed committee room. How do we get from Freud's lifetime of psychoanalysis to 15 minutes and you're done? It's about a handful of decisions made by identifiable people and identifiable rooms in the late 70s and the early 80s that produced a system that even its own architects spent the rest of their lives apologizing for and largely trying to undo.

But they, the architect, were not as powerful as the machine anymore. And it's about a crucial bet that the profession of psychology made in the 90s that had it paid off, would have retroactively justified everything. But the bet was that the brain-mind problem was close to being solved, that human beings would behave like a machine. And so we could go ahead and preemptively structure, you know, it's not anti-scientific, it's just pre-scientific. The science will catch up to the direction that we're going,

but we're not going in a non-scientific direction. That, you know, the biology of mental illness would be understood in time to save this diagnostic system that had been built on the promise of this biology. and they bet the field's future on a scientific development that they were sure was imminent and they were wrong. The biology did not arrive and the diagnostic systems that had been built on the expectation that it would arrive could not be unbuilt. And maybe it still can't. And that is the deepest reason that the apparatus, even now, even after its own scientific authority has been declared invalid, continues to operate. It's a cathedral built on a foundation that turned out not to exist.

And by the time anyone could prove that the foundations did not exist, the cathedral was already holding up too much weight, too much structural infrastructure to ever be demolished. Are you angel? Are you engine? Are you hunger? Are you light? I press my ear against your casing here. A heartbeat in the bite.

Every little little gospel. Levy freeze a kind of sign If I crash here in your cradle, will you rewrite this Old design Gold machines You hump the space between Where's sweat on the screen Old machines

Where's caught in your fever dream In 1973, David Rosenhan published a study in science called On Being Sane and Insane Places And the premise is very elegant, elegant, you know, it claimed that, you know, seven graduate school students of his, they presented themselves at 12 different psychiatric hospitals, reporting one single symptom, hearing a voice say the word thud. But once admitted, they would just immediately stop pretending that it was, you know, they were having any symptoms and they would just behave normally.

And they were nevertheless held for an average of 19 days. And when they were diagnosed with schizophrenia, they were given antipsychotic medication. and the hospital had no ability to distinguish a sane person from the insane. And so Rosenhan's point was that when you make psychology just this subjective thing where these people pretend to be experts, you know, these people, some of them he worked with and didn't like, you know, wanted to kind of show the lie to their expertise, you know, he would just say, you know, hey, look, if I go in here, anything that I do in the self-sealed system, it can't prove that I'm not, I can't prove that I'm not insane.

Everything is self-reinforcing because it's just based on these experts who just kind of make things up. And so if I go in there and I act normally, everything that I will be doing in the medical record is going to be interpreted my normal behavior as abnormal behavior because it's all just vibes. So you can't tell the difference between a sane and an insane person. So why, you know, have psychiatrists. And the study was this giant bomb on the profession that it got cited everywhere and it was taught in every undergraduate

psychology class for the next generation. I mean it's taught to me and it was you know all of these journalists were reporting on this it really put egg on the face of psychiatry and you know later when Susan Callahan is writing on her book the great pretenders she goes and tries to find some of these people and tries to find the records and she finds Rosohans records and she discovers that you know maybe he made some things up and And a lot of that study is, you know, open for critique now. But the point of it is that it made psychiatry very insecure. And a lot of people, even if the study was fake, you know, knew that what Rosenhand was saying was true. And so, you know, the embarrassment was very real.

And there's earlier stories done by, you know, people like Beck and Ash, you know, they'd published. And they'd shown that the agreement rate between psychiatrists looking at the same patient could be as low as 40% on really big categories, like anxiety or depression. and on specific diagnoses, they could be 20% in agreement on something like, you know, generalized anxiety disorder. And so two psychiatrists that examine the same patient, and they confidently produce these two different diagnoses, that's not a scientific system. And they could recommend two different treatments now evolving, you know, from, you know, these new psychotics, antipsychotic drugs.

You know, they could prescribe two different medications based on which psychiatrist you And a lot of these things have serious side effects. They're dangerous drugs if you're giving them to the wrong person. So the Rosenhan study was just holding up a lie to this thing that the profession already knew. And that's why it took off. And the profession was also in this panic because at that same moment, the Rose Enhan's publishing, you know, the insurance industry was starting to ask, like, why should we reimburse for this at all? You want to talk to these people for 25 years.

That doesn't look like a medical service. They could just talk to someone else. So practitioners who couldn't agree on what they were treating. And behaviors, you know, started arguing that, you know, these behaviorists, they started arguing that the entire psychoanalytic enterprise was unscientific anyway. And you should just look at the behavior because why look at something slippery and fuzzy like emotion or, you know, whether or not they're happy or meaning. I mean, who cares about this stuff? Can they go to work?

Can they do it? You meet criteria or not based on what you're actually doing, not on how you feel. And so they stop talking about emotion. If the emotion is important, it'll stop them from doing something important. You know, Thomas Zaz is also a psychiatrist, and he had published the myth of mental illness around this time. And he argued that, you know, the whole field was this moral system, but it was basically pretending to be a scientific one. But really it was about morality, because you're just saying, these people don't contribute or we don't like them or they live in a way that it's different from the mainstream. So they're crazy, not because of a biomedical or biological reason, but just the culture doesn't like them.

So we're making a moral judgment. And insane and insane, there really wasn't that much. science too, that you're emasquerading a moral system as a medical one. And drugs that are coming out right now, you know, after the first generation of thorazine, and you're getting second generation antipsychotics, they need diagnoses so that they can get FDA approval. How do we know if it treats it or not if we can't, you know, research? Same thing that affects the profession to today. And so if you don't have a diagnosis, you can't get someone to treat that diagnosis, you know, pay for it or prescribe a drug for it. And so, you know, you know, you, you know, you

You needed these reliable things in order to keep the industry going. And drug money was just going to dry up, which the profession needed to be able to function in the hospital and justify its existence as someone who could do something other than talk. But at the same time, you have a schizophrenia epidemic in the 70s because, you know, you have heroin and you have trauma from Vietnam and you have homelessness. And you have all of these kids that are no longer smoking dirtweed. And they're on harder drugs. and they're becoming psychotic.

