Alfred Freeborn (Max Planck Institute for the History of Science) was awarded the 2024 History of the Human Sciences Early Career Prize for his essay ‘Testing Psychiatrists to Diagnose Schizophrenia: Crisis, Consensus and Computers in post-war Psychiatry’. The article is forthcoming in the journal. We asked him some questions about the winning text and his future research.
History of the Human Sciences: Congratulations on winning the Early Career Prize. Could you begin by briefly introducing your winning article, situating it in the context of your broader research project?
Alfred Freeborn: My current project looks at the history of psychiatric epidemiology and medical statistics in the 20th century in order to understand how mental health became the global field it is today. I seek to explain how the place and meaning of diagnosis in psychiatry fundamentally shifted in this period from being an act of detective-like intellectual synthesis to something more like automated pattern recognition and statistical analysis. In my article I show how the availability of certain technologies, such as mainframe computers and videotapes, enabled new ways of experimentally dissecting and reassembling the diagnostic procedure, ultimately laying the ground for a new way of evaluating the quality of the diagnostic data produced both in mental hospitals and in research. In a nutshell, the epistemic threshold of psychiatric diagnosis was massively lowered in order to secure professional consensus, and the purpose of diagnosis was increasingly understood as a tool for surveying populations, rather than the identification of natural disease entities.
HHS: What was the US-UK Diagnostic Project (DP) (1965-1975) and how did you come to be interested in it?
AF: The DP was a series of important studies comparing how psychiatrists in these two countries diagnosed people experiencing psychosis, in order ultimately to test the trustworthiness of mental hospital statistics. The basic idea was to take two mental hospitals, one in Brooklyn and one in London, and install a small group of psychiatrists trained to use a standard diagnostic procedure at both. These psychiatrists would diagnose new patients over a set period of time and their results would be compared with the local hospital statistics. The findings revealed that while the local hospital statistics showed more cases of schizophrenia in Brooklyn, the trained psychiatrists from the DP diagnosed more or less the same number in each hospital. In addition to this, a set of patient interviews were videotaped and shown to large audiences of psychiatrists in both countries who were then asked to make a diagnosis. The results in some cases were really dramatic: for one patient, known as Patient F, three-quarters of the American psychiatrists diagnosed schizophrenia, compared with almost none of the Brits. I first really took interest in the DP while working in the UK National Archives with records of the Medical Research Council when I discovered some early exchanges between the American and British sides of the project.
HHS: How is the DP usually remembered by psychiatrists and/or historians?
AF: Among psychiatrists the DP is remembered as a famous study in which the British collaborators undermined the professional credibility of American psychiatrists. It is canonised in the cultural memory of modern psychiatry as having shown that American psychiatrists over-diagnosed schizophrenia. While historians take note of the DP, the US-centric historiography has by and large failed to dwell on the importance of this collaboration. Through my archival work I realised there was another dimension to the DP. While the Americans had the money, machines and manpower and were further along in doing psychiatric epidemiology than the Brits, there was no national system for collecting mental hospital statistics in the US. The UK’s National Health Service and the statistics of the General Register Office were therefore seen as a useful data set by researchers from the American side. The Americans had ambitious plans to establish a research centre for psychiatric epidemiology in London and conduct studies with the UK census data but this was rejected by the Brits. I think the DP was not just an interesting episode in understanding how psychiatric diagnosis works, but was part of a broader struggle over how psychiatry would be reconfigured as a public health problem in the postwar era. In other words, as a struggle over who would count as an expert in the evaluating and planning of the new community care services as mental hospitals started to be closed.
HHS: How did the DP influence diagnostic reform in psychiatry?
AF: Key players in the DP went on to reform both the International Classification of Diseases (ICD) and the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and in the latter case the DP’s results were used as leverage to replace psychodynamic concepts with ostensibly testable and statistically reliable diagnostic criteria. I also think the focus on schizophrenia in the DP had an impact. On the one hand, the DP was about enabling reliable comparisons of local and national statistics, and the focus on distinguishing schizophrenia and affective psychoses was in response to increasing evidence that lithium salts helped treat mania but not schizophrenia, therefore distinguishing these two disorders had real therapeutic implications. But the DP was also strategically designed to capture the difference between American and British psychiatrists. The very design of the DP Project aimed to highlight and showcase the psychodynamic approaches to diagnosing schizophrenia which were dominant in New York at the time and, unsurprisingly to everyone involved, it was successful in revealing that these psychiatrists in New York did things rather differently than the psychiatrists in London.
HHS: Could you introduce Aubrey Lewis and Morton Kramer and explain the significance of their ‘competing interests’ for your arguments?
AF: So Aubrey Lewis was probably the most influential psychiatrist in postwar Britain: he was clinical director of the Maudsley Hospital in south London and the first professor of psychiatry (from 1946 to 1966) at its medical school, renamed the Institute of Psychiatry in 1946. The hospital and medical school became the leading centre for a methodology-focused form of social psychiatry. Maudsley psychiatrists, led by Lewis, prided themselves on taking meticulously detailed patient case histories and avoiding the theoretical excesses of both organic and psychodynamic approaches. Morton Kramer in contrast was a stats guy. Kramer became Director of the Biometrics Branch of the US National Institute of Mental Health in 1949 with no experience of psychiatry, having been trained in statistics and epidemiology. He was perceived by his more clinically engaged colleagues as a serious epidemiologist who was focused strictly on data about populations, lacking perhaps the concern for the individual patient.
