Crazy Like Us

You've probably heard about Crazy Like Us, the new book by Urban Tribes author Ethan Watters. But you probably haven't bought it yet. You really should.

Crazy Like Us is a vivid, humane, and thought-provoking examination of "the globalization of the American psyche" - the process by which, slowly but surely, the world has adopted America's way of thinking about mental illness.

*

The key to the American approach is the 844-page Diagnostic and Statistical Manual of the American Psychiatric Association - the DSM, or as the saying goes, the Bible of psychiatry. The heart of the DSM is a long list of disorders, each with a code number, and each with an accompanying list of symptoms: Major Depressive Disorder (296.2), Post-Traumatic Stress Disorder (309.81), Schizophrenia (295.90), etc. The DSM is more than just a catalogue of names and numbers, however; it's part a conceptual system, a way of deciding what kind of feelings and behaviours are normal, and which are pathological; it's almost a philosophy of life.

On the most straightforward level, Crazy Like Us is the story of how, over the past 20 years, this system has gone from being American to international, displacing the ways of thinking found in other countries and cultures. In four chapters, Watters describes the rise of anorexia in Hong Kong, PTSD in Sri Lanka following the 2004 tsunami, schizophrenia in Madagascar, and major depressive disorder in Japan.

This much is plain fact. The DSM is now the internationally-recognized standard for psychiatric diagnosis; almost all academic papers in psychiatry make use of the American criteria, or the extremely similar ICD-10. What's interesting, however, is Watters' account of how the DSM spread so quickly to other countries, displacing what were - in many cases - equally rich and complex local vocabularies of distress and disorder.

In the case of Japan, Watters' answer is simple: the big drug companies, in the hopes of opening a new market for SSRI antidepressants, promoted the concept of clinical depression as a common ailment, through campaigns in the Japanese media. (Japan did have an "indigenous" concept of depression, utsubyo, but it was seen as a rare, serious disease, like schizophrenia.)

But in "developing" countries, such as Sri Lanka, the picture is rather more complex. Sri Lankans were eager to learn from the West about mental illness because of their respect for Western science and technology. Americans can put people into space - surely, they know a lot about everything, including medicine, including psychiatry.

*

Yet there's another level to the story of Crazy Like Us, a more interesting and more controversial one. Watters' argues that the globalization of the American way of thinking has actually changed the nature of "mental illness" around the world. As he puts it:

In the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.

Essentially, mental illness - or at least, much of it - is a way of unconsciously expressing emotional or social distress and tension. Our culture, which includes of course our psychiatric textbooks, tells us various ways in which distress can manifest, provides us with explanations and narratives to make our distress understandable. And so it happens. The symptoms are not acted or "faked" - they're as real to the sufferer as they are to anyone else. But they are culturally shaped.


The historian of psychiatry, Edward Shorter, has written of how, in late 19th century Europe, people (mostly women) were said to be especially prone to suffering from "hysterical paralysis", but every time and place has its own shared "symptom repertoire". Culture does not just create symptoms out of thin air - there has to be some kind of underlying stress. As Watters puts it

We can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. ... Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening.

Watters links anorexia in 1990s Hong Kong to the anxiety caused by the impending transfer of control from Britain to China, a geopolitical event which caused personal worry and social disruption as people or families emigrated. But it was the high-profile 1994 case of a young girl's death from self-starvation, and the subsequent media attention paid to the Western concept of Anorexia Nervosa (DSM code 307.1), that put self-starvation into the symptom repertoire for distressed young women and led to the rise in cases.

The idea that America has exported not just concepts of illness, but illnesses themselves, is a provocative one. Is it true? Commentators have pointed out that Watters' explanation of the rise of anorexia in Hong Kong is rather simplistic. There were many social and cultural changes going on during the 1990s, most of which had nothing to do with the DSM. How do we know that increasing media promotion of dieting, and the fashion for thinness, wasn't also important? In truth, we don't, but I do not think that Watters' argument requires psychiatry to be the only force at work.

*

Overall, Crazy Like Us is a fascinating book about transcultural psychiatry and medical anthropology. But it's more than that, and it would be a mistake - and deeply ironic - if we were to see it as a book all about foreigners, "them". It's really about us, Americans and by extension Europeans (although there are some interesting transatlantic contrasts in psychiatry, they're relatively minor.)

If our way of thinking about mental illness is as culturally bound as any other, then our own "psychiatric disorders" are no more eternal and objectively real than those Malaysian syndromes like amok, episodes of anger followed by amnesia, or koro, the fear the that ones genitals are shrinking away.

In other words, maybe patients with "anorexia", "PTSD" and perhaps "schizophrenia" don't "really" have those things at all - at least not if these are thought of as objectively-existing diseases. In which case, what do they have? Do they have anything? And what are we doing to them by diagnosing and treating them as if they did?

Watters' does not discuss such questions; I think this was the right choice, because a full exploration of these issues would fill at least one book in itself. But here are a few thoughts:

First, the most damaging thing about the globalization of Western psychiatric concepts is not so much the concepts themselves, but their tendency to displace and dissolve other ways of thinking about suffering - whether they be religious, philosophical, or just plain everyday talk about desires and feelings. The corollary of this, in terms of the individual Western consumer of the DSM, i.e. you and me, is the tendency to see everything through the lens of the DSM, without realizing that it's a lens, like a pair of glasses that you've forgotten you're even wearing. So long as you keep in mind that it's just one system amongst others, a product of a particular time and place, the DSM is still useful.

Second, if it's true that how we conceptualize illness and suffering affects how we actually feel and behave, then diagnosing or narrativizing mental illness is an act of great importance, and potentially, great harm. We currently spend billions of dollars researching major depressive disorder and schizophrenia, but very little on investigating "major depressive disorder" and "schizophrenia" as diagnoses. Maybe this is an oversight.

Finally, if much "mental illness" is an expression of fundamental distress shaped by the symptom pool of a particular culture, then we need to first map out and understand the symptom pool, and the various kinds of distress, in order to have any hope of making sense of what's going on in any individual on a psychological, social or neurobiological level. To put it another way, you need to understand people before you can understand psychiatry. After reading Crazy Like Us, I think I understand both a little bit better, and I strongly recommend it.

Links:

• Ethan Watters' Crazy Like Us blog.
  
• The Americanization of Mental Illness, Watters' much-read NYT article which is a fine summary of the book's argument, but being so short, misses much of the human detail which make Crazy Like Us so interesting, in particular when Watters is writing about the response of PTSD experts to the 2004 tsunami, and the life of a Madagascan woman with schizophrenia and her family.
  
• Exporting American Mental Illness, an excellent discussion of the article over at Neuroanthropology.
• Did Antidepressants Depress Japan? A 2004 article on the Japanese antidepressants and depression story.

Crazy Like Us

You've probably heard about Crazy Like Us, the new book by Urban Tribes author Ethan Watters. But you probably haven't bought it yet. You really should.

Crazy Like Us is a vivid, humane, and thought-provoking examination of "the globalization of the American psyche" - the process by which, slowly but surely, the world has adopted America's way of thinking about mental illness.