And, you know, there's still some disagreement about how much of schizophrenia is genetic and how much of it is environmental. We know it's a little bit of both. But the people who had the genes were definitely during this time having the trauma, you know, activate. It's not the 50s anymore. And a lot of them have, you know, basically been in Vietnam watching their friends get killed. And now they're, they have PTSD and they're doing hard drugs and they're homeless. And so schizophrenia and the first generation antipsychotics at the same time as Rosenhan,

And that really saves the profession too, which that's an under-discussed point because, you know, before that, psychiatrists were just seen as sort of like sedating housewives. You know, you're just giving the nervous housewives these pills that are functionally time-released alcohol. And now, but there's not really anything that you can do, like that a heart surgeon can. There's all this insecurity. And then what happens is that you have all of these studies that say, okay, these psychoanalysts sat with the people with schizophrenia and they talked to them and they these people were psychotic and

they came up with all these heady conceptualizations about how the psychosis was like an extended metaphor for trauma that happened to them as a child but then also the trauma was like um you know reactivated during vietnam and the hallucination is actually to this metaphor and people are like who cares you talk to them for two years and nobody got better this guy gave him a pill and all of a sudden the guy's putting down a sign that says that he's Napoleon um or the rebirth of jesus or something and he's putting on a tie and he's going to work and he's getting discharged from the hospital. And so finally there was something that psychiatry could do. So Robert Spitzer shows up in the middle of this crisis.

And Robert Spitzer is a psychiatrist, but he was not really thought of as a clinician because he didn't particularly like to sit in rooms with people. He wasn't really curious about human nature. He didn't really like talking to anybody. He viewed people kind of more as obstacles to be fit into systems or to be overcome. And, you know, what Spitzer loved was classification and talks taxonomy, that, you know, science could talk about how animals evolve. It could talk about, like, all the different, you know, philologies of insects and how they're, you know, related. And, you know,

he loved the cold satisfaction of fitting these messy realities into clean categories. And so the American Psychiatric Association, APA, they asked him to chair the task force that would produce this third edition of the diagnostic and statistical manual. It's kind of a hell marry to try and get psychiatry back on track and get it, you know, accepted with the cool kids again. And so Spitzer, was looking for this model and he looked at Washington University in St. Louis. There's a group of psychiatrists that are led by Eli Robbins, Samuel Goose, George Winnicor. And they had spent, you know, these decades, or they had spent about 10 years trying to operationalize psychiatric diagnosis. They were called the St. Louis group. And in 1972,

they had produced what came to be called the Fegner criteria, you know, after the author is John Fegner. So the Fegner criteria was this diagnostic checklist where there's five symptoms from this list that last for this amount of time, and that equals this diagnosis. And so the St. Louis group was deeply hostile to psychoanalysis, and they were really committed to a biomedical model of mental illness, which didn't exist yet. And they'd figured out how to make psychiatric diagnoses look like the rest of medicine, finally. You know, you do a blood test to find out which virus somebody has. And you do a tumor marker to find out if somebody has cancer. But there wasn't something like that for the brain.

You know, as Rosenhand approved, you could just go in and lie and you looked crazy. So Spitzer takes this idea and he runs with it. And the way that he ran with it tells you everything that you need to know about was about to happen. You know, he told participants that they couldn't leave. Like you literally would lock the door. They described it as typewriter parties. You know, he'd get people wine and genitonic and, you know, they'd be in his apartment. And he would just say, how long does anxiety be?

last and half the group says, well, it's got to be at least a month. And the other half says, no, it's got to be six months. And he says, no, you got to decide. And they get in a fight. And he won't let him leave. And then finally they're like, okay, fine, three months. You know, somebody else is like, I refuse. And they're like, okay, because of Bob, we got to do two months. All right, there, there you go. And, you know, one of the things that Spitzer did was force these people to actually talk about the diagnosis that they were giving. Because before that, they were all these, like, little kings in their kingdom that didn't really have to agree. So Spitzer put an end to that pretty fast. And this process has to tackle the entire scope of diagnosis. So it's like the first Webster's

dictionary. Like it's not very good and they have to kind of, but unlike, you know, the Webster's dictionary, they have to move at light speed to get this done. Like there's a 40 minute period where Spitzer says, okay, brief psychosis, you know, brief reactive psychotic disorder or brief reactive of psychosis. You've got that, and that's where somebody is having psychosis just for a minute, and that goes away. And then you have a factitious disorder where they're basically lying about being psychotic. How do you tell the difference? And the people talk for about 30 minutes. He types on the keyboard, everything that they're saying. The last 10 minutes, he makes, I think, four total edits and then says, all right, there you go. There's your list. And they go through the

whole entirety of mental health diagnosis in that way. Some of them get a little bit more time than that. But big project real quick. And the criteria work, you know, in a specific narrow sense. You know, he's making a punch card now for the profession. Two psychiatrists can look at the same patient and they can apply the same checklist. And they would now arrive at the same diagnosis, supposedly. And so reliability in the early testing goes up because people are just reading the lists. So they're not really doing therapy.

They're kind of testing out the system. And so this crisis is marked as solved and the profession was saved. in the eyes of the people doing this in the 70s. And so the DSM3 is published in 1980. There's 265 categories. There's 494 pages. It restructured American psychiatric practice within five years. But here's what Spitzer has done is solving a reliability problem.

But he completely abandoned the validity problem. Yeah, they agree. But do they agree on something that's right? Reliability is the question of whether two clinicians agree about a diagnosis. but validity is the question of whether the diagnosis corresponds to anything that is actually real, right? If I say everyone who has a blue shirt but also owns a blue of bare pants that they may or may not be wearing and drives a car is now defines as a yabula, then I've just made up a category. But that isn't really a very useful category because that's a thing that I just made up.

And psychiatry had inherited a lot of things that before this time people had just made up and then written a book on. And so you're not really measuring depth and meaning of a person's despair or even a purpose of how this diagnosis is going to be used. You've just measured five out of nine items on a checklist. And you've reduced the profession to essentially that. And the DSM3 was, you know, supposed to be a theoretical. That's what Spitzer was really proud of. You had all these people that were different schools of thought. And they wanted to come together at a conference and they wanted to fight.

And they wanted to say, my school of thought is better. We should move past Freud. My school of thought is better. We should move back to Freud who was going deep. My school of thought is better. I'm a behaviorist. We shouldn't talk about emotion at all. And Spitzer had no interest in the messiness of those fights.

He wanted to sit these people down and say, yeah, who cares about Freud? Who cares about behavior? Which one of these boxes would you check if you were going to give somebody that thing? And then force them to agree. And he did. So, you know, it would describe symptoms and group them into diagnoses or diagnoses. And, you know, this was supposed to be this great virtue, the thing that allowed psychiatrists of all theoretical orientations to use without having anyone really win a fight. But what it actually did was hide an enormous theoretical commitment behind a claim of neutrality.

Because by reducing diagnosis to symptom counting, it implicitly committed to a model, a biomedical model, where this symptom is now the disease. and where the question of why symptoms exist, you know, where it comes from, what its particular purpose is in a person's life, is it normal for most people to have it? Well, if most people have it and it's all around a life transition, can you call it a disease? You know, the history and the body and the meaning, it's just officially declared irrelevant to clinical care. And so the wound was no longer going to be something that was analyzed or understood or even looked at. It was just going to be something that affected the checkboxes that we ticked. And here's this thing about when you do that.

