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<h1 class="reader-title">Psychiatry's Cycle of Ignorance and
Reinvention: An Interview with Owen Whooley</h1>
<div class="credits reader-credits">Ayurdhi Dhar, PhD</div>
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<p><span>O</span>wen Whooley is an associate professor of
sociology at the University of New Mexico. His book <a
href="http://www.owenwhooley.com/knowledge-in-the-time-of-cholera"><em>On
the Heels of Ignorance</em></a><em>: Psychiatry and
the Politics of Not Knowing</em> 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.</p>
<p>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.</p>
<p><i>The transcript below has been edited for length and
clarity. Listen to the audio of the interview here.</i></p>
<h6><strong>Ayurdhi Dhar: How did you end up studying
psychiatry, its ignorance, fault lines, and tumultuous
history?</strong></h6>
<p><em>Owen Whooley</em>: 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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<h6><strong>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?</strong></h6>
<p><em>Whooley:</em> 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?</p>
<p>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.</p>
<p>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”.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<h6><strong>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?</strong></h6>
<p><em>Whooley:</em> In sociology, we talk about
jurisdictions—what profession controls what area of
work. For psychiatry’s jurisdiction, we have tasked it
to <em>deal with</em> 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.</p>
<p>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.</p>
<h6><strong>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?</strong></h6>
<p><em>Whooley:</em> In historian Barbara Tuchman’s
wonderful book called <a
href="https://en.wikipedia.org/wiki/The_March_of_Folly"><em>The
March of Folly</em></a>, 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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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, <a
href="https://www.madinamerica.com/2017/02/new-data-showslack-efficacy-antidepressants/">the
initial claims of efficacy</a> are shown to be
problematic, and ignorance once again rears its head.
Then psychiatry moves on to the next thing.</p>
<h6><strong>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?</strong></h6>
<p><em>Whooley:</em> 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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<h6><strong>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?</strong></h6>
<p><em>Whooley:</em> 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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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.”</p>
<h6><strong>Dhar: That was an important phrase, “paradigm
shift,” and they said that early on. Yes.</strong></h6>
<p><em>Whooley:</em> 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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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).</p>
<p>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.</p>
<h6><strong>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.</strong></h6>
<p><em>Whooley:</em> 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?</p>
<p>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.</p>
<h6><strong>Dhar: For people on ground, what is the cost
of these reinventions?</strong></h6>
<p><em>Whooley:</em> 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.</p>
<p>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.</p>
<p>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 <a
href="https://www.madinamerica.com/2019/03/slow-tapering-best-antidepressant-withdrawal/">discussion
around tapering</a> 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?</p>
<p>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.</p>
<h6><strong>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. </strong></h6>
<h6><strong>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?</strong></h6>
<p><em>Whooley:</em> 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.</p>
<p>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.</p>
<p>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.</p>
<p>Psychiatrists are really sensitive when you bring out
this kind of relationship with pharmaceutical companies.
You have folks <a
href="https://www.madinamerica.com/2019/07/chemical-imbalance-theory-dr-pies-returns-again/">like
Ronald Pies saying</a>, “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.</p>
<p>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.</p>
<h6><strong>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?</strong></h6>
<p><em>Whooley:</em> 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.</p>
<p>****</p>
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