*

The key to the American approach is the 844-page Diagnostic and Statistical Manual of the American Psychiatric Association - the DSM, or as the saying goes, the Bible of psychiatry. The heart of the DSM is a long list of disorders, each with a code number, and each with an accompanying list of symptoms: Major Depressive Disorder (296.2), Post-Traumatic Stress Disorder (309.81), Schizophrenia (295.90), etc. The DSM is more than just a catalogue of names and numbers, however; it's part a conceptual system, a way of deciding what kind of feelings and behaviours are normal, and which are pathological; it's almost a philosophy of life.

On the most straightforward level, Crazy Like Us is the story of how, over the past 20 years, this system has gone from being American to international, displacing the ways of thinking found in other countries and cultures. In four chapters, Watters describes the rise of anorexia in Hong Kong, PTSD in Sri Lanka following the 2004 tsunami, schizophrenia in Madagascar, and major depressive disorder in Japan.

This much is plain fact. The DSM is now the internationally-recognized standard for psychiatric diagnosis; almost all academic papers in psychiatry make use of the American criteria, or the extremely similar ICD-10. What's interesting, however, is Watters' account of how the DSM spread so quickly to other countries, displacing what were - in many cases - equally rich and complex local vocabularies of distress and disorder.

In the case of Japan, Watters' answer is simple: the big drug companies, in the hopes of opening a new market for SSRI antidepressants, promoted the concept of clinical depression as a common ailment, through campaigns in the Japanese media. (Japan did have an "indigenous" concept of depression, utsubyo, but it was seen as a rare, serious disease, like schizophrenia.)

But in "developing" countries, such as Sri Lanka, the picture is rather more complex. Sri Lankans were eager to learn from the West about mental illness because of their respect for Western science and technology. Americans can put people into space - surely, they know a lot about everything, including medicine, including psychiatry.

*

Yet there's another level to the story of Crazy Like Us, a more interesting and more controversial one. Watters' argues that the globalization of the American way of thinking has actually changed the nature of "mental illness" around the world. As he puts it:

In the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures.

Essentially, mental illness - or at least, much of it - is a way of unconsciously expressing emotional or social distress and tension. Our culture, which includes of course our psychiatric textbooks, tells us various ways in which distress can manifest, provides us with explanations and narratives to make our distress understandable. And so it happens. The symptoms are not acted or "faked" - they're as real to the sufferer as they are to anyone else. But they are culturally shaped.


The historian of psychiatry, Edward Shorter, has written of how, in late 19th century Europe, people (mostly women) were said to be especially prone to suffering from "hysterical paralysis", but every time and place has its own shared "symptom repertoire". Culture does not just create symptoms out of thin air - there has to be some kind of underlying stress. As Watters puts it

We can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. ... Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening.

Watters links anorexia in 1990s Hong Kong to the anxiety caused by the impending transfer of control from Britain to China, a geopolitical event which caused personal worry and social disruption as people or families emigrated. But it was the high-profile 1994 case of a young girl's death from self-starvation, and the subsequent media attention paid to the Western concept of Anorexia Nervosa (DSM code 307.1), that put self-starvation into the symptom repertoire for distressed young women and led to the rise in cases.

The idea that America has exported not just concepts of illness, but illnesses themselves, is a provocative one. Is it true? Commentators have pointed out that Watters' explanation of the rise of anorexia in Hong Kong is rather simplistic. There were many social and cultural changes going on during the 1990s, most of which had nothing to do with the DSM. How do we know that increasing media promotion of dieting, and the fashion for thinness, wasn't also important? In truth, we don't, but I do not think that Watters' argument requires psychiatry to be the only force at work.

*

Overall, Crazy Like Us is a fascinating book about transcultural psychiatry and medical anthropology. But it's more than that, and it would be a mistake - and deeply ironic - if we were to see it as a book all about foreigners, "them". It's really about us, Americans and by extension Europeans (although there are some interesting transatlantic contrasts in psychiatry, they're relatively minor.)

If our way of thinking about mental illness is as culturally bound as any other, then our own "psychiatric disorders" are no more eternal and objectively real than those Malaysian syndromes like amok, episodes of anger followed by amnesia, or koro, the fear the that ones genitals are shrinking away.

In other words, maybe patients with "anorexia", "PTSD" and perhaps "schizophrenia" don't "really" have those things at all - at least not if these are thought of as objectively-existing diseases. In which case, what do they have? Do they have anything? And what are we doing to them by diagnosing and treating them as if they did?

Watters' does not discuss such questions; I think this was the right choice, because a full exploration of these issues would fill at least one book in itself. But here are a few thoughts:

First, the most damaging thing about the globalization of Western psychiatric concepts is not so much the concepts themselves, but their tendency to displace and dissolve other ways of thinking about suffering - whether they be religious, philosophical, or just plain everyday talk about desires and feelings. The corollary of this, in terms of the individual Western consumer of the DSM, i.e. you and me, is the tendency to see everything through the lens of the DSM, without realizing that it's a lens, like a pair of glasses that you've forgotten you're even wearing. So long as you keep in mind that it's just one system amongst others, a product of a particular time and place, the DSM is still useful.

Second, if it's true that how we conceptualize illness and suffering affects how we actually feel and behave, then diagnosing or narrativizing mental illness is an act of great importance, and potentially, great harm. We currently spend billions of dollars researching major depressive disorder and schizophrenia, but very little on investigating "major depressive disorder" and "schizophrenia" as diagnoses. Maybe this is an oversight.

Finally, if much "mental illness" is an expression of fundamental distress shaped by the symptom pool of a particular culture, then we need to first map out and understand the symptom pool, and the various kinds of distress, in order to have any hope of making sense of what's going on in any individual on a psychological, social or neurobiological level. To put it another way, you need to understand people before you can understand psychiatry. After reading Crazy Like Us, I think I understand both a little bit better, and I strongly recommend it.

Links:

• Ethan Watters' Crazy Like Us blog.
  
• The Americanization of Mental Illness, Watters' much-read NYT article which is a fine summary of the book's argument, but being so short, misses much of the human detail which make Crazy Like Us so interesting, in particular when Watters is writing about the response of PTSD experts to the 2004 tsunami, and the life of a Madagascan woman with schizophrenia and her family.
  
• Exporting American Mental Illness, an excellent discussion of the article over at Neuroanthropology.
• Did Antidepressants Depress Japan? A 2004 article on the Japanese antidepressants and depression story.

Yo Momma, Victorian Style

I've just finished Extraordinary Popular Delusions and the Madness of Crowds, which is something of a cult classic amongst people of an atheist or skeptical persuasion. Written by Scottish author Charles Mackay in 1841, the book details some of the bizarre things that people had believed and done over the preceding centuries.

It's best known for its chapters on outbreaks of mass irrationality, such as financial bubbles like the Tulipomania, the European witch trials, and "animal magnetism" (the sections on which include some excellent descriptions of psychosomatic illness and the placebo effect). Heavy stuff.

But my favorite bit was the charming "Popular Follies of Great Cities", which covers the spread of comedy catchphrases in 19th century London. Remember when everyone went around saying "Wasssssssssssupppppppp?" or "Doh!" or some variant of "Your mum / yo momma?" (that last one is still going on). It turns out this is nothing new.