Once that diagnosis is a checkbox, the treatment can also be a checkbox. So you've now manualized mental health in a way where if the patient does these things, the clinician does this, and that's therapy. And so it started to turn the psychiatrist into a machine. Once the diagnosis is a category, that can be reliably reproduced across clinicians. The treatment can be a protocol that can be reliable. liably reproduced across clinicians that feel scientific. And once treatment is now a protocol, it can be measured.

And once it's measured, it can be reimbursed. And once it can be reimbursed, the insurance company has the leverage to dictate which treatments will be paid for. And once the insurance company has that leverage, the only treatments that survive are the ones that can be standardized into a protocol. And so the DSM3 didn't just save the profession. It rewrote the profession. And it mandated what the profession was allowed to be from the system.

that moment in time onward. But clinical infrastructure is not the only thing changing because Reagan has just been elected and Thatcher's been elected in Britain. So, you know, the other half is the financial infrastructure for therapy and psychology. Something that other professions like heart surgery don't really have to think about, something that the military doesn't really have to, if they want a whole bunch of money for bombs, they just tend to get it in America. Psychology does not work that way. And so the story of the financial infrastructure is kind of a funny catastrophe. in American medicine. It's darkly funny, but it's the story of this country that's now so committed to the mythology of the free market that it couldn't see that what it was constructing was one of the

largest centrally planned price-setting bureaucracies in the developed world to this day, while telling itself that this was the opposite of central planning. In 65, you know, Lyndon Johnson signs Medicaid or Medicare into law. And so suddenly the federal government is paying for the medical care of every American over 65. So the question immediately arises, what does the government pay for each procedure? Because what they were asking us to pay is exorbitant. And so in a centrally planned system, the answer is pretty obvious. The government, you know, after consulting experts, it would just set a price. And this is what happens in every other developed country. You know, the state just has a price list for care. Knee surgery should cost the same thing. If you're charging

too much, you're not doing knee surgery efficiently enough or something. You know, so doctors just get paid the price. But the American medical establishment had just spent the previous half century terrified that any government involvement in health care would lead to socialized medicine, communism, you know, which they understood as this existential threat to their existence. And a lot of the new myth of the morning in America was about a free market. So the American Medical Association had just, you know, they killed Truman's National Health Insurance Plan in the late 40s, you know, by spending what was, you know, then the largest lobbying budget in American history ever and saying that they were fighting Bolshevism in America. And a lot of this stuff gets talked about like the 80s because the 80s is kind of where it

comes to a head. But it starts way earlier with the Cold War. Like in 61, Medicare is still just a proposal. It's not a law yet. And the bill that's on the table is actually called the King Anderson bill, which is a Kennedy administration effort. And that's how far it goes back to provide federally funded health insurance for elderly people. So the American Medical Association is viscerally opposed.

And they've been opposing federal health insurance since the 30s. And so since FDR first even talks about that as being part of Social Security. And that had, you know, that was killed. They made sure that Truman's, you know, national health insurance proposal in the late 40s is killed by spending, you know, at the time, what is really the most amount of money that's ever been spent on any of this stuff when you look at inflation. But in 1961, they had a well-developed playbook for killing this federal health legislation, and they wanted to deploy that again. So the campaign that they run against the King Anderson bill is called Operation Coffee Cup.

And it is even by the standards of the mid-century lobbying really weird. The American Medical Association hires Ronald Reagan, who at this point is just a fading B-movie actor who had done his last serious work in the 1950s. and he's now hosting the General Electric Theater on television. He's a spokesperson for corporations, which would be very useful to the corporations when he became a president because he knew how to sort of wander their talking points. And so Reagan had drifted from being this kind of New Deal Democrat in the 40s

to being like a corporate spokesperson in the 50s and kind of a B actor. And then his politics had kind of followed that direction. And so he was known for being, you know, charming and telegenic and, you know, this conservative kind voice. and kind of grandfatherly even when he's younger. And so the AMA pays him to record LPs, like records, titled Ronald Reagan speaks out against socialized medicine.

And it's approximately 10 minutes long. You can still find this audio on YouTube. This episode's longer, so I'm not going to clip as much. But on the record, you know, Reagan warns that if Medicare passes, it will lead to full socialized medicine, and that socialized medicine will lead to the end of American freedom itself. So the signature line that is on the record, You know, one of these days, you and I are going to spend our sunset years telling our children and our children's children what it once was like in America when men were free.

Those are the stakes, you know, that still are, you know, a part of the system that affect psychotherapy and probably, probably worse than other professions. You know, and he says this about a bill that would provide hospital insurance for people over 65. So what's weird is that they sent all of this to doctor's wives because they know they kind of have the doctor's ear and they like like free things in the mail basically. But they also know that the wives get together and they play records at coffee gatherings and then they kind of get whipped up about politics. And so the doctor's wives essentially get these records in the mail. And then while they're having coffee like, oh, what is this? Let's put it on. and then get terrified and then talk to their husbands.

So, yeah, that's Operation Coffee Cup. So, you know, when Medicare does pass, the costs do immediately explode because doctors aren't stupid. So the law says if Medicare will pay you what you say your usual rate is because we have a free market, you now just get to make your rate anything that you want and the government has to pay it. So the rate increase is just compound. You know, people start tripling the cost of what they're doing.

But again, you know, the project is the free market, this myth of a free market that is always better and more competitive than a fixed rate somehow. So now you're, this becomes a problem. So by the mid-80s, it becomes a fiscal emergency. And the country has a choice. You know, it could do what every other country had done, which was have the government set prices through transparent regulatory processes or just have people vote on it. Or it could keep pretending that it had a free market. in healthcare, even though there was no free market in healthcare because the patients couldn't shop and the prices were paid by a third party.

And because like healthcare in America, especially now, but even then, lacks any of the features of anything that you could remotely call a market. But they want to stop it. And so in 1989, Congress passed legislation creating the Medicare resource-based relative value scale, what would be called, what would eventually become the RUC or the RUC. So the idea was that. that instead of paying what doctors said was customary, Medicare would assign each medical procedure a score based on the resources required to perform it. So it makes sense, right? It's a centralized

planning without the centralized planning or oversight or democracy. But, you know, just you rank these things on time, skill, and then overhead. You need a $500 device to do it. How long does it take you to require the skills to do it? Is there a whole lot of risk where you need to cover liability insurance and then how much time. That should, you know, tell us what anything costs. So, you know, the score, which is called the relative value unit or RVU, like would be multiplied by a conversion factor to produce the Medicare payment. And so this would be this objective thing, you know, scientific and resource based. And the opposite of central planning, somehow, even though it was very obviously the central setting of prices for the largest healthcare market in the world, but it can't

look like that. And so here's another kind of weird thing is Congress is having created the system, and then they ask the question that every central planning bureaucracy has to answer, which is, like, who actually scores the procedures? And so the answer, because the AMA had spent 25 years, you know, building the lobbying infrastructure to ensure that this answer was that doctors were schooled their procedures. So Congress aren't doctors. You need a committee of the American Medical Association called the Specialty Society. relative value scale update committee or the Ruck and this is the modern iteration. So 31 specialists and they're almost all proceduralists.

