Psychiatry’s Cycle of Ignorance and Reinvention: An Interview with Owen Whooley

Owen Whooley is an associate professor of sociology at the University of New Mexico. His book On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing deals with the tumultuous history of psychiatry and its equally unstable present. In his book, he documents psychiatry’s ignorance, insecurity, hubris, and hype. Owen Whooley is an expert in the field of the sociology of mental health, sociology of knowledge, and sociology of science.

In this interview, we will cover his histography of psychiatry, engage with his writings on the DSM, and talk about what gives psychiatry its almost supernatural powers to rise from near death over and over and over.

 

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Ayurdhi Dhar: How did you end up studying psychiatry, its ignorance, fault lines, and tumultuous history?

Owen Whooley: My research is linked to my personal biography. Growing up, my father had mental health challenges—major depression, comorbid substance abuse, and multiple suicide attempts.

I was a kid, but two things were deeply ingrained from that experience. One is the uncertainty that permeates living with a loved one who is going through mental health crisis. The other was seeing the failures of my father to get adequate help. Whether that was a failing of his, of his providers, or some combination of both, the problem never got solved.

I realized that not only do I not understand what’s going on with my dad, but he also doesn’t seem to understand it, and his providers don’t seem to understand either. Flash-forward 30 years, and I’m writing a book on psychiatric ignorance.

The other moment was in graduate school, where someone flippantly said, “Everyone knows that the chemical imbalance theory is a myth, or it’s not supported.” I was like, “What? I’ve been told this for decades! Everyone knows that it’s not true?” I realized it was not quite that the emperor has no clothes, but the emperor is scantily clad.

 

Dhar:  In your book, you write that since its inception, psychiatry has been in trouble and that psychiatrists know it. You write that unlike other medical professions, psychiatry has amassed a frustrating record of failures, false starts, and dead ends—but here is the interesting thing—it continues to persist and is resilient. My question is, why? What has made this profession which is in continuous crisis, survive, and in many ways, thrive?

Whooley: The history of American psychiatry is a history of ignorance. Psychiatry lacks the basic understanding of the mechanisms underlying mental distress, mental disorder, and mental suffering—whatever terminology we’re using. Is it genetic, neurochemical, social, psychological, or family dynamics?

What struck me was the extent to which psychiatrists themselves talk about this ignorance. Given this ignorance and psychiatrists’ own acknowledgement, how has it been able to persist? I have two broad causes.

One reason is what psychiatrists themselves have done—the collective management of ignorance. When we look over American history, psychiatry looks vastly different in each era. Psychiatry has gone through a series of reinventions. These are moments when faced with a crisis pertaining to its ignorance, elite psychiatric professionals reinvent the profession, which allows psychiatry to restart the clock, to say, “Yes, we were in this crisis of ignorance, but that’s a problem of the past. We now have hit on this new way of thinking about mental illness, of studying and treating it”.

Over the course of 150 years, there has been this constant cycle of reinvention. Starting with the asylum period, you get a reinvention with the psycho-biological period, and then a reinvention into psychoanalysis, a brief attempt at community psychiatry, and then we’re here at the current moment. This reinvention allows psychiatry to make an important claim vis-à-vis its ignorance, namely that mental illness, although not known yet, is knowable.

Now, I don’t want to excuse Psychiatry’s numerous legions of abuses, but I think the tumultuous history of psychiatry and its persistence is also related to our collective social failure. We get the psychiatry that we deserve by not forcefully questioning it, and by stigmatizing and marginalizing individuals living with mental illness. It’s a combination.

Psychiatry persists because of the profession’s strategies to manage its ignorance and because of our collective indifference to the clientele that psychiatry purports to serve.

 

Dhar: If it was any other medical profession reinventing itself continuously, somebody would’ve said, “You really don’t have your shit together. How many times are you going to say we are right there, so close.” Does psychiatry serve some purpose to benefit the status quo that it’s able to reinvent itself over and over?

Whooley: In sociology, we talk about jurisdictions—what profession controls what area of work. For psychiatry’s jurisdiction, we have tasked it to deal with the highly marginalized communities around whom there is a ton of ignorance. This is the collective failure. As a society, we are willing to hand over the responsibility for this community—individuals living with severe and chronic mental illness—to psychiatry because other medical professionals don’t want to deal with this population.