Two hundred years ago Londoners, at least working-class ones, were fond of such phrases too. There was the question "Who are you?", which could be aimed at anyone doing or trying to do something above their station; the universal answer to any stupid or unwelcome question, "Quoz", and best of all, "Has your mother sold her mangle?" the implications of which Mackay does not discuss in detail.

Each of these were popular for a few months and then went out of fashion. Personally, I think it's time we brought some of them back into use. So - has your mother sold her mangle? I thought so.

Yo Momma, Victorian Style

I've just finished Extraordinary Popular Delusions and the Madness of Crowds, which is something of a cult classic amongst people of an atheist or skeptical persuasion. Written by Scottish author Charles Mackay in 1841, the book details some of the bizarre things that people had believed and done over the preceding centuries.

It's best known for its chapters on outbreaks of mass irrationality, such as financial bubbles like the Tulipomania, the European witch trials, and "animal magnetism" (the sections on which include some excellent descriptions of psychosomatic illness and the placebo effect). Heavy stuff.

But my favorite bit was the charming "Popular Follies of Great Cities", which covers the spread of comedy catchphrases in 19th century London. Remember when everyone went around saying "Wasssssssssssupppppppp?" or "Doh!" or some variant of "Your mum / yo momma?" (that last one is still going on). It turns out this is nothing new.

Two hundred years ago Londoners, at least working-class ones, were fond of such phrases too. There was the question "Who are you?", which could be aimed at anyone doing or trying to do something above their station; the universal answer to any stupid or unwelcome question, "Quoz", and best of all, "Has your mother sold her mangle?" the implications of which Mackay does not discuss in detail.

Each of these were popular for a few months and then went out of fashion. Personally, I think it's time we brought some of them back into use. So - has your mother sold her mangle? I thought so.

Go Us!

I'm reading a story at the moment. It's pretty good, but I'm having trouble deciding who to root for.

It starts off OK. About 150,000 years ago Homo sapiens evolves in Africa and starts exploring the world. It's easy to support them - they're humans, battling for survival in a world of wild animals (and Neanderthals, in some cases). Woo, go us!

But then it gets confusing. The humans split up into nations, and they start conquering each other. Which side to cheer on? Take the Sumerians, who built the world's first cities over 7000 years ago, in what's now Iraq. They were conquered by the Akkadians, who also lived in what is now Iraq. Who was "us" and who was "them" in that conflict? Neither.

I'm English, so you might expect that it would get easier when the British Isles come into play. But it doesn't. When the Romans start invading Britain in 55BC, I initially rooted for the native Britons, defending their lands against the Roman oppressors. I'm a Briton, right? 2000 years ago, there were Britons living where I'm sitting right now! Go us!

However, I then found out that in the end the Romans won, and took over. The Britons ended up confined to the fringes of the islands, hundreds of miles away. So I'm a Roman, not a Briton, and I should have supported the armies of Rome as they brought the benefits of civilization to the primitive Briton barbarians. But then, a few hundred years later, the Anglo-Saxons successfully invade, and then again with the Normans - leaving me really confused.

Once we get to the Middle Ages, English people are finally on the scene, but things don't get much easier. For example, at first, I was 100% behind the English colonists who settled North America. The French were trying to take over the continent too, but we beat them - go us! (As for the natives, they split off from us about 50,000 BC, the losers.)

But hang on - a few pages later those colonists are declaring, and achieving, independence. They're them, suddenly. Hmm. But doesn't that mean I shouldn't have rooted for the colonists in the first place, since they ended up fighting a war against us? When did they stop being "English" and become "Americans"? Us, them?

Overall, the story is OK, but it needs editing. It's unnecessarily complicated, and it's hard to identify with any of the characters.

*

What I'm saying here (inspired by this book I'm reading, although there are better world histories out there) is that "identity" is not real. I could identify myself with the Normans, or the Romans, or the Britons, or indeed the Native Americans. None of these would be right or wrong. I'm me, and all the other people were themselves, individuals. "Us" and "them" are all in my head.

If you look anyone up on Wikipedia the first three things you get are their name, their dates, and their nationality. Only then do you learn what they did. "Charles Robert Darwin (12 February 1809 – 19 April 1882) was an English naturalist..." But it's only in past few hundred years that nationality has been thought of an important part of identity. In Europe 500 years ago, the King of England had little, if anything, in common with an English peasant. They barely even spoke the same language. He had a lot in common with the King of France or the Queen of Poland, though - in fact, they were probably related.

It's a historical accident that I think of myself as "English", and it's a historical accident that we think of ourselves in terms of nations at all.

Go Us!

I'm reading a story at the moment. It's pretty good, but I'm having trouble deciding who to root for.

It starts off OK. About 150,000 years ago Homo sapiens evolves in Africa and starts exploring the world. It's easy to support them - they're humans, battling for survival in a world of wild animals (and Neanderthals, in some cases). Woo, go us!

But then it gets confusing. The humans split up into nations, and they start conquering each other. Which side to cheer on? Take the Sumerians, who built the world's first cities over 7000 years ago, in what's now Iraq. They were conquered by the Akkadians, who also lived in what is now Iraq. Who was "us" and who was "them" in that conflict? Neither.

I'm English, so you might expect that it would get easier when the British Isles come into play. But it doesn't. When the Romans start invading Britain in 55BC, I initially rooted for the native Britons, defending their lands against the Roman oppressors. I'm a Briton, right? 2000 years ago, there were Britons living where I'm sitting right now! Go us!

However, I then found out that in the end the Romans won, and took over. The Britons ended up confined to the fringes of the islands, hundreds of miles away. So I'm a Roman, not a Briton, and I should have supported the armies of Rome as they brought the benefits of civilization to the primitive Briton barbarians. But then, a few hundred years later, the Anglo-Saxons successfully invade, and then again with the Normans - leaving me really confused.

Once we get to the Middle Ages, English people are finally on the scene, but things don't get much easier. For example, at first, I was 100% behind the English colonists who settled North America. The French were trying to take over the continent too, but we beat them - go us! (As for the natives, they split off from us about 50,000 BC, the losers.)

But hang on - a few pages later those colonists are declaring, and achieving, independence. They're them, suddenly. Hmm. But doesn't that mean I shouldn't have rooted for the colonists in the first place, since they ended up fighting a war against us? When did they stop being "English" and become "Americans"? Us, them?

Overall, the story is OK, but it needs editing. It's unnecessarily complicated, and it's hard to identify with any of the characters.

*

What I'm saying here (inspired by this book I'm reading, although there are better world histories out there) is that "identity" is not real. I could identify myself with the Normans, or the Romans, or the Britons, or indeed the Native Americans. None of these would be right or wrong. I'm me, and all the other people were themselves, individuals. "Us" and "them" are all in my head.

If you look anyone up on Wikipedia the first three things you get are their name, their dates, and their nationality. Only then do you learn what they did. "Charles Robert Darwin (12 February 1809 – 19 April 1882) was an English naturalist..." But it's only in past few hundred years that nationality has been thought of an important part of identity. In Europe 500 years ago, the King of England had little, if anything, in common with an English peasant. They barely even spoke the same language. He had a lot in common with the King of France or the Queen of Poland, though - in fact, they were probably related.