There's mainly, you know, high insurgents talking about a high end specialty, would meet three times a year in a hotel ballroom and they would assign these RVU scores to the procedure that their own specializations, you know, they would split the money up basically amongst their professions, their specializations. You know, the issue with that, though, is that no one really sees it and no one except for them has a whole lot of say. And Congress will go with their recommendation almost, I think it's like 93% of the time. Just almost all the time Congress will do whatever they say unless funding gets cut later and then they kind of have to play with it.

But it's almost always just sort of a direct doctors are still telling Congress what to pay. The doctors are just keeping themselves in check because they really don't want the federal government to ever set rates still. So these deliberations are sealed. And that committee operates outside of the federal rulemaking committee that would require public, you know, comment or transparency or accountability. And so it's a private club of doctors who set prices that the federal government pays doctors. And the federal government, having outsourced the price setting, then enforces the prices through the largest healthcare payment system in the world. And private insurance, you know, pays attention to Medicaid rates because they have to make theirs competitive with that. And better than that, you know, so you would pay for private insurance.

And so that RUC effectively sets the price of every medical procedure in the country, which affects psychology and specifically psychotherapy in a strange way that a lot of people still don't understand. But that RUC being a committee of specialists and proceduralists, it has consistently scored procedures higher than evaluation. And, you know, if you know where I'm going with this, psychiatry and especially therapy like me, you know, we don't have a procedure, right? It's just talking. cataract surgery, an outpatient procedure that takes, you know, this competent ophthalmologist, 15 minutes, it's been valued at an effective hourly rate that is multiples of what a primary care doctor earns when they spend an hour with you, you know, coordinating the care of all the things in your life that you want to know before you say that somebody's healthy or unhealthy or make

a recommendation to change medication or behavior. You know, cardiac catheterization is generously reimbursed, but the hour of psychiatric evaluation is not. And you can do these procedures really quickly. And so it changes the profession where no one really wants to be a psychiatrist anymore. You want to go, you know, where the money is. And psychiatry and general practice medicine, which is what the majority of Americans will actually encounter in the health care system are the ones that get no money, no funding, and get covered up with bureaucracy. Whereas the people that do like some sort of high tech, you know, foot surgery or now like, you know, you shoot protons at a cancer tumor or something and you need a you know four million dollar device to do this

they're sucking up the majority of the money and those things are important too but they're things that will not affect most americans will not affect most people and so you know that whole kind of arrangement is wild because you have conservative politicians who spend the 80s and 90s railing against the inefficiency of socialized medicine in europe you know uh you want socialized medicine you've got to play socialist taxes was always the line. And the British National Health Service, you know, and the Canadian system, they hate it. Let me come up with every, you know, problem that those things have. But the horror of letting the government set medical prices is something they're saying.

But meanwhile, the American government was setting medical prices for the largest health care market on Earth. And it was markedly less efficient than any of those systems. Again, not a political argument. This is just sort of a structural analysis of how we got here and how these things work. So it was doing through private committee, whose deliberations were sealed, whose membership was determined by professional politics, whose incentives were aligned with the specialties

that benefited most, you know, the people who were clinging to an existing arrangement, the country had built this centrally planned price-setting bureaucracy and convinced itself it was a free market. When if this was not somebody making a recommendation to Congress, that Congress just followed, it would be by in any world a cartel. This is the definition of a cartel,

but it isn't because it's separate. They just say, hey, do this and then Congress does it. So it's not a cartel because they're two separate organizations that this is the system, guys. So it got the inefficiency of a centrally planned economy combined with the lack of accountability of a private capture model. And it has the absence of any redistribution towards unmet need that you would expect a centrally planned system to provide.

And so the field that paid the highest price was psychiatry, because psychiatry eventually, you know, treats most people, or, you know, somebody that you know. And so almost every American will at some point in their life have a mental health episode that would benefit from some kind of careful evaluation. That doesn't mean that most Americans will seek it out, but data tells us that they probably should at some point. and they will need something that now the system will not pay for.

And when the system would not pay for it, the system stopped providing it. And so the wait list for actual psychiatrists became years long. And sometimes. And the 15-minute med check became standard. Psychiatrists just in order to pay off the college loans that they had had to meet with you for 15 minutes. And so this whole category of presentation, anything that couldn't be reduced to a clean diagnostic checkbox and a correspondence. responding medication became uneconomic, which means that a lot of people don't do it anymore. And there was a lot of lost muscle memory.

There was a lot of lost institutional knowledge after the 70s, which is why when you read therapy today, books published today, and there's some good ones, and you read therapy in the 1970s, it's sad. It's sad how much better they were at doing these things. The doctors and Congress had both set their own rates. and they'd done so behind a curtain of mythology that prevented anyone from noticing it. And the bureaucracy was the free market.

And the free market was the bureaucracy. And the mythology was the bureaucracy. And so the cold machine was beginning to dominate the warm ghost. Fever dream. The third piece of the apparatus at this time is what the behaviorists were up to. And this is something that still affects

psychotherapy today. I want to be clear when I'm talking about CBT because it's widely practiced and many therapists are trained in it and they're great clinicians who help people and I'm not arguing that CBT doesn't work because I do it, everyone does it. You know, it's just that when therapy

starts and stops there, you've made a horrible reduction of what psychology is. What I'm arguing is that the reason that CBT became the only thing that the apparatus could see at this point. Cognitive behavioral therapy was developed by Aaron Beck and Albert Ellis in the late 50s and 60s. And again, I'm not indicting these guys.

What I'm saying is that the success of CBT, and they were very lucky, you know, it became the only thing the apparatus could see. And the apparatus started actively preventing the development of anything that wasn't it, you know, for the next 30 years, at least. Some people tell me that that's actually not true anymore, the last 15, whatever, whatever.

I would just say call up 15 people and see what's on the front page of their website. But anyway, you know, the success of it has very little to do with whether or not it works. The success of it has to do with whether or not it can be measured. And CBT is designed for you to be able to measure things in the same way that the DSM3 was. So, you know, what Albert Ellis and Aaron Beck, you know, start doing. And Ellis is really more REBT, which is still kind of a copy. behavioral therapy. But what they're doing is saying this is just distorted thinking. It's just distorted thinking produces feelings that are distorted and then distorted behavior based on those feelings.