We’ve farmed it out to psychiatry and said we’ll let you handle it. We won’t intervene or look into it, and in doing so, we wash our hands. This is social control; take this problem and control it, so we don’t have to deal with it.

 

Dhar: You write that psychiatry is an insecure profession, and different historians often make the same mistake by assuming that the profession is coherent and that psychiatrists know what they are doing. You say that’s giving too much credit to the profession, which is basically, in your words, ‘muddling through.’ Can you talk more about this and whether the profession’s hubris is connected to their insecurity?

Whooley: In historian Barbara Tuchman’s wonderful book called The March of Folly, she writes that when historians look back on important events and try to make sense of them, they impose on them a reason or rationality. They want to make sense of ‘why did so and so make this decision?’ They can impute more coherence than there actually was. Sometimes people just make bad decisions, and then there is happenstance and mere chance. When you impose coherence retrospectively, you distort the understanding of what actually happened. That’s how I think about psychiatry.

We, as social scientists, want to make sense of the world, but if we look at my historiography of psychiatry, there is no coherent program here. There is no overarching narrative of progress here. What you see is the cyclical replaying of the same problems over and over. We see this with treatments and with theories around mental distress.

The history around the reinvention of psychiatry goes something like this. Psychiatry has this underlying ignorance. Eventually, it erupts. There is a crisis, and the response of reformers is to reinvent the profession—that is, a very dramatic transformation of the profession. We get new ideas, theories, treatments, organizations, and institutions. They actually redefine what mental distress is—there are fundamental, epistemological, and ontological changes.

In order to make those changes and to promote those reinventions, psychiatrists engage in hype. Sociologists of technology talk about what’s called the hype-disappointment cycle. In Silicon Valley, we get a new idea, and we’re going to really hype it up. We get investors, create a buzz, and secure resources. That’s what psychiatry does.

Now the flipside to hype is hubris. Psychiatrists believe the hype and then undertake these transformations in an incredibly aggressive way. That’s where hubris is tagged along with the reinvention. We’re seeing it play out today with psychopharmaceutical medications—eventually, the sheen begins to wear off, the initial claims of efficacy are shown to be problematic, and ignorance once again rears its head. Then psychiatry moves on to the next thing.

 

Dhar: Let’s talk about specific types of reinventions. You write about psychoanalysis and how it was one of the reinventions that used the strategy of mystification to reinvent psychiatry. Your quote was, “Mystification is the process of making expertise inaccessible to external judgment”—if you haven’t been through analysis, you can’t critique analysis. Can you tell us about how psychoanalysis managed this and how it eventually failed?

Whooley: Let’s say you have an insecure knowledge base. What do you do? One strategy is to essentially remove that problematic knowledge from public scrutiny, to hide it, but in hiding it, imbue it with a kind of prestige or mystique.

How do psychoanalysts do this? In its more traditional forms, psychoanalysis is a form of knowledge production based on the interpretation of a patient’s subconscious. So, you already have a level of removal. It’s an interpretation that is an emergent property of the interaction between the analyst and the patient. One can just say, “if you’re not in that room, you don’t understand the dynamics that are happening that are leading to these interpretations.” If you were to challenge the claims made by psychoanalysts, you really have little grounds to do so. The rhetoric is: you’re not there; you don’t understand.

Also, psychoanalytic knowledge is couched in a particular jargon and a set of concepts that only those who are trained in that tradition can make sense of. This mystification allowed American psychiatry to embrace psychoanalysis to an extreme degree. Eventually, people begin to ask for evidence. At the beginning of the 1970s, insurance companies got involved in paying for therapy. They wanted oversight and some account of the efficacy—your patient has been in psychoanalysis for two decades. What’s the outcome? The FDA begins to commit to randomized controlled trials. Very hard to fit a psychoanalytic paradigm within a randomized controlled trial.

In the 1970s, American psychiatrists/psychoanalysts were presented with this challenge. There were feeble attempts to bend psychoanalytic thinking to meet these new evidentiary regimes, but they couldn’t do so. Then there was a crisis, and it wasn’t just about evidence. This was also the emergence of the antipsychiatry movement in the US. This crisis led to the DSM and the diagnostic psychiatry that that followed.