It's a historical accident that I think of myself as "English", and it's a historical accident that we think of ourselves in terms of nations at all.

ECT in Nixonland

I've just finished Nixonland, Rick Perlstein's history of the 1960s. Some things I learned: Richard Nixon was a genius, albeit an evil one; the 1960s never ended; Rick Perlstein is my new favourite political author.

The book also reminded me of a sad episode in the history of psychiatry.

George McGovern ran against Nixon as the Democratic candidate for President in 1972. He was essentially the Obama of the 60s generation: unashamedly liberal and intellectual, he unseated the "established" candidate, Hubert Humphrey, to clinch the Democrat's nomination after a bitter primary campaign thanks to his idealistic young grass-roots.

McGovern had difficulty choosing his vice-presidential running mate, and eventually chose a little-known Senator from Missouri, Thomas Eagleton (left in the photo). It seemed a safe enough choice. Until Eagleton's first press conference.

Eagleton revealed that he'd been treated in a psychiatric hospital for "exhaustion" - everyone knew he meant clinical depression - three times, and that he had received electroconvulsive therapy twice. McGovern hadn't known this when he picked him.

From there it was all downhill. McGovern initially said he backed Eagleton "1000%". But to some, the idea of putting someone who'd had shock therapy a heartbeat away from the Presidency was unacceptable, and after two weeks of gossip, McGovern dropped him from the ticket.

Perlstein notes that this move wrecked McGovern's image as the idealistic and authentic alternative to politics-as-usual. Polls showed that Americans overwhelmingly trusted Nixon over McGovern, even as the facts about Watergate were emerging. Nixon won a landslide.

ECT in Nixonland

I've just finished Nixonland, Rick Perlstein's history of the 1960s. Some things I learned: Richard Nixon was a genius, albeit an evil one; the 1960s never ended; Rick Perlstein is my new favourite political author.

The book also reminded me of a sad episode in the history of psychiatry.

George McGovern ran against Nixon as the Democratic candidate for President in 1972. He was essentially the Obama of the 60s generation: unashamedly liberal and intellectual, he unseated the "established" candidate, Hubert Humphrey, to clinch the Democrat's nomination after a bitter primary campaign thanks to his idealistic young grass-roots.

McGovern had difficulty choosing his vice-presidential running mate, and eventually chose a little-known Senator from Missouri, Thomas Eagleton (left in the photo). It seemed a safe enough choice. Until Eagleton's first press conference.

Eagleton revealed that he'd been treated in a psychiatric hospital for "exhaustion" - everyone knew he meant clinical depression - three times, and that he had received electroconvulsive therapy twice. McGovern hadn't known this when he picked him.

From there it was all downhill. McGovern initially said he backed Eagleton "1000%". But to some, the idea of putting someone who'd had shock therapy a heartbeat away from the Presidency was unacceptable, and after two weeks of gossip, McGovern dropped him from the ticket.

Perlstein notes that this move wrecked McGovern's image as the idealistic and authentic alternative to politics-as-usual. Polls showed that Americans overwhelmingly trusted Nixon over McGovern, even as the facts about Watergate were emerging. Nixon won a landslide.

The Guineapigs

Before waterboarding, there was wall standing.

The Guineapigs is a book by John McGuffin. It was published in 1974, at the height of "The Troubles" in Northern Ireland, and banned in Britain almost immediately.

The "guineapigs" in question were 14 men from Northern Ireland detained by British security forces during the 1971 campaign of internment of suspected Irish Republican Army militants and sympathizers. The book details the treatment they experienced in the week after their detention, specifically "sensory deprivation".

The men were forced to stand up against a wall, with a black hood over their head, in a room into which a loud noise - described as something like a jet engine or gushing water - was played. If they fell or otherwise moved from this stance, they were forced back up. This went on for up to 48 hours, during which time they were given neither food nor sleep.

After this the treatment became a bit less harsh, and they were interrogated at various intervals. After about a week, they were released into a "normal" prison, and the story came out. A government inquiry, the Compton Report, followed, confirming that the "Questioning in Depth" had occurred but denying that it constituted "brutality".

The Guineapigs contains first person accounts from several of the men, describing the disorientation, hallucinations and terror they experienced during the procedure, and also details the psychological after-effects they reportedly suffered, including several cases of mental illness and at least psychiatric hospitalization.

McGuffin's most controversial claim was that the whole thing was a psychological experiment. It could not, he said, have been meant to gather useful information per se, because the 14 "subjects" were not especially high-value suspects; they seemed to have been chosen at random from the hundreds interned. Instead, he said, it was a research project, a trial of the technique of sensory deprivation as torture.

During the 1960s and 1970s there was lots of academic research on sensory deprivation, in which volunteers often reported hallucinations, paranoia, mood changes and other "psychotic" symptoms after being deprived of sight, sound and touch stimuli for a few hours. According to McGuffin, the British government decided to "field test" to procedure to see whether the same thing happened in "real life" with test subjects who weren't willing volunteers.

I'm not sure whether to believe this explanation of what happened; McGuffin was hardly an unbiased observer - he was himself interned in 1971, although he wasn't amongst the guineapigs - and he was a lifelong opponent of British rule in Northern Ireland. We'll probably never know for sure. But maybe it's as convincing as any other explanation.

Links: Lots of the book is online here. Mind Hacks on a recent sensory deprivation study, and a documentary about s.d. interrogation during WW2. I found a paper by T Shallice (1972) on The Ulster depth interrogation techniques and their relation to sensory deprivation research, but I haven't been able to access it yet. John McGuffin obits.

The Guineapigs

Before waterboarding, there was wall standing.

The Guineapigs is a book by John McGuffin. It was published in 1974, at the height of "The Troubles" in Northern Ireland, and banned in Britain almost immediately.

The "guineapigs" in question were 14 men from Northern Ireland detained by British security forces during the 1971 campaign of internment of suspected Irish Republican Army militants and sympathizers. The book details the treatment they experienced in the week after their detention, specifically "sensory deprivation".

The men were forced to stand up against a wall, with a black hood over their head, in a room into which a loud noise - described as something like a jet engine or gushing water - was played. If they fell or otherwise moved from this stance, they were forced back up. This went on for up to 48 hours, during which time they were given neither food nor sleep.

After this the treatment became a bit less harsh, and they were interrogated at various intervals. After about a week, they were released into a "normal" prison, and the story came out. A government inquiry, the Compton Report, followed, confirming that the "Questioning in Depth" had occurred but denying that it constituted "brutality".

The Guineapigs contains first person accounts from several of the men, describing the disorientation, hallucinations and terror they experienced during the procedure, and also details the psychological after-effects they reportedly suffered, including several cases of mental illness and at least psychiatric hospitalization.

McGuffin's most controversial claim was that the whole thing was a psychological experiment. It could not, he said, have been meant to gather useful information per se, because the 14 "subjects" were not especially high-value suspects; they seemed to have been chosen at random from the hundreds interned. Instead, he said, it was a research project, a trial of the technique of sensory deprivation as torture.