And so if you just look at all the places where somebody is thinking incorrectly, you can debug it. So if you can teach the patient to identify and correct the distorted thinking, the feeling and the behavior will follow after that, which is something that a lot of people do need. But again, that's not all psychotherapy is. You can't fit all of psychology into that framework. And so there's is a wisdom in that. You know, there are clinical situations where teaching someone to recognize a catastrophic thought as a catastrophic thought is genuinely useful that you're catastrophizing. This isn't real. It's something that you're just being afraid of because you know how to be anxious and so you're finding a way to make that anxiety happen. You know, Beck himself,

was a pretty thoughtful clinician and he never claimed that CBT was the only thing that worked. He was just sort of making a model that was more efficient than psychoanalysis and fit the time. And he understood, you know, what he was taking out when he was. simplified his model. He didn't think that the infrastructure would forget all of the things that weren't included in that model in the way that I would argue that they have today. But CBT had these three properties that made it a perfect fit for the apparatus of the time. First, it was time limited. A typical CBT protocol could be completed in eight sessions. Some of them are as long as 16, but they're generally pretty fast. And that fit insurance authorization periods because, well,

you're going to do therapy. And if it's not done in 16 sessions, that's what the therapy was written to be done in. So then it didn't work. You need to assume that you didn't respond to the drug, the treatment. So, you know, second, it's manualizable. You could write a protocol that is specific and standardized. We have standardized diagnosis. Now we're standardizing care based on those diagnoses. So it specifies that what the therapist did in session one, session two, session three was all part of this intervention for the thing that you were treating. And so you could train a clinician to follow that protocol, and then you could have control over what everyone was doing. And so you could measure whether the clinician had followed the protocol.

And third, it produced measurable symptom changes, supposedly. So if you administered the pHQ 9, which is a depression questionnaire before treatment, and then after treatment, you could see if the therapy had done anything. Now, granted, you're just looking for that one thing, but that's what we wanted to do at this time. This wasn't an analysis of the soul. It wasn't a reconfiguring of your values. It wasn't a construction of meaning. It was you have this one diagnosis.

You want that one diagnosis treated. This is a protocol that treats that diagnosis. You completed the protocol. It either worked or it didn't. And we have nothing else for you if it didn't. And so, you know, here's where the academic apparatus, you know, got involved. Because the National Institute of Mental Health, which is the federal funding agency for psychiatric research, was simultaneously being reorganized around the same logic.

You know, the funding criteria shifted to get a research grant. you needed to study an intervention with a clearly defined mechanism of action, a manualizable protocol and measurable outcomes. And the gold standard of evidence became the randomized controlled trial. So you could take 100 depressed patients and you could randomly assign them to receive either your protocol or a placebo, just kind of have them do random stuff. And then you could compare and see if the PHQ 9 scores at the end were better than doing random things.

And so the modalities that fit, you know, this template, they flourished. And CBT fit the template really well. And so DBT is another one. You started to see psychotherapy fit itself into this protocol in the new things that it was creating. Because if they couldn't fit in, they couldn't be studied, and then you could never say that they worked. And so anyone who did fit these manualizable treatments during this error, they got studied, they got published, and then they got cited. And they built up what looked like an enormous evidence base. And the evidence base that was used to argue that they were the only legitimate treatments for various conditions.

Anyone else was unscientific because they hadn't been bothered to be studied. And so licensure board standards, insurance standards, they started requiring all of this to be used. And so the modalities that didn't fit the template did not get studied, not because they didn't work, but because they couldn't be manualized. Internal family systems, you know, works by tracking what emerges in the room between the therapist and the patient, responding in real time. A lot of somatic therapies worked that same way. You know, it's a material that the therapist could not have predicted before the session. This leaves out the fact that you can't write a manual for things that come up in the middle of treatment. And, you know, the EVP people will say, well, then you would just go back and do a treatment plan every single time that a patient brings up a new issue or a new understanding emerges.

But in really complex therapy, that's happening minute by minute, not even session by session. And that's one of the things that people not experienced in these other depth modalities and somatic modalities and experimental modalities or people who write them off and don't read them don't understand. don't understand. You know, semantic therapy, which Peter Levin makes, you know, it works by following the patient's nervous system through these cycles of activation and discharge that are felt very strongly. If you've ever done it as a patient or a provider, but you can't really measure because then you'd be stopping the person and have them answer 50 questions. Now you've changed what they're feeling. It's like quantum physics. When you observe a particle, that particle changes. And now you can't go back and study it as an unobserved particle

because you've already observed it. And so you can't put any of that into a protocol, let alone a research study. You know, these new approaches, a lot of them, they have substantial clinical evidence, you know, things like brain spotting and somatic experiencing. And the therapist trained in them report these dramatic results. You know, often with patients who failed every other type

of manualized treatment for a long time because those are more common. And then, you know, there is published research on a lot of these things, but it's usually people will say, well, it's lower quality. Yeah, it didn't cost $2 million because they, didn't have it. But the research apparatus has not funded these large-scale randomized controlled trials that would be established as this system of evidence-based practice that you had to have to be doing anything that anyone else should take seriously within that system. And the reason that it hasn't funded any of that is structural. There's no pharmaceutical company that sponsors research on

therapeutic relationship because you can't patent it. And there is no device company sponsoring research on tracking the somatic field. The funding streams that built CVT's evidence bases do not exist for these modalities because they don't lead to a billable product. And they're not able to study, you know, new depression drug combined with CVT over six to 30 sessions results in this. You can't do that for somatic experiencing because those sessions can look so different because they're following the patient, not following a manual.

And so the research just doesn't happen. And the modalities remain officially unproven, even though a lot of times. they bypass you know the academic stuff and they follow they get onto Instagram because somebody like Bessel van der Kolk or Gabor Matte wrote a book we're still here none of this changed and and so that academic incentive structure compounds a lot of these problems because you have these three forces all working in a way that never really went away but that no one remembers and that nobody really sees anymore it's just the way it is and so this is how

you end up with thousands of papers on CBT for depression that all cite each other. And none of them substantially advance our understanding of depression and zero papers on the semantic dimension of trauma, you know, that the field has known about clinically since, you know, Pierre Genet, basically, was writing about it in 1880, you know, but that evidence space is just not a map of clinical reality anymore. It's a map for what is funded. But we don't see that.

And we mistake it for science. So there was a time when the academy could have served a different function, when it could have been placed where, you know, physicists or anthropology or psychoanalysts and contemplatives could collide and create these new things like the Eastland Institute in the 60s. For all of its excesses, you know, it did this, for all the weirdness of the New Age movement. They did this.

The Macy conferences on cybernetics did this. You know, Gregory Bateson held meetings on dolphins and schizophrenia and double-blind theory in the same room. There was cross-pollination across fields, which is how you get new ideas, is from the other sciences that are studying human. That's how you get them in psychology. You need those humanities in a way that CBT does not accommodate. And this new apparatus does not accommodate.