 

Dhar: Then comes the biomedical model, the most recent reinvention. You write that these were people following Emil Kraepelin’s work, and in the emerging DSM, the biomedical model was implicitly present with this idea of psychological distress as a disease. What was the promise of this reinvention? How did professionals popularize this vision of psychiatry, that it’s a medical branch dealing with real diseases? How do you see it failing?

Whooley: Back in the 1970s, antipsychiatry emerged. One major critique focused on diagnosis. Can psychiatrists actually identify people who have a mental illness versus people who don’t? The famous but now debunked Rosenhan study takes place. What you have then is this crisis and the need for the next thing. A pretty small group of psychiatrists who self-identified as neo-Kraepelinians, led by Robert Spitzer, wanted to reinvent psychiatry along more medical lines. They decided to radically revise the diagnostic and statistical manual of mental disorders in a particular way, the revisions to DSM III.

The previous DSMs were very psychodynamic in nature. Psychoanalysts themselves are not that interested in diagnoses because their treatment is based on the specificities of the patient. In fact, one of the reasons that neo-Kraepelinians took over was that no one else wanted to do it. It was seen as an unglamorous bureaucratic thing, but Robert Spitzer had a vision, and he wanted to harness the DSM III revision to reinvent the profession. The explicit aim of the DSM revision was to improve reliability by addressing this issue of diagnosis. So, if I’m doing research on major depressive disorder and you’re doing it in your lab, then we are looking at the same thing.

They revised the very conceptualization of what a mental disorder was, which to this day, is a list of various symptom criteria that patients need to meet in order to qualify for a diagnosis. The idea was that these are agnostic towards any kind of causal argument. But the broader vision was to build a biomedical knowledge base. The idea was that reliability would lead to a robust biomedical research program, which would finally solve the puzzle of mental illness and legitimize psychiatry as a medical science.

Now that hasn’t happened. Fast-forward to DSM V—in the lead-up to DSM V, once again, psychiatrists begin to recognize their ignorance. 30 years into the DSM III’s research program, we still don’t have an understanding of the underlying biological mechanisms of mental distress. We put a lot of hype into genetic science, which ends up being a mess. Neuroscience is still a little bit too premature, but even that’s showing that maybe we got off the wrong track with DSM III, because, at the end of the day, reliable diagnoses do not equal valid diagnoses. Validity means it reflects an actual real thing in reality.

There were concerns among the folks leading DSM V that “we’ve gotten off the wrong track with DSM III. Let’s use DSM V to introduce a new paradigm shift in psychiatry.”

 

Dhar: That was an important phrase, “paradigm shift,” and they said that early on. Yes.

Whooley: It was always unclear what the paradigm shift would be. Initially, they wanted to redefine mental health diagnoses based on the best science of the day, biomedical science. That was way too premature. Eventually, they decided they were going to redefine mental disorders from discreet categories to dimensional things.

DSM III carved out the universe of mental disorders into very discrete categories. We no longer talk about anxiety generally; we talk about specific kinds of anxiety, OCD, social anxiety, etc. The DSM V research shows these things tend to work along a spectrum.

Dimensionality became the means by which the paradigm shift was to happen. This didn’t happen because you get a lot of pushback within the profession about the state of its ignorance. Was the DSM III’s model inherently flawed, or have we just not given it enough time? Many elites in the profession fell into that latter group.

What you have is a professional disaster or, at the very least, an embarrassment, where you have previous chairs of the DSM arguing with the new DSM V. I interviewed 30 individuals involved with the DSM V. It was a very disorganized process. They felt like they didn’t have much guidance beyond, “Do something dramatic with the categories you’re assigned to.” So, at the end of the day, a paradigm shift doesn’t happen. DSM V looks pretty similar to DSM III.

Then, even more embarrassingly for the profession, the National Institute of Mental Health announced, literally a couple of weeks before the publication of DSM V, that they were no longer going to be using the DSM and were moving to a new diagnostic system, which they called the Research Domain Criteria (RDoc).

The DSM dominated psychiatry because it was seen as useable for both researchers and clinicians. Now you have the most important mental health research funder saying no, the DSM is not good enough; we’re going to require anyone who wants funding to use this other diagnostic system.