During the 1960s and 1970s there was lots of academic research on sensory deprivation, in which volunteers often reported hallucinations, paranoia, mood changes and other "psychotic" symptoms after being deprived of sight, sound and touch stimuli for a few hours. According to McGuffin, the British government decided to "field test" to procedure to see whether the same thing happened in "real life" with test subjects who weren't willing volunteers.

I'm not sure whether to believe this explanation of what happened; McGuffin was hardly an unbiased observer - he was himself interned in 1971, although he wasn't amongst the guineapigs - and he was a lifelong opponent of British rule in Northern Ireland. We'll probably never know for sure. But maybe it's as convincing as any other explanation.

Links: Lots of the book is online here. Mind Hacks on a recent sensory deprivation study, and a documentary about s.d. interrogation during WW2. I found a paper by T Shallice (1972) on The Ulster depth interrogation techniques and their relation to sensory deprivation research, but I haven't been able to access it yet. John McGuffin obits.

Book: Deep Brain Stimulation

Jamie Talan's Deep Brain Stimulation: A New Treatment Shows Promise In The Most Difficult Cases is the first book to offer a popular look at DBS, one of the more exciting emerging treatments in neurology and psychiatry.

Deep Brain Stimulation is not a textbook and the depth of scientific detail is kept pretty low, but the breadth of the material is good. Talan reviews the many kinds of disorders for which DBS has been trialled, from the early 1990s when it was used in Parkinson's disease up to the past five years where it's been tried for everything from epilepsy, depression and Tourette's Syndrome up to lifting patients out of persistent vegetative states (maybe).

Unfortunately, Talan doesn't discuss the controversial history of the first era of human brain stimulation, including the morally murky work of Robert G. Heath at Tulane University in the 1960s. She mentions Tulane once in passing but more detail would have been welcome, if only because it's a rather spicy tale.

The book's most engaging passages are the stories of individual patients. There's the man with Parkinson's who experienced amazing benefits from DBS, and who was so keen to keep them that he didn't tell doctors about the infection which developed a few weeks after surgery, in case they took the electrode out. After literally keeping the infected site under his hat for a few days, it progressed to a brain abscess, and he nearly died. Happily, he not only survived but was able to get the electrodes reimplanted.

Then there's the most moving case, that of the woman suffering from severe OCD and depression, who was given experimental DBS for the former condition. She died by suicide several months later, but said in her suicide note that the DBS had worked - her OCD symptoms were gone. Her depression was as bad as ever, though, and this is what led her to suicide. She wanted people to know that deep brain stimulation helped her, and didn't want her death to go down in the records as a mark against it.

The precursor to DBS was ablative neurosurgery - destroying particular parts of the brain in order to relieve symptoms. Talan describes its use in movement disorders such as Parkinson's, but she glosses over the history of "psychosurgery", the use of surgery to treat mental illness. People using DBS in psychiatry often prefer not to talk about psychosurgery - it's not exactly good PR. But clearly it is relevant. For all its faults, psychosurgery did seem to help some patients, which is why it's still used today in rare cases, although DBS may soon replace it.

DBS for depression and OCD usually target the same prefrontal white matter pathways that psychosurgery severed, so scientifically, psychosurgery has lessons for DBS. The ethical issues overlap too. Although DBS is reversible, unlike brain lesioning, it carries the same risks of serious complications like infection or brain bleeding. And there's the same question of whether seriously mentally ill people can give informed consent.

The book's strongest chaper is the last, which covers the ethical and practical difficulties of DBS. The danger is that enthusiastic doctors with no experience of the procedure, encouraged by the tales from other hospitals, might start doing it inappropriately. There's also a risk that patients or their families might volunteer for DBS prematurely or have impossibly high expectations. The initial results have been very promising, but there have been no large placebo-controlled trials so far (except in some movement disorders). And even with the best surgeons, in most disorders the response rate seems to hover around the 50-60% mark. Talan warns that DBS risks being a victim of its own hype. That's an important message.

Book: Deep Brain Stimulation

Jamie Talan's Deep Brain Stimulation: A New Treatment Shows Promise In The Most Difficult Cases is the first book to offer a popular look at DBS, one of the more exciting emerging treatments in neurology and psychiatry.

Deep Brain Stimulation is not a textbook and the depth of scientific detail is kept pretty low, but the breadth of the material is good. Talan reviews the many kinds of disorders for which DBS has been trialled, from the early 1990s when it was used in Parkinson's disease up to the past five years where it's been tried for everything from epilepsy, depression and Tourette's Syndrome up to lifting patients out of persistent vegetative states (maybe).

Unfortunately, Talan doesn't discuss the controversial history of the first era of human brain stimulation, including the morally murky work of Robert G. Heath at Tulane University in the 1960s. She mentions Tulane once in passing but more detail would have been welcome, if only because it's a rather spicy tale.

The book's most engaging passages are the stories of individual patients. There's the man with Parkinson's who experienced amazing benefits from DBS, and who was so keen to keep them that he didn't tell doctors about the infection which developed a few weeks after surgery, in case they took the electrode out. After literally keeping the infected site under his hat for a few days, it progressed to a brain abscess, and he nearly died. Happily, he not only survived but was able to get the electrodes reimplanted.

Then there's the most moving case, that of the woman suffering from severe OCD and depression, who was given experimental DBS for the former condition. She died by suicide several months later, but said in her suicide note that the DBS had worked - her OCD symptoms were gone. Her depression was as bad as ever, though, and this is what led her to suicide. She wanted people to know that deep brain stimulation helped her, and didn't want her death to go down in the records as a mark against it.

The precursor to DBS was ablative neurosurgery - destroying particular parts of the brain in order to relieve symptoms. Talan describes its use in movement disorders such as Parkinson's, but she glosses over the history of "psychosurgery", the use of surgery to treat mental illness. People using DBS in psychiatry often prefer not to talk about psychosurgery - it's not exactly good PR. But clearly it is relevant. For all its faults, psychosurgery did seem to help some patients, which is why it's still used today in rare cases, although DBS may soon replace it.

DBS for depression and OCD usually target the same prefrontal white matter pathways that psychosurgery severed, so scientifically, psychosurgery has lessons for DBS. The ethical issues overlap too. Although DBS is reversible, unlike brain lesioning, it carries the same risks of serious complications like infection or brain bleeding. And there's the same question of whether seriously mentally ill people can give informed consent.

The book's strongest chaper is the last, which covers the ethical and practical difficulties of DBS. The danger is that enthusiastic doctors with no experience of the procedure, encouraged by the tales from other hospitals, might start doing it inappropriately. There's also a risk that patients or their families might volunteer for DBS prematurely or have impossibly high expectations. The initial results have been very promising, but there have been no large placebo-controlled trials so far (except in some movement disorders). And even with the best surgeons, in most disorders the response rate seems to hover around the 50-60% mark. Talan warns that DBS risks being a victim of its own hype. That's an important message.

The British are Incredibly Sad

Or so says Oliver James(*) on this BBC radio show in which he also says things like "I absolutely embraces the credit crunch with both arms".

