On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing

by Owen Whooley

Psychiatry has always aimed to peer deep into the human mind, daring to cast light on its darkest corners and untangle its thorniest knots, often invoking the latest medical science in doing so. But, as Owen Whooley’s sweeping new book tells us, the history of American psychiatry is really a record of ignorance. On the Heels of Ignorance begins with psychiatry’s formal inception in the 1840s and moves through two centuries of constant struggle simply to define and redefine mental illness, to say nothing of the best way to treat it. Whooley’s book is no antipsychiatric screed, however; instead, he reveals a field that has muddled through periodic reinventions and conflicting agendas of curiosity, compassion, and professional striving. On the Heels of Ignorance draws from intellectual history and the sociology of professions to portray an ongoing human effort to make sense of complex mental phenomena using an imperfect set of tools, with sometimes tragic results.

Genres: Psychology, Politics

304 pages, Paperback

Published April 23, 2019

Reviews

[Lee · Rating 5 out of 5]

One way to understand any profession is in terms of the politics of ignorance. There are some fields in which most of us are ignorant but a few are recognized to be knowledgeable. If the knowledgeable few maintain their own journals, form associations, and control their membership, then the lay public may recognize their authority to confer credentials and even grant them some autonomy to regulate themselves. That's what makes it a profession. Law and medicine are typical examples of professions.

Psychiatry in America is a typical profession in some respects: those who treat mental illness have their own associations, journals, credentials, and so on. But it is atypical in one important respect: over its history there are been several crises in which many people within and outside of the field have doubted that psychiatrists know much about what mental illness is or how it can be treated. Whooley's book is an account of these crises and an explanation of the political means by which the profession survived despite them.

This isn't an anti-psychiatry book. Whooley seems almost admiring of the profession's candid self-criticism and ability to reinvent itself. He's a historical sociologist who believes he has found an interesting puzzle: how the hell is this profession surviving all these reinventions in the last couple centuries? From asylum-keepers to lobotomists to psychoanalysts to prozac-prescribers. His explanations are mostly fine-grained and historical: such-and-such group lobbied state legislatures, or so-and-so got themselves appointed to a committee.

The exception to this is the concluding chapter, which is strongly condemnatory and surprisingly moving. There Whooley's tone changes, and he ventures a more sweeping, speculative explanation of how across all these crises this profession was able to pull off these stunning reinventions. In short, the theory is: we permit psychiatrists to do this because, no matter how difficult their subject matter may be, they have agreed to relieve us of the burden of responsibility for the mentally ill, a stigmatized population we very evidently would rather not think about.

Here is a podcast interview with the author about the book:
https://newbooksnetwork.com/owen-whoo...

