[D66] Psychiatry's Cycle of Ignorance and Reinvention

[René Oudeweg]

madinamerica.com 
<https://www.madinamerica.com/2023/02/psychiatrys-cycle-of-ignorance-and-reinvention-an-interview-with-owen-whooley/> 



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

Ayurdhi Dhar, PhD
19–24 minutes
------------------------------------------------------------------------

Owen Whooley is an associate professor of sociology at the University of 
New Mexico. His book /On the Heels of Ignorance/ 
<http://www.owenwhooley.com/knowledge-in-the-time-of-cholera>/: 
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/ <https://en.wikipedia.org/wiki/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 
<https://www.madinamerica.com/2017/02/new-data-showslack-efficacy-antidepressants/> 
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 
<https://www.madinamerica.com/2019/03/slow-tapering-best-antidepressant-withdrawal/> 
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 
<https://www.madinamerica.com/2019/07/chemical-imbalance-theory-dr-pies-returns-again/>, 
“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./ <https://www.madinamerica.com/thomas-jobe-fund/>
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://www.tuxtown.net/pipermail/d66/attachments/20230405/e21c07d6/attachment-0001.html>