Oliver James is a British psychologist best known for his theory of "Affluenza". This is his term for unhappiness and mental illness caused, he thinks, by an obsession with money, status and possessions. Affluenza, James thinks, is especially prevanlent in English-speaking countries, because we're more into free-market capitalism than the people of mainland Europe. In fact, he regularly makes the claim that we in Britain, the U.S., Australia etc. are today twice as likely to be mentally ill as "the Europeans". This is because rates of mental illness supposedly surged in the English-speaking world due to 1980s Reagan/Thatcher free market policies. Hence why he welcomes the current economic unpleasantness.

Were all of this true, it would be incredibly important. Certainly important enough to justify writing three books about it and seemingly endless articles for the Guardian. But is it true? Well, this is Neuroskeptic, so you can probably guess. Also, bear in mind that James is someone who is on record as thinking that

[The Tears for Fears song] Mad World. With the chilling line "The dreams in which I'm dying are the best I've ever had", in some respects it is up there with TS Eliot's Prufrock as a poetic account of bourgeois despair.

Obviously poetic taste is entirely subjective etc., but honestly.

Anyway, where did James get the twice-as-bad-as-Europe (or, in some articles, three times as bad) idea from? He says the World Health Organization. Presumably he is referring to one of the World Health Organization's World Mental Health Surveys, such as the analysus presented in this JAMA paper.

At first glance, you can see what he means. This paper reports that the % of people reporting suffering from at least one mental illness over the last year was far higher in the US (26.4%) than in say Italy (8.2%), or Nigeria (4.7%). But on closer inspection, even this data includes some incongruous numbers. Why is Beijing (9.1%) twice as bad as Shanghai (4.3%)? Worse, why does France have a rate of 18.4% while across the border in Germany it's just 9.1%? Are the French twice as materialistic as the Germans? The answer, of course, is that these numbers are more complicated than they appear. In fact, if you believe those figures at face value, you are...well, you're probably Oliver James.

These numbers come from structured interviews, conducted by trained lay researchers, of a random sample of the population. In other words, some guy asked some random people a series of fairly personal questions, reading them off a list, and if they said "Yes" to questions like "Have you ever in your life had a period lasting several days or longer when most of the day you felt sad, empty or depressed?" they might get a tick for "depression". We know this because the interviews used the WHO-CIDI screening questionaire, the first part of which is here.

As part of my own research, I have been that guy asking the questions (in a slightly different context). At some point I'll write about this in more detail, but suffice to say that it's hard to trying to retrospectively diagnose mental illness in someone you've never met before. The potential for denial, mis-remembering, malingering, forgetting or just plain failure to understand the questions is enormous, although it doesn't come across in the final data, which looks lovely and neat.

The authors of the JAMA paper are well aware of this which is why they're skeptical of the apparantly large cross-national differences. In fact, most of their comment section consists of caveats to that effect. Just a few (edited, emphasis mine - see the full paper for more, it's free):

An important limitation of the WMH surveys is their wide variation in response rate. In addition, some of the surveys had response rates below normally accepted standards [i.e. many people refused to participate]... performance of the WMH-CIDI could be worse in other parts of the world either because the concepts and phrases used to describe mental syndromes are less consonant with cultural concepts than in developed Western countries [almost certainly they are] or because absence of a tradition of free speech and anonymous public opinion surveying causes greater reluctance to admit emotional or substance-abuse problems than in developed Western countries. [again, almost certainly, and Europeans are generally more reserved than Americans in this regard.] ... some patterns in the data (e.g. the much lower estimated rate of alcoholism in Ukraine than expected from administrative data documenting an important role of alcoholism in mortality in that country) raise concerns about differential validity.

There's another, more fundamental problem with this data. On any meaningful criterion of "mental illness", a society in which 25% people were mentally ill in any given year would probably collapse. The WHO survey, however, is based on the DSM-IV criteria of mental illness. These are are increasingly regarded as very broad; for example, DSM-IV does not distinguish between feeling miserable & down for two weeks because your boyfriend leaves you, and spending a month in bed hardly eating for no apparant reason. Both are classed as "depression", and hence a "mental illness", although 50 years ago, only the second would have been considered a disease. For someone who styles himself a rebel in the mould of R. D. Laing, it's baffling that James accepts the American Psychiatric Association's dubious criteria.

What other data could we look at? Ideally, we want a measure of mental illness which is meaningful, objective and unambigious. Well, there aren't any, but suicide rates might be the next best thing - they're nice hard numbers which are difficult to fudge (although in cultures in which suicide is strongly taboo, suicides may be reported as deaths from other causes.) Although not everyone who commits suicide is mentally ill, it is fair to say that if Britain really were twice as unhappy as the rest of Europe, we would have a relatively high suicide rate.

What's the data? Well, according to Chishti et. al. (2003) Suicide Mortality in the European Union, we don't.
In fact suicide rates in the UK are boringly middle of the road. They're higher than in places like Greece and Spain, but well below rates in France, Sweden and Germany. Suicide rates are not a direct measure of rates of mental illness, because not everyone who commits suicide is mentally ill, and the rate of succesful suicide depends upon access to lethal means. But does this data look compatible with James's claim that rates of "mental illness" are twice as high in Britain as on "the Continent"? - or indeed with James's implicit assumption that "the Continent" is monolithic?

What's odd is that James clearly knows a bit about suicide, or at least he does now, because just today he wrote a remarkably sensible article about suicide statistics for the Guardian. So he really ought to know better.

Drug sales are another nice, hard number. Of course, medication rates do not equal illness rates - in any field of medicine, but especially psychiatry. Doctors in some countries may be more willing to use drugs, or patients may be more willing to take them. With that in mind, the fact that population-adjusted (source, also here) British sales of antidepressants drugs are twice those of Ireland and Italy, equal to those of Spain, and half those of France, Norway and Sweden does not necessarily mean very much. But it hardly supports James's theory either.

Interestingly, although James holds up Denmark as an example of the kind of happy, "unselfish capitalism" that we should aspire to, the Danes take 50% more antidepressants than we do! (They also have a much higher suicide rate.) True, sales of anxiety drugs and sleeping pills are relatively high in the UK, but still less than Denmark's. Most interestingly, sales of antipsychotics are very low in the UK - roughly the same as in Germany and Italy but less than a quarter of the sales in Ireland and Finland!

So cheer up, Anglos. We're not twice as sad as the French. More likely, we are just more open about talking our problems in the interests of scientific research. However, the French, to their credit, didn't give the world Oliver James.

[BPSDB]

(*) This is Oliver James, psychologist. Not to be confused with: Oliver James, heartthrob actor; Oliver James, Fleet Foxes song, and Oliver James, Ltd.

The WHO World Mental Health Survey Consortium (2004). Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys JAMA: The Journal of the American Medical Association, 291 (21), 2581-2590 DOI: 10.1001/jama.291.21.2581

The British are Incredibly Sad

Or so says Oliver James(*) on this BBC radio show in which he also says things like "I absolutely embraces the credit crunch with both arms".