Here are a few things I found surprising:
- Psychiatry emerged with the transformation of our understanding of mental asylums as sites for moral therapy into places for medical treatment. In retrospect that transformation was remarkable because (a) it was motivated by popular interest in the bunk science of phrenology, and (b) it immediately put psychiatry in professional tension with the already-established field of neurology.
- President Garfield's assassin pled legal insanity, and that provided a high profile forum for expert witnesses in neurology to deride psychiatry as a science of gardening and farming (ie, asylum design).
- The psychobiological and pragmatic turn bring psychiatry into contact with William James's pragmatism, moral suasion, hypnotism, and eugenics. It also setup a recurring Lucy-pulling-away-the-football play: as soon as the cure for neurosyphilis is found, the disease is reclassified as a somatic illness suited to medical treatment rather than a mental illness suited to a psychiatric one.
- In the 1930s psychiatry developed an in-office technique for removing pathological ideas directly via driving a trocar (a sharp-pointed steel surgical instrument) through the patient's eye socket and into their brain, severing fibers in the prefrontal cortex. 17,000 of these lobotomies were performed between 1936 and 1951. In 1949 the Portuguese neurologist who developed the technique was given the Nobel prize. Thorazine was developed in 1945 and used to treat psychotic disorders; it had some responsibility for the decline in lobotomies, but it had its own negative side effects.
- Freud visited America only once, and American psychoanalysts transformed his idea in ways he strongly disapproved of: it was more optimistic, more medical, less sexual. The result was an "ego psychology" more focused on unconscious defenses of ego rather than the unconscious drives of the id. The goal of therapy became more ambitious and more conservative than he had envisioned: they were attempting to reconcile unconscious drives to social compliance via sublimation, trying to help patients achieve self-reliance.
- Formerly psychiatry had emphasized the need to identify discrete mental illnesses, but the psychoanalysts followed Freud in conceiving of neuroses as existing in greater or lesser degrees in everyone. Interpretation was substituted for diagnosis. Case studies were used to train practitioners; the elusive nature of mental distress required an indescribable feel and tact acquired via apprenticeship. Each patient presented a unique case. As a result psychoanalysis eluded codification and achieved a mystique. Abra­ham Myerson, an early critic of psychoanalysis, complained it was a “very ingenious subterfuge for escaping criticism.”
- By 1960s psychoanalysis was hegemonic in American psychiatry. Treatment of respected and upper-class patients became acceptable. Psychiatry was moving out of state-run facilities and into private practice. By the 1970s new epistemic norms in medicine and means of paying for medicine spelled trouble for obscure and expensive psychoanalytic treatments. Insurance companies and eventually the federal government demanded record-keeping and evidence of efficacy. Gobbledygook and ideological baggage became liabilities.
- In the 1960s and 1970s the two-thirds of psychiatrists who worked in institutions sought to expand their professional legitimacy beyond the custodial duties inside mental hospitals via a program of "community psychiatry." Embracing activists' critiques of mental hospitals, the profession moved to deinstitutionalize psychiatric treatment by preventatively addressing societal ills in communities. Congress passed the Community Mental Health Act in 1963. State mental hospitals were closed, 90% of their beds disappeared, and without long-term funding (especially under Reagan) the community service centers never opened or disappeared. A bad system was replaced with no system. A Ralph Nader group wrote a damning report on them and their lack of focus: "the definition of mental illness to include a kaleidoscope of disorders from organic and functional psychoses to neurotic disorders, alcoholism, drug addiction, school learning difficulties, juvenile delinquency, employment and marital problems, and even political dissent." CMHA resulted in seriously ill people living on the streets, and is now acknowledged to have been one of the greatest disasters in psychiatry. See Wikipedia page on the [CMHA](https://en.wikipedia.org/wiki/Communi...).
- Criticism came from all quarters by 1970s: mental hospital exposés, One Flew over The Cuckoo's Nest, legal challenges to involuntary commitment, doubts about psychoanalysis, criticism of drug treatments, academic attack of its history (Foucault), full-blown mental illness skepticism (Thomas Szasz), activist demands that homosexuality no longer be considered a mental illness (1973 APA vote), and more general demands to reform the classifications and diagnoses in the Diagnostic and Statistical Manual (DSM).
- DSM-III was a revolutionary revision that moved psychiatry from a "troubled mind" to "broken brain" model. Pharma welcomed the targets for future products, and insurance companies liked that it gave them another reason to stop paying for psychotherapy. DSM-IV was a conservative revision, but critics said it pathologized some conditions that were not mental illnesses.
- DSM-5 was supposed to be revolutionary, adopting validity rather than reliability as its goal. Pharma and patient groups disliked talk of a paradigm shift while revisions were being considered for the upcoming DSM-5, sensing it would spell disruption for them. They pushed for the establishment of advisory scientific review committee. That committee recommended a requirement of empirical justification for proposed changes. Since most existing empirical research was conducted in terms of DSM-III categories, this requirement quashed any possibility of paradigm change, mostly locked in existing categories, and favored incrementalism.
- Days before the DSM-5 was published the National Institute for Mental Health (NIMH) announced they would no longer rely on the clinically-oriented ontology of the DSM but instead develop their own psychiatric nosology, the Research Domain Criteria (RDoC), based on underlying neurobiological mechanisms.
- Psychiatrists saw their influence diminish. They now mostly just manage pill prescribing, and in fact physicians do most of that. Five states now allow clinical psychologists to get in on that. Today doubts are arising that the pills being pushed are anything but placebos; critics see psychiatry as in league with pharma.
- Working in psychiatry's favor now is the public's beguilement by glowing fMRI imagery on magazine covers and the like. This is a potential new source of mystique for the profession. Obama leaned into this with his BRAIN (Brain Research through Advancing Innovative Neurotechnologies) initiative. Most of the NIMH's budget has gone to neuroscience, including the Human Con­nectome Project, a five-year effort to build a network map of the brain. Only 10% goes to clinical research. The latest interest is in optogenetics.