And these institutions were containers for what we might call, you know, horizontal collision, the productive friction between disciplines that generate genuinely new ideas. And those things are gone now. And academia has siloed itself into, you know, these tiny little fields where you can't talk about something outside of your field. shouldn't even really know about it. And we're definitely not going to reward you. If anything, you're a problem. And when you do that, you get what happens after 1980, which is not really that many new modalities, not really that much more discovery, but a whole lot of papers. And, you know,

the bridge disciplines that would let you see patterns across all these fields like mythology and philosophy and the history of consciousness, science, other sciences, like cybernetics, like systems learning. You know, they're marginalized into electives that no graduate program required. And the interpretive capacity that would have let an American psychologist recognize the convergence between, you know, a Buddhist insight and a contemporary trauma research, or between Jungian act of imagination and internal family systems, and say, hey, these things are really saying the same thing. They're just doing it a different language. So maybe there's something neurological there that we should look under the hood and see if there's a biomarker for that, not just what we're calling diseases now.

All that's been structurally eliminated from the training pipeline, let alone the research and academic pipeline. And so the wall that the wound speaks into is not just a financial wall, but it's a diagnostic one. It's a cognitive wall built into the very structure of how knowledge is produced. And the clinicians who can actually heal are not the ones who get research funded. The researchers who get research funded are not the ones whose interventions actually work on the deepest level. levels, and definitely not in new ways. And the graduate programs that train students in the funding of research, you know,

those licensure boards that credential them based on training programs, the insurance panels that reimburse them based on licensure, and the patients who arrive seeking help to get the only treatment that the system has built itself to deliver are now stuck with what we have. And, you know, Robert Spitzer aged out of running the DSM after the third edition. The fourth edition, you know, was chaired by a different psychiatrist named Francis. And Francis is the second tragic figure in the story because Francis was a careful and deliberate guy. And he had watched what the DSM3 had done and he didn't really like it. He had different problems with it than I did.

But, you know, he had seen the criteria getting applied to populations that they were never designed for. He had seen ADHD explode and autism diagnosis explode to where this diagnosis of autism could mean you know, somebody who is like, sheltered a little bit too much by mom or all the way to somebody who's completely nonverbal. And it was like, this isn't science. What are we doing? You know, childhood bipolar disorder.

You know, it appeared out of nowhere. And he's like, well, something like autotism should be lots of different diagnoses or something like trauma should be lots of different diagnoses. And then these other ones that are teeny tiny, like why are they even there at all? This looks like something that was invented for insurance or invented for, you know, somebody to have

the kind of medical identity, essentially, were his critiques. And so Francis's entire mission with the DSM4 was, you know, to go in and to stop the medicalization of everyday life so that people could just kind of be people again. And he would tell you, he failed. The DSM4 came out in 1994 and within a decade it has presided over the three largest psychiatric epidemics in American history. ADHD and children quadrupled, children, which he was intentionally trying to stop, children, you know, childhood by bipolar disorder, which had barely existed as a diagnosis before the ESM4, became this routine label that was applied to disruptive children, you know, with corresponding prescriptions of mood

stabilizers and antipsychotics for kids as young as four. And it is real. There are some kids who need treatment. But essentially, when you move to a checkbox system, you can just have a parent kind of complain about how a child's acting, and that becomes a pathologization of the child, which is still a problem that we have. That doesn't mean that childhood mental illness isn't real. it just means that our tools for measuring it are not great and may vary based on the psychiatrists that you see just like before the DSM3 you know the autism spectrum was widened you know partly for legitimate reasons of trying to recognize mild presentations and you know um but there was still the diagnostic creep that francis abhorred and francis spent the rest of his

career trying to undo what he had done he wrote a book called saving normal which was you know this sort of devastating confessional, you know, written by the insider who had done it. And he gave interviews. He wrote op-eds. He said, this is wrong, and I'm the one who did it. So I should know. And it didn't matter. It changed nothing.

The diagnostic infrastructure was already in place. The pharmaceutical companies were already marketing to these new things. They were not going to go away. And the school systems were already requiring this diagnosis to get the care that they were legally required to provide. And so the insurance and families were desperate to get those diagnoses to, to get things that they were entitled to from the schools. So the insurance companies were already reimbursing it,

and Francis's confession was heartfelt, it didn't matter. And the hinge of this whole story is, you know, to understand why the DSM-5 process goes the way that it does after the three and four, you know, why the resulting book is so weird and hollow. You have to understand the bet that the field had been making since the 80s. It was this bet that they keep saying, yeah, but just go ahead and get something out

because eventually this problem will go away and we won't have to solve it. And had it paid off, it would have retroactively justified everything that Spitzer's typewriter parties and Francis's failed attempts at, you know, restraining the industry and they would have worked.

It just, unfortunately, 30 years of pharmaceutical research dollars didn't provide the thing that they thought was going to happen. And the bet was on this thing called the brain mind problem. Bessel van der Kolk talks about this a lot and the body keeps the score. But, you know, in the DSM3, it's shipped in 1980 as this provisional document. And Spitzer and the people around him knew that the diagnostic categories were not biologically validated. And they knew that the checklist were crude and they knew that the reliability had been achieved by abandoning validity.

And they also just believed in a way that now seems kind of touchingly optimistic that the biology was coming and that once you got a, you know, diagnosis like in the DSM3, eventually, you know, people were going to figure out how to do something smart in the room, even though they weren't required to anymore. They would sit with subtlety, and they would look at the things between the numbers, which increasingly was not a thing that happened. You know, the human genome is being sequenced at this time. You've got digital imaging. You've got computers that are able to sequence something as complicated as DNA.

It takes a lot of time, but they could do it. And so brain imaging is improving, and neurotransmitter pharmacology was generating what looked like this insight into a mechanism of action, one that didn't really materialize, or at least it's controversial. But, you know, the assumption across the field that was explicit in Spitzer's own later writings was that the DSM categories were placeholders. They were just temporary scaffolding, and it would be dismantled and replaced as this underlying biology was mapped. So just use it until the bridge gets you to the next thing. But the bridge went off a cliff. And you'd eventually just, you know, replace these major depressive disorders.

with, you know, this set of specific neurobiological syndromes, and each would have its own mechanism and its own biomarker and its own medication and its own targeted treatment. And we would just know enough that if we take this book on faith, the next one we won't have to. But the 90s in the 90s is this decade of the brain where, you know, George H.W. Bush signs this proclamation and funding pours into it around neuroimaging and the Human Genome Project.