Oliver James is a British psychologist best known for his theory of "Affluenza". This is his term for unhappiness and mental illness caused, he thinks, by an obsession with money, status and possessions. Affluenza, James thinks, is especially prevanlent in English-speaking countries, because we're more into free-market capitalism than the people of mainland Europe. In fact, he regularly makes the claim that we in Britain, the U.S., Australia etc. are today twice as likely to be mentally ill as "the Europeans". This is because rates of mental illness supposedly surged in the English-speaking world due to 1980s Reagan/Thatcher free market policies. Hence why he welcomes the current economic unpleasantness.

Were all of this true, it would be incredibly important. Certainly important enough to justify writing three books about it and seemingly endless articles for the Guardian. But is it true? Well, this is Neuroskeptic, so you can probably guess. Also, bear in mind that James is someone who is on record as thinking that

[The Tears for Fears song] Mad World. With the chilling line "The dreams in which I'm dying are the best I've ever had", in some respects it is up there with TS Eliot's Prufrock as a poetic account of bourgeois despair.

Obviously poetic taste is entirely subjective etc., but honestly.

Anyway, where did James get the twice-as-bad-as-Europe (or, in some articles, three times as bad) idea from? He says the World Health Organization. Presumably he is referring to one of the World Health Organization's World Mental Health Surveys, such as the analysus presented in this JAMA paper.

At first glance, you can see what he means. This paper reports that the % of people reporting suffering from at least one mental illness over the last year was far higher in the US (26.4%) than in say Italy (8.2%), or Nigeria (4.7%). But on closer inspection, even this data includes some incongruous numbers. Why is Beijing (9.1%) twice as bad as Shanghai (4.3%)? Worse, why does France have a rate of 18.4% while across the border in Germany it's just 9.1%? Are the French twice as materialistic as the Germans? The answer, of course, is that these numbers are more complicated than they appear. In fact, if you believe those figures at face value, you are...well, you're probably Oliver James.

These numbers come from structured interviews, conducted by trained lay researchers, of a random sample of the population. In other words, some guy asked some random people a series of fairly personal questions, reading them off a list, and if they said "Yes" to questions like "Have you ever in your life had a period lasting several days or longer when most of the day you felt sad, empty or depressed?" they might get a tick for "depression". We know this because the interviews used the WHO-CIDI screening questionaire, the first part of which is here.

As part of my own research, I have been that guy asking the questions (in a slightly different context). At some point I'll write about this in more detail, but suffice to say that it's hard to trying to retrospectively diagnose mental illness in someone you've never met before. The potential for denial, mis-remembering, malingering, forgetting or just plain failure to understand the questions is enormous, although it doesn't come across in the final data, which looks lovely and neat.

The authors of the JAMA paper are well aware of this which is why they're skeptical of the apparantly large cross-national differences. In fact, most of their comment section consists of caveats to that effect. Just a few (edited, emphasis mine - see the full paper for more, it's free):

An important limitation of the WMH surveys is their wide variation in response rate. In addition, some of the surveys had response rates below normally accepted standards [i.e. many people refused to participate]... performance of the WMH-CIDI could be worse in other parts of the world either because the concepts and phrases used to describe mental syndromes are less consonant with cultural concepts than in developed Western countries [almost certainly they are] or because absence of a tradition of free speech and anonymous public opinion surveying causes greater reluctance to admit emotional or substance-abuse problems than in developed Western countries. [again, almost certainly, and Europeans are generally more reserved than Americans in this regard.] ... some patterns in the data (e.g. the much lower estimated rate of alcoholism in Ukraine than expected from administrative data documenting an important role of alcoholism in mortality in that country) raise concerns about differential validity.

There's another, more fundamental problem with this data. On any meaningful criterion of "mental illness", a society in which 25% people were mentally ill in any given year would probably collapse. The WHO survey, however, is based on the DSM-IV criteria of mental illness. These are are increasingly regarded as very broad; for example, DSM-IV does not distinguish between feeling miserable & down for two weeks because your boyfriend leaves you, and spending a month in bed hardly eating for no apparant reason. Both are classed as "depression", and hence a "mental illness", although 50 years ago, only the second would have been considered a disease. For someone who styles himself a rebel in the mould of R. D. Laing, it's baffling that James accepts the American Psychiatric Association's dubious criteria.

What other data could we look at? Ideally, we want a measure of mental illness which is meaningful, objective and unambigious. Well, there aren't any, but suicide rates might be the next best thing - they're nice hard numbers which are difficult to fudge (although in cultures in which suicide is strongly taboo, suicides may be reported as deaths from other causes.) Although not everyone who commits suicide is mentally ill, it is fair to say that if Britain really were twice as unhappy as the rest of Europe, we would have a relatively high suicide rate.

What's the data? Well, according to Chishti et. al. (2003) Suicide Mortality in the European Union, we don't.
In fact suicide rates in the UK are boringly middle of the road. They're higher than in places like Greece and Spain, but well below rates in France, Sweden and Germany. Suicide rates are not a direct measure of rates of mental illness, because not everyone who commits suicide is mentally ill, and the rate of succesful suicide depends upon access to lethal means. But does this data look compatible with James's claim that rates of "mental illness" are twice as high in Britain as on "the Continent"? - or indeed with James's implicit assumption that "the Continent" is monolithic?

What's odd is that James clearly knows a bit about suicide, or at least he does now, because just today he wrote a remarkably sensible article about suicide statistics for the Guardian. So he really ought to know better.

Drug sales are another nice, hard number. Of course, medication rates do not equal illness rates - in any field of medicine, but especially psychiatry. Doctors in some countries may be more willing to use drugs, or patients may be more willing to take them. With that in mind, the fact that population-adjusted (source, also here) British sales of antidepressants drugs are twice those of Ireland and Italy, equal to those of Spain, and half those of France, Norway and Sweden does not necessarily mean very much. But it hardly supports James's theory either.

Interestingly, although James holds up Denmark as an example of the kind of happy, "unselfish capitalism" that we should aspire to, the Danes take 50% more antidepressants than we do! (They also have a much higher suicide rate.) True, sales of anxiety drugs and sleeping pills are relatively high in the UK, but still less than Denmark's. Most interestingly, sales of antipsychotics are very low in the UK - roughly the same as in Germany and Italy but less than a quarter of the sales in Ireland and Finland!

So cheer up, Anglos. We're not twice as sad as the French. More likely, we are just more open about talking our problems in the interests of scientific research. However, the French, to their credit, didn't give the world Oliver James.

[BPSDB]

(*) This is Oliver James, psychologist. Not to be confused with: Oliver James, heartthrob actor; Oliver James, Fleet Foxes song, and Oliver James, Ltd.

The WHO World Mental Health Survey Consortium (2004). Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys JAMA: The Journal of the American Medical Association, 291 (21), 2581-2590 DOI: 10.1001/jama.291.21.2581

Seven Things You Didn't Know About Milgram

There's been a lot written about psychology professor Jerry Burger's recent replication of the famous "obedience" experiments first carried out by Stanley Milgram in the early 1960s. Here's Burger's paper in which he reports that obedience rates are almost the same today as they were nearly 50 years ago.