Interesting sounding works referenced:
- Luhrmann, Of Two Minds: An Anthropologist Looks at American Psychiatry
- Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates
- Rose, Governing the Soul: The Shaping of the Private Self (New York: Routledge, 1990)
- Mary Douglas, How Institutions Think
- Stuart Firestein, Ignorance: How It Drives Science
- Ian Gold and Joel Gold, Suspicious Minds: How Culture Shapes Madness
- Foucault, Madness and Civilization
- "For accessible histories of psychoanalytic thought, see George Makari, Revolution in Mind: The Creation of Psychoanalysis (New York: HarperCollins, 2008); Stephen A. Mitchell and Margaret J. Black, Freud and Beyond: A History of Modern Psychoanalytic Thought (New York: Basic Books, 1995)"
- Janet Malcolm, Psychoanalysis: The Impossible Profession
- Jasper, Getting Your Way: Strategic Dilemmas in the Real World

[Jay E. Valusek · Rating 4 out of 5]

Whooley does an excellent job documenting psychiatry's 200-year history of ignorance, without descending into an "antipsychiatry screed," which I both appreciated and questioned, upon finishing his book. The upshot is, in effect, a serious smack down of the entire psychiatric enterprise, era by era. Whooley is keen to demonstrate the cyclical nature of psychiatry's reinvention, every 30-40 years, discarding and disavowing the past and promising a whole new paradigm, which, ultimately proves elusive, crashes, burns, and yet another phoenix rises from the ashes, generation upon generation . . . without ever penetrating, much less, defining psychiatry's "object": mental illness. No one to date has managed to figure out, make sense of, or find any meaningful way of treating mental illness, if, in fact, it even exists (which Whooley himself does not seem to question; I'm making the observation myself; he cites, but does not endorse, Thomas Szasz's infamous The Myth of Mental Illness). I can't, for the life of me, understand why anyone still supports anything the psychiatric profession does or says, so publicly have been its snafus, so egregious its harms, so recalcitrant its leaders in the face of its epic, unmitigated ignorance. Yet, as Whooley so brilliantly explains in the conclusion, the culpability lies not solely at the feet of the American Psychiatric Association, but at ours, as well. We, the people, as Whooley notes, have never given much of a damn about the so-called mentally ill, especially the "severely" ill, and shown ourselves willing to relegate them to the dustbins of psychiatric control, even as we all shake our heads and wonder what the hell is going on. No one, anywhere, understands mental illness. So we hand off the problem to psychiatry, which keeps the fires of ignorance burning for yet another generation. And, as Whooley points out, the entire shaky enterprise stands on nothing but promises, promises, promises that, one day, all will be understood, and psychiatry's biomedical obsessions will be vindicated, at last. Despite 200 years of failed promises. I give On the Heels of Ignorance four stars, rather than five, because, after such brilliant exposition of the ignominious history of ignorance, he never fully explicates the horrifying damage, disease, and death the the profession is propagating, in cahoots with its enablers and co-conspirators, the pharmaceutical industry and health insurance machinery. He never quite turns his sharp gaze at the cost in lives and well-being, nor holds them fully to account for their ongoing crimes against humanity. Alas, I realize that was not his scholarly intent, but after all the rest, I wanted him to go there. In any case, I highly recommend this book to anyone intent upon understanding what went wrong with psychiatry, and why, it seems, nothing will ever change. It's up to us to withdraw our support, and dollars, from these charlatans posing as doctors of medicine. The whole edifice needs to come down. Soon.