 

Dhar: In your book, you mention that in the 1950s or ’60s, the NIMH refused to fund studies of neo-Kraepelinians, the biomedical people, and then it flipped, and in the early 2000s, they decided to only focus on funding biomedical research.

Whooley: That is a recurring story. This kind of massive investment in particular ideas and programs that, after decades, don’t bear fruit. It raises really deep philosophical questions. Is mental distress knowable? Or is it knowable in one way? Psychiatry is compelled by the desire to find the explanation. What is the one explanation?

As a sociologist, I would say, stop looking for one explanation. You get the hype of the new thing, and you invest all your resources into it, neglecting all the other possible venues.

 

Dhar: For people on ground, what is the cost of these reinventions?

Whooley: I think the major cost is the perniciousness of the hype that leads to wanton experimenting upon mental health patients, especially in this current moment around psychopharmaceutical drugs.

I also have taken psychopharmaceutical drugs under the premise of chemical imbalance theories, explicitly told to me on various occasions. We’ve conducted a mass medicating of people under flimsy theoretical scientific premises.

To be fair, many people benefited from it, and now we might say that’s a placebo effect, but for some people, these drugs are perceived by some as life savers. Given this current discussion around tapering and questions of efficacy of these medications, what’s the social effect of the growing perception that there was this mass deception? What’s the effect culturally, of the ways in which we made sense of mental distress for the last three decades and the ways in which we’ve invested resources based on that understanding?

The sociologist in me will say, we’ve spent so much time medicalizing these things that we disinvested in the social factors and determinants that lead to mental distress. We’ve undermined the treatment infrastructure by focusing solely on pills.

 

Dhar: For me, one of the biggest costs is how it has changed people’s experience of themselves and how they understand and story their distress. 

You have described the role of psychopharmaceuticals in the success of DSM III, the development of Prozac, and direct advertising of drugs to consumers, and you write, “DSM III locked psychiatry in a symbiotic relationship with pharmaceutical companies.” Could you elaborate?

Whooley: DSM III carved out the universe of mental distress into smaller and smaller bits, and produced—to put it crudely—more ways of being mentally ill. That is a gold mine for pharmaceutical companies because it defines more markets for their wares. Not just more markets for them to test and develop drugs, but more markets to reframe existing drugs.

Paxil is an antidepressant that does pretty much what Prozac does. Prozac had already captured the market on depression. So, they reframed Paxil as a treatment for social anxiety. The DSM doesn’t have the same kind of packed punch without pharmaceutical companies.

Happening concurrently with the development of these drugs is emergence of direct-to-consumer advertisements. Pharmaceutical companies, through advertisements directly to the public through television, become the voice disseminating DSM categories.

Psychiatrists are really sensitive when you bring out this kind of relationship with pharmaceutical companies. You have folks like Ronald Pies saying, “We’ve never supported the chemical imbalance theory,” which is a cynical argument that’s too cute by half. Yes, maybe the APA didn’t come out and say, “Yes, the cause of mental illness is chemical imbalance,” but the entire profession was premised on that idea.

What’s interesting is what’s happening now with pharmaceutical companies that are getting out of the business of psychopharmaceutical medications and not seeing it as a particularly fruitful endeavor. As existing drugs are being increasingly challenged for their efficacy, pharmaceutical companies are backing off, which begs the question, where does psychiatry head because, essentially, psychiatrists have really narrowed their practice to medication management.

 

Dhar: You write that psychiatrists moved away from doing clinical work to medication management, but that the latter is now primarily done by general practitioners. So, where does that leave psychiatrists?

Whooley: If I were a psychiatrist, I’d be concerned because, as you mentioned, they ceded psychotherapy to psychologists and other counselors, and most psychopharmaceutical prescriptions come from general practitioners. The new hope for psychiatry is neuroscience, but that begs the question, why wouldn’t it just be neurology rather than psychiatry, if neuroscience pans out? There is a long history where once we medically can explain a condition, we take it away from psychiatry and give it to another medical specialty. I think the next 20 years are going to be really interesting for psychiatry, and I don’t pretend to know where it’s headed.

 

****

MIA Reports are supported, in part, by a grant from The Thomas Jobe Fund.