Wikipedia's page on this experiment has an excellent summary of the methodology and results of the original study if you're not familiar with it.

It's a testament to the importance of the original obedience experiment that many who know nothing else about psychology have at least heard of it, and it's common knowledge that Milgram found that a startlingly high proportion of ordinary volunteers were willing to administer very strong "shocks" to an innocent victim, on the orders of the experimenter. But there's much more to the "Milgram Experiment" than many people realize. So - read on. That's an order.

1. There wasn't just one experiment In 1974, Milgram discussed the results and implications of his research in a book, Obedience to Authority: An Experimental View. (The cover is rather amusing). In it he describes no fewer than 19 different experiments, not including pilot studies. Most of the studies included 40 participants, although some of the later ones used 20. The basic nature of the experimental situation was the same in each case, but important factors were varied between expriments, offering some insight into the conditions which drive obedience (see below). All of this work was performed at or near Yale between 1960 and 1963. Milgram also refers to later replication studies carried out in"Princeton, Munich, Rome, South Africa and Australia" where "the level of obedience was invariably somewhat higher than that found [in the Yale studies]". So, whatever was going on in the Milgram experiments, it wasn't unique to the USA, and the fact that Jerry Burger has just obtained very similar results shows that it wasn't unique to the 1960s either (although, to look at it the other way, the USA today is not especially conformist.)
2. Subjects were paid $4 each Milgram's book is full of details such as this, including plenty of photos and drawings illustrating what happened. The picture here shows the designated "victim" in most of the experiments - James McDonough, "a 47-year old accountant, trained for the role; he was of Irish-American descent and most observers found him mild-mannered and affable". This is the face that launched a thousand shocks - seeing it, for me, brought home the results of the obedience studies very starkly. How could anyone shock that guy? Another important detail is that rather than recruiting undergraduate students, as most psychology experiments do, Milgram placed adverts in local newspapers and, when that only got a few hundred volunteers, resorted to cold-calling names in the New Haven telephone directory. This meant that the participants were (as far as possible) representative of the normal population - a crucial point.
   
3. Milgram was an Evolutionary Psychologist Well, sort of. He was into Evolutionary Psychology before it became a buzzphrase - indeed, before the term had been coined. In his book, Milgram notes that "the formation of hierarchically organised groupings lends enormous advantage to those so organized in coping with dangers of the physical environment, threats posed by competing species, and potential disruption from within." In other words, an animal which has the ability to submit to authority when necessary might be more likely to survive than one which was stubbornly individualistic. He goes on to theorize that humans have evolved a psychological mechanism for obedience, which he calls the "Agentic State", a special state of mind in which our normal moral inhibitions are bypassed and we become an agent of an authority. I'm not sure many people would buy this as a good explanation, and it isn't clear if Milgram's evolutionary logic relies on Group Selection theory, but it's certainly interesting.
   
4. It was stressful Most of the subjects were acutely distressed during the procedure - hardly surprising given the screams and protests of their "victim". Some subjects shook with tension; one started laughing whenever they had to give a shock. Yet most of them continued to give the shocks despite being tangibly upset about it. They didn't want to hurt the "victim" - but they did. This inner conflict suffered by the subjects comes across vividly in Milgram's writing, and it led to some fascinating behaviour. In Experiment 7, in which the "experimenter" giving orders left the room and spoke to the subjects by telephone, many subjects continued to give shocks but gave much milder shocks than they were supposed to. In other words, they were unwilling to hurt the victim but also unwilling to openly disobey (although in this case, 80% of subjects eventually did). Most people also seemed to try to keep the shocks as short as possible, and tried to minimize the number of punishments by helping the victim to give the right answers. Milgram argued that this ruled out the view that his experiment showed people to be "aggressive" or "sadistic" - rather, people were naturally averse to causing harm, but the situation they found themselves in led them to do so anyway. As he put it "The social psychology of this century reveals a major lesson: often it is not so much the kind of person a man as the kind of situation in which he finds himself that determines how he will act."
   
5. There was follow-up Milgram's sometimes accused of being a cavalier or even callous researcher who exposed his volunteers to emotional harm. In fact although, as the cliche goes, Milgram's studies would never pass an ethics committee today, he seems (at least on his own account) to have gone to great effort to ensure that his participants were not traumatized and to record how they felt about the experiment. Immediately after the experiment was finished the subjects were "debriefed" and told what had really happened; if they had been obedient, they were reassured that this was normal behaviour (true, of course). Then, a few weeks later, they were sent a write-up of the results of the research and an explanation of the rationale. A questionairre asked how they felt about the study overall; 43% said they were very glad to have done it, 40% said they were glad, and just 1.3% were sorry or very sorry to have done it; there was little difference between those who obeyed and those who didn't. Commenting on the fact that people seemed remarkably relaxed about what they had done, in retrospect, Milgram wryly noted "The same mechanisms that allow the subject to perform the act...continue to justify his behaviour for him".
   
6. Not everyone obeyed You probably already know this, but you think of it as less exciting than the fact that most people did. In the best known version of the experiment (Experiment 5), 35% of people refused to administer the highest shock level, and some of those came close to it. In other experimental set-ups, obedience rates were different - when the study was carried out in a run-down city apartment, rather than in the presitgous surroundings of Yale, obedience rates dropped (but were still 47.5%). When the subjects did not have to administer the shocks themselves but simply sit by and take notes while someone else did, almost everyone complied (92.5%). Yet there were no clear explanations for why some individuals obeyed and some did not. Some people were chillingly obedient, others were boldly defiant, but it's not clear why. Age, religion (Catholic vs. Protestant), and political affiliation did not seem to matter. Most of the studies used male volunteers only, for some reason, but Experiment 8 used women; compared to Experiment 5 the results were pretty much identical. In the early experiments there were some indications that better educated and higher-status men were more defiant, but this did not seem to hold for all of the studies.
   
7. This actually happened Again, you already knew this, but it's worth taking a moment to remember it. This really happened and it's been replicated ad nauseum; so far as I can see, no-one has succesfully criticized the basic assumptions of the paradigm (although if anyone has please let me know.) Milgram's faith in humanity seems to have been shaken by his research - his book contains case studies of individual participants which are are cynical to the point of misanthropy, even down to the level of the physical appearance and personality of the participants ("Mr Batta is a 37-year old welder...he has a rough-hewn face that conveys a conspicuous lack of alertness. His overall appearance is somewhat brutish...[during the experiment] what is remarkable is his total indifference to the learner; he hardly takes cognizance of him as a human being...the scene is brutal and depressing...at the end of the session he tells the experimenter how honored he has been to help him.") The subjects who disobeyed authority get a slightly better treatment, but not much better. Yet who can blame Milgram for this? It's worth bearing in mind also that Milgram was Jewish. His text is full of references to Nazi Germany, Hannah Arendt, the Vietnam War and the Mai Lai massacre. The hero of the book, if there is one, seems to be the young man who took part in the experiment and, as a result, decided to apply for Conscientous Objector status to avoid being sent to Vietnam. He got it.
   

Links: Dr Thomas Blass's StanleyMilgram.com - excellent.
Dr Blass's review paper on the Milgram paradigm.