Dear Steven
22nd August 2005

We have crossed swords in the past about the role of genes in behaviour, an area where it is all too easy to drift into a phoney “nature vs nurture” argument. This time I am glad that we are debating a subject that is not only intellectually intriguing but is also of enormous public health importance—the roots of disorders such as depression, bipolar disorder (what used to be called manic depression) and schizophrenia.

Although I have spent most of my career researching psychiatric genetics, it was reading the works of Sigmund Freud when I was a teenager that spurred me to become a psychiatrist. Freud, of course, believed that he had invented a new branch of science, psychoanalysis, and in the late 1960s this seemed more exciting than the science I was studying. And what particularly interested me were the writings of people who challenged the whole basis of orthodox psychiatry. I admired RD Laing and his followers, who argued that disorders such as schizophrenia were actually sane responses to a crazy society. I even had time for the more right-wing Thomas Szasz, who proposed that mental illness was a myth: there were no demonstrable brain abnormalities or lesions in most cases, he argued, so how could these be real diseases? It was only when I got to see psychiatric patients for myself that the light began to dawn. The people I saw were sick and suffering. If what they had was a myth, it was a myth of an astonishingly debilitating variety.

I also discovered that the treatments that worked were the ones that had a rational scientific basis and (to my initial horror) that Freudian analysis was not one of these. Some of my teachers regarded Freud not as a scientist at all but rather a purveyor of sometimes useful metaphors about mental life and the therapist-patient relationship. Over the years I came to realise that they were right. The real pioneer of effective “talking cures” was Ivan Pavlov, not Freud. Pavlov’s discovery of classical conditioning and the subsequent discovery by others of “operant” (reward-based) conditioning paved the way for the development of behaviour therapy and later cognitive behaviour therapy (CBT), the two most strikingly successful types of treatment for mental disorders. CBT is not only based on sound scientific principles derived from experimental psychology, it also lends itself to scientific scrutiny. In randomised controlled trials where patients are allocated to either an active treatment—CBT—or a “dummy” treatment (like chatting to a therapist), CBT has consistently come out on top in the treatment of depression. And it has not stopped there. Therapies based on CBT are being developed and refined to treat phobias, obsessive compulsive disorder and even bipolar disorder and schizophrenic symptoms.

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