And pharmaceutical research budgets balloon. And the human genome project completes. This thing we were waiting for it to complete. And every year brought a new paper claiming to identify a brain region or a gene or a receptor subtype associated with some kind of psychiatric condition. But then all of a sudden these things don't have validity either. Nobody can agree on the numbers. And so the field is writing what felt like this exponential curve. Everyone assumed that the curve would continue when the DSM-5 task force,

assembled in the late 90s on the early 2000s, was working under this explicit expectation that by the time they shipped their manual, the biology would be far enough along to fundamentally restructure psychiatric diagnosis. And they'd be able to replace it with some of these DSM-4 categories. You could replace them with biologically grounded dimensions

and find out what the understructure was really there. The biology didn't arrive. The problem is the biology would never arrive because they were trying to find things that essentially programmed humans, that humans are just a result of their genes or a result of, you know, just something easy, not something fuzzy, not something hard,

not something subjective. And the science never found that thing. And so, you know, the thing that's important is that, you know, after we mapped the human genome and we developed functional magnetic resonance imaging and diffusion tensor imaging and, you know, magneto, insulin, cephalography, and we spent billions of dollars on genome-wide association studies.

We did meta-analysis after meta-analysis of these neuroimaging studies, and at the end of 30 years, the most sophisticated biological psychiatry research ever conducted, and we had not identified a single biomarker that anyone could agree on. You know, some people would tell you they found one. Your LinkedIn will definitely tell you that. But none of them could reliably diagnose a single DSM condition and a single individual patient. And not depression, not schizophrenia, not bipolar disorder, not ADHD, not autism, not anxiety. Every major category when you look at it biologically dissolves because all of these things

are about like William James had said, the space between the context. It's about the context of how they're connected. It's about the space between the numbers. And the brain imaging findings are, you know, this group level statistical differences that are two. That are two. small and too overlapping to diagnose in individuals. We can talk about what's going on in a group of 500 brains, probably. That's not really useful for looking at one and telling you if you have that thing. The neurotransmitter theories turned out to be these vast oversimplifications that became, the pharmaceutical industry continued to promote long after the underlying science had abandoned them.

What's his name? The Maddamerica guy talks about that all the time. You know, that they said dopamine disorders. I still say dopamine disorders. Now, after studying these things for a long time, yeah, you know, dopamine, serotonin, you know, sometimes these things change as levels when you medicate somebody, but we don't really think that's the medication, the mechanism of action anymore. After spending, you know, millions and millions of dollars, we actually know less about why they

work. We just know our guesses are wrong on how they actually work. And, you know, there's a lot of theories. There's a lot of papers out there. There's a lot of really good theories. There is not a consensus. And for everyone who says that there is a consensus, I can find you four people that'll tell you you're wrong.

I don't have a dog in the race, but there's not a consensus. We'd abandoned any kind of idea of a subjective ghost in the machine, and then we had failed to figure out how that machine worked, leaving us with what? I was born in a room of wise, buzzing light through a borrowed name. Grandma's hymn and a cracked, cassette, shaking hands while the decade changed, dusty frame on a plastic show, a soft eyes in a screen door glow, now a voice rides a broken signal through the teeth of the radio

snow. Cold choirs of the machine. Sing my family. But wait, we still have to publish these books because our revenue comes. from it and they define the industry and they have to be updated because you update science. So what does that leave the DSM-5? It leaves it in a hell of weird place. The DSM-5 is hard to talk about because it was a whole lot of committees.

There was no head, you know, fighting in a room after they signed NDAs and the record is sealed away. We can only kind of guess what happened based on people's politics, you know, politics of the academic psychology, not politics of politics. But, and then also like things that leak. which is pretty speculative. And so we don't have a Spitzer, we don't have a Francis that we can analyze,

you know, what they were doing and why. There were these factions with the DSM-5 who wanted to make the manual fully dimensional, treating conditions as these continuous spectra rather than these discrete categories because they saw that as being more scientific and more accurate, more valid. And there were factions that wanted to preserve

the DSM-4 categorical structure because clinical practice had already organized around it, and they were afraid that it would be too disruptive. So there were factions who wanted to add new categories and factions who wanted to remove them. And the committees fought for a decade, and then they had to meet for a couple months. And because the biology that they were waiting for never arrived,

there was no external arbiter of who was right, which they had always kind of assumed that the science would be the referee, and the science never showed up. And so with the DSM-5, which is published in 2013, you know, there's this kind of negotiated monument to the fights instead of waiting for the arbiter of the brain-mind problem to be solved by the scientists.

And so they make changes, like Asperger's is folded into autism spectrum disorder, which some researchers liked, and then it infuriated some, you know, patients and clinicians who treated that diagnosis that no longer went away or their kid was diagnosed with it, and now he has to get a different one, which means under the new paradigm, a different type. of treatment because it's a different diagnosis and these things have to be

you know prescribed based on the diagnoses under the system that we just talked about so you know there's some things about bereavement I've talked a little bit about that before and it really isn't the point of this I mean the DSM 5 is just such a weird document it's like a new nothing it's this fight-ridden compromise that preserved the infrastructure of the four while pretending to update it but without changing anything but still needing to make changes because it needed to do performative science and science is updated. And all these experts came together.

So surely they contributed something, right? So, you know, the biology, the committees had bet on for 20 years, never arrived, and they still had to ship something. And so in the weeks before the publication of this thing, not even before it was out, Thomas Encel, who probably has a better line on what's going on than I do, gives this speech, you know, where he says, we're ending this enterprise. He's the director of the National Institute of Mental Health at that time. And he was by any institutional measure of the most powerful figure in American mental health research.

And he had spent his entire tenure at the DIMH, 13 years, redirecting the agency towards the neurobiological research that was supposed to validate the DSM. And then in April 2013, three weeks before the DSM-5 was scheduled to ship, Insull posts a statement. And he puts it on the NIMH blog. called transforming diagnosis. And he says in so many words, the DSM categories were not scientifically valid, not now, not ever, and they're not moving in a way

towards any sort of scientific consensus or validity. And they don't correspond with any identifiable biological substrate. And as a framework for research, they're actively misleading. They're doing more harm by existing than they would if they didn't exist. And the NIH would be moving its research, funding away from the DSM categories,

and towards a new framework, called the research domain criteria, Ardoc, which is something it wasn't finished. Ardoc was about 10 years from completion when he moved everything over to it. It's still not done. So this was a huge jumping of the ship, and I'm not saying that I agree with Ensel. I'm saying that that is a huge deal that most therapists and even many academics in this field don't know about. You know, the director of a federal agency had funded, you know, three decades of biological

psychiatry. And that research was officially acknowledging that the biology that the field had been building towards never arrived and that the diagnostic system had been built in anticipation of that biology was not scientifically valid. And the thing that they had kicked down the road since the three was no longer anything that anyone was going to do. And so the walkback was immediate because this makes the whole industry freak out. You know, not the people who are, you know, doing the therapy a lot of the time, but the people who are making the money off the people doing the therapy are the ones that freak out. So the NIMH and the APA issued this joint statement together. It's pretty cold, you know, saying that the DSM-5 would remain the gold standard for clinical care,