These two figures were by no means the only players in shaping the DP, but I show how their different perspectives on how to reform diagnostic classifications reveal an ongoing tension in our attempts to standardise psychiatric diagnosis. Lewis argued that reliable statistics would only be possible if psychiatrists working across the NHS could be convinced to take diagnosis seriously and use careful and detailed methodology. Kramer argued that a field trial was necessary to create public trust in psychiatrists and that the diagnosis of schizophrenia was the most suitable test case for this task since there seemed to be sufficient consensus on this issue. The DP was a synthesis of these two interests: the Maudsley consensus was used to establish a trustworthy gold standard for schizophrenia diagnosis. But the tension between these two interests endured, as I argue that the creation of these standards in the long run alienated the diagnostic intelligence of the psychiatrist and reduced the role of the expert diagnostician.
HHS: What role did computers and videotapes play in the story your article tells? What does this reveal about the relationship between technology and psychiatry?
AF: There is a wonderful passage I cite in my article where Aubrey Lewis talks about fighting for the “diagnostic souls” of psychiatrists in order to make sure they do not simply apply labels but produce careful and accurate diagnoses. For me, this is a rejection of the idea that psychiatric diagnosis can be treated purely as a technology: it is a recognition that the psychiatrist is as much part of the process of diagnosis as the particular tool they use. The videotape and the mainframe computer were deployed in the experimental dissection of psychiatric diagnosis into two parts: recording mental symptoms and applying a diagnostic algorithm. Both offered analogues for an idealised scenario in which psychiatrists would all observe the same symptoms when interviewing the patient and reliably apply the same diagnostic decision-making tree. In this scenario, the theoretical differences between individual psychiatrists and their concepts of mental disorder were made into comparable statistical differences. Using videotapes to train psychiatrists to diagnose is now completely standard practice. Computers not only enabled the application of totally reliable diagnostic algorithms, but more work intensive forms of statistical analysis to try and identify new clusters of mental symptoms and potentially improve existing classifications. However, by the mid-1970s this approach had already proved more or less a dead end. While engagement with these statistical methods led psychiatrists to re-describe diagnosis as a type of statistical analysis, in reality they made little impact on actual diagnostic classifications, which reflected consensus positions reached by committees of psychiatrists like those in the DP.
HHS: Why was ‘schizophrenia’ such a contested diagnostic category?
AF: In a fundamental sense, schizophrenia or dementia praecox has always been a contested category since its inception as a disease concept at the end of the 19th century; it is more like a set of competing yet overlapping concepts with vague boundaries than a stable or singular entity. But in the 1960s the diagnostic category became the focus of public controversy for several reasons: neo-Freudian, existential and social psychiatric ideas became dominant and challenged older views of schizophrenia as an inherited brain disease; numbers in mental hospitals peaked in the 1950s leading to overcrowding and awful conditions for patients while the mass media was filled with reports from within asylums; the new social movements grew around patient rights and so on. This story is well known by historians of psychiatry. But while most historians have tended to agree with contemporaries that schizophrenia had become a catch-all term under the influence of psychodynamic theories, I turn this on its head by suggesting that in fact in the UK there was widespread consensus on the important symptoms involved in diagnosing schizophrenia.
What do you mean by the ‘methodological imperialism of the Maudsley’?
AF: The phrase first occurred to me when interviewing the American psychiatrist William Carpenter Jr. about his time working on the WHO International Pilot Study of Schizophrenia (1965-1973), a study which used many of the same methods developed in the DP. He recalled how as a young psychiatrist he was deeply impressed and intimidated by the Maudsley psychiatrist John Wing’s knowledge of German psychopathology and that Wing reminded him of Colonel Nicholson from The Bridge on the River Kwai (1957). This comparison really stuck with me. In the film the Colonel orders his men to build a bridge for their Japanese captors in order to maintain their morale and professional image as soldiers, but in the process lets his enthusiasm for this technical project and following the rules obscure his sense of the bigger conflict and values. Looking at the longer history of diagnostic reform in psychiatry and its failure to identify valid disease concepts or lead to better treatments, the comparison is striking. In this article I wanted to use the phrase to evoke how the methodological authority of the British psychiatrists in this period was perceived by their American colleagues. I think there is something more to say here analytically, but that will have to wait for another paper.
HHS: What do you conclude was most historically significant about the DP?
AF: The argument I am making in the article concerns in particular how psychiatric diagnosis was evaluated: it describes changes in methodological concepts, rather than changes in everyday clinical practice. This is not because I am not interested in clinical practice, but that I think too often historians gloss over the difficulty of actually making generalisable claims about diagnosis in clinical practice. The historian seeking to make such claims must make use of the statistical data from the time and faces the same methodological challenges as their historical actors who doubted the accuracy of these numbers. Other historians have already argued that the real changes in diagnostic practices in the UK and USA were most likely shaped by changes in health insurance and pharmaceutical companies, not the official classification systems. What I think is important is that the DP showed that to create reliable statistics on psychiatric diagnosis required small groups of trained psychiatrists conducting lengthy and detailed interviews, and this approach was clearly not suitable for everyday clinical practice. Rather than solve the problem of whether we can trust mental hospital statistics, the DP helped usher in a new way of evaluating psychiatric diagnosis in statistical terms – the tensions of which remain with us today.
HHS: Finally, I wonder if you could briefly discuss what you’re currently working on and what your next project might be?
I recently hosted a conference in Berlin on the history and legacy of the WHO studies of schizophrenia which was a wonderful experience: we not only had historians of psychiatry, but anthropologists, philosophers and psychiatrists from the field. I am now working on turning that into a collected volume. I am also currently working up revisions on my first monograph Biomedical Madness: Schizophrenia and the Making of Biological Psychiatry which will hopefully appear with University of Chicago Press next year. As in my article, which is based on a chapter from the book, I use the British context to develop new perspectives on the history of postwar biological psychiatry.
Interview by Hannah Proctor.