while the R-Doc would be used for research. And the clinical and research enterprises had now officially separated, which is a thing that science isn't supposed to do. The categories that determined what insurance would pay for and what diagnoses got entered into your medical record were officially declared invalid by the federal agency that funded research into the conditions that the categories named. And everyone agreed to keep using them anyway, though, because the alternative would just be to get rid of the infrastructure. But for some reason, people who concern troll that what other therapists are doing is not evidence-based practice will defend this system, or worse, not know about it at all. And this is the moment that the apparatus revealed,

what it has become. It's not a science. A science commits to rules about evidence, and it lets the evidence apply to its own claims, even if that evidence threatens institutions or profit motives. You have to pick. And it's not a mythology. A mythology at least knows that it is a mythology, and it lets you argue inside of a story based on subjective rules. But the apparatus has become a secular religion, worse than either. Hard science, when it needs to exclude a dissenter, but a little interpretive framework when it needs to dodge a contradiction. And saying that this thing is not evidence-based for research because it's BS, yet, and I'm not saying which one I think, I'm just telling you what it's said. But when you're treating somebody in the room with their mental

health care, it's completely evidence-based and find-to-guide treatment. If anyone has another take on how to fuse those things together, I don't. But what strange is in the 70s, much smaller problems had resulted in a crisis of confidence, for the lack of a better word, in an entire industry. And when you have somebody coming out and saying, we're going to keep doing something that we know is not really hooked up to anything, we're going to keep hitting buttons that we know are not plugged into the wall, it's something that we don't even know anymore. Because the machine has replaced so much thinking. And the machine and the apparatus is slowly revealing what it's become. You know, beneath the theological face of this thing, the infrastructure just keeps running.

and the bet has been lost that we were hoping what happened for 30 years, but no one even remembers that we made it. The biology never came, but the cathedral had been built on the expectation that the biology would come, and the cathedral was holding up too much of the surrounding infrastructure to ever be demolished. So the billing codes needed these categories, and the residency programs needed categories, and the pharmaceutical marketing needed categories.

And so everyone agreed to keep worshipping in this church, whose foundation they knew was hollow, not because they still believed, but because the cathedral had become infrastructure. And the town that surrounded it, tearing it down, would take the town with it. The problem is, most people weren't making this choice actively. They were making it based on an incentive structure, a machine that made sure that they would never even know that these things had happened. An Encel himself, after leaving the NIMH in 2015, gave an interview to Wired Magazine, 2017. And I'm just going to read it.

He said, I spent 13 years at the NIMH, really pushing on the neuroscience and genetics of mental disorders. When I look back on that, I realize that while I think I succeeded in getting a lot of really cool papers published by cool scientists at fairly large costs, I don't think that we move the needle in reducing suicide and reducing hospitalizations and improving recovery for the tens of millions of people who have mental illnesses in America. $20 billion, $13 years, cool papers, the needle didn't move. And this is the institutional confession of what the bet cost from the man who oversaw the betting. The people who built the system don't like it, and the system is stronger than any of these people. This is an infrastructure trap now. And like all infrastructures, it has its own logic and its own incentives, and its own self-preservation instincts.

The infrastructure has produced exactly what infrastructures produce when they've lost their connection to their original purpose. It's produced the symptoms that infrastructure produces when they are operating contrary to their stated mission. The patients are not getting better. The depression rates are climbing. The anxiety rates are climbing. And I'm not saying that psychotherapy sitting in a room with someone is bad, that it will make you worse off. And I'm not even saying that psychotherapy is getting worse over the last 10 years. What I'm saying is that the way that we research, the way that we innovate, the way that we fund, the way that we talk about these things, has gotten markedly worse, which is not.

good for what's happening in the room. But there are a lot of great therapists doing really good work. If you are, if you are hurting from mental illness, I'm not telling you not to go to therapy. I'm saying that there are problems with the system that could be better. And then it shouldn't be as hard as it is for you to get funding, for you to get help and for the profession to be the clinical room, to be talking to the research room, to be talking to the academic room. And for those things to be working together to help you. That's all I'm saying. It's still your best bet. Please don't take this to mean that you should avoid a therapy or that mental health in America is bullshit.

That's not what I'm saying. What I'm saying is that there are very real problems with this system that we need to look at. You know, the opioid epidemic is killing Americans more than the Vietnam were killed. But we don't feel these things anymore. You know, the drugs that the apparatus prescribes are being shown in study after study to be effective, but not really is effective for most things that are not, you know, a dopamine disorder like schizophrenia, to not really be more effective than therapy. the therapy apparatus that the apparatus reimburses us on it's making things briefer shorter shallower

and then what then what patients actually need even if they don't know that they need that and the apparatus is is generating symptoms that it claims to treat you have some things that prescribe medications that have the same side effects as the condition how do you tease those apart when you're so reliant on medication without therapy. You know, a therapist might be able to tell, but a psychiatrist in 15 minutes, like, that is very hard for them to do in 15 minutes because it takes a very qualified therapist weeks some of the time.

You know, the wound is still speaking that we talked about in the last episode. The conspiracy theories, the cults, you know, the changing content of madness, the paranoid style of culture is turning into a dissociative one. But the wound is still speaking. It's always speaking. And the question of this series, the question I keep returning to, is whether there is anything left in the apparatus that can hear that enough to respond to it. In the next episode, we're going to look at what happens when the apparatus' own data

starts making the case against the apparatus, not just the failed bet on biology, but the flagship clinical trial of the medication first paradigm. An honest reanalysis of the largest antidepressant study ever funded by the federal government And it would show that the sustained recovery rate of the standard treatment paradigm was 2.7%. The published headline was 67%. Big difference. The replication crisis that swept psychology starting around 2011 found fewer than 40% of the foundational findings that the field had bet itself on could be reproduced. And the drugs were shown to be barely distinguishable from placebo. and nothing about the clinical apparatus changed.

And again, it's not just that this happened. It's that no one knows. And that is the next episode. You know, the apparatus's own data destroying the apparatus's own case. And the apparatus continuing to operate anyway. Because the infrastructure has become independent of the truth. It's become independent of science that originally justified it. And the cold machine running on its own momentum with the warm ghost locked outside,

banging on the wall, speaking in tongues that no one is trained to hear. The paranoid style is increasingly becoming a dissociative one, with the people whose job it is to know these things for some reason don't know, don't care, and don't talk about them. Laugh and dial-up shrieks, yeah. Tiny metal birds, wings of green tear. I'm humming. Wants a back in cold to guitar,

slightly bending on a trembling silver road. to warm ghosts, cold machines, space between breath and sweat on on your fever dreams. You're never caught in your fever dream. Hey guys, thanks for listening. I wanted to remind you to check out the website, get therapy,

Birmingham.com. We got a robust blog with lots of different articles that spark different times of engagement. And I really genuinely make these because I like connecting with the people who they connect with. If you want to submit an email, I am covered up with those.

I do genuinely like getting them and I like conversing. Thank you for listening and look forward to part seven next week.