On the Ignorance of Psychiatry and the Ignorance of Critics
I would encourage folks to read the discussion by George Ikkos, “Not doomed: sociology and psychiatry, and ignorance and expertise,” and commentary by Peter Huxley and Rob Poole, “Social psychiatry lives!” in BJPsych Bulletin before or after reading this post. I have chosen not to repeat pertinent points from their exchange here, but I benefitted from it tremendously and it provides the background for my discussion below.
“The history of American psychiatry is a history of ignorance,” declares sociologist Owen Whooley in the opening statement of his 2019 book On The Heels of Ignorance: Psychiatry and the Politics of Not Knowing (University of Chicago Press, 2018). “Psychiatrists lack basic knowledge regarding mental illness. Madness evades articulation.”
“The fruitless search for answers has placed psychiatry in an ever precarious position. Professions are granted authority on the basis of their ability to convince other that they possess the requisite knowledge and the skill to intervene in well-defined problems… Ignorance threatens this professional authority. It strikes at the very justification for professional authority.” (p 3-4) Whooley’s narrative therefore ends up in a place where the authority and legitimacy of psychiatry are genuinely up for debate.
“Psychiatry’s ignorance comprises two related, but distinct, dimensions. First, there is its ontological dimension, namely, psychiatry’s inability to pin down the essence of its object. Psychiatry struggles with what mental distress actually is… The second dimension of psychiatry’s ignorance is epistemological, involving concerns over the nature of psychiatric knowledge… Psychiatry, however, has been unable to settle on the appropriate way of knowing its object. Instead, it has vacillated between drastically different visions of knowledge, or “styles of reasoning.”” (p 4-5)
“Other medical specialties can make more credible claims to progress; they have accomplishments to point to as indicators of the accumulation of knowledge. Psychiatry, however, has amassed a frustrating record of failure, of false starts and dead ends. With progress so slow, insights so few, and uncertainty so tenacious, psychiatry is propelled less by the accumulation of its knowledge and more by the stubbornness of its ignorance.” (p5)
“And yet, despite the intransigence of its ignorance, psychiatry survives… This book addresses a simple question: Why do we have psychiatry? It does not pose this question flippantly or disparagingly… I ask this question as a serious puzzle in need of explanation. My intent is not to condemn, but to explain the resiliency of American psychiatry.”
Whooley’s discussion vacillates between whether this resiliency is a good or a bad thing. Should we understand this resilience cynically, with psychiatry’s survival justified by empty rhetoric, false promises, and self-serving reinventions, or should we view it admiringly, as clinical and scientific persistence in the face of a very difficult task. The answer, in Whooley’s opinion, turns out to depend on the nature of “ignorance” that confronts psychiatry.
“When a crises emerges and psychiatry’s ignorance is exposed, psychiatric reformers frame these failures as stemming not from unattainable knowledge but from the improper conceptualization of its object and misguided assumptions underlying its research agenda.” (p 15)
“At its core, reinvention serves a central function for psychiatrists looking to maintain their authority in the face of their ignorance. It allows psychiatrists to frame their ignorance as unknown but knowable rather than unknown and unknowable… This is a crucial distinction; the implications of drawing it are monumental professionally, involving nothing less than the maintenance of professional power. If its ignorance is temporary, we might be frustrated by psychiatry’s failures and dead ends, but still hold out hope for the future. We might even admire psychiatry’s doggedness in the pursuit of knowledge. But if we understand its ignorance to be permanent, that there is something inherently unknowable about mental illness, psychiatry becomes something of a Sisyphean task, destined to end in failure. We might react with pity or scorn, but either way, permanent ignorance compromises psychiatry’s claim to expertise, its professional authority, and its entirely legitimacy.” (p 16)
This is astonishing to me. How is framing mental illness as “inherently unknowable” even an option for us — not just as psychiatrists, but collectively as all of us, including the scientific community and the people with mental illness? Sure, we may posit it as an abstract philosophical question, but there is no way to prove or demonstrate that something is “inherently unknowable.” In fact, the idea that some phenomenon is, in principle, beyond the reach of our understanding is antithetical to the very spirit of scientific inquiry. David Deutsch writes in The Beginning of Infinity: “Any assumption that the world is inexplicable can lead only to extremely bad explanations. For an incredible world is indistinguishable from one ‘tricked out with capricious ad hoc magic’: by definition, no hypothesis about the world outside the bubble of explicability can be a better explanation than that Zeus rules there - or practically any myth or fantasy one likes.”
The same is true for any assumption that holds the mind or its pathologies to be inexplicable in some fundamental sense: it can only lead to extremely bad explanations. We have no choice but to treat mental illness as unknown but knowable. We may never acquire complete knowledge of it – just as we may never acquire complete knowledge of fundamental physics – but it is not an option to declare it as unknowable in principle. We are always at the beginning of infinity, there is always more ignorance ahead of us.
The same is true for any assumption that holds the mind or its pathologies to be inexplicable in some fundamental sense: it can only lead to extremely bad explanations. We have no choice but to treat mental illness as unknown but knowable.
It is noteworthy that some of the most zealous contemporary critics of psychiatry, such as a group of critically oriented psychologists in the UK associated with the British Psychological Society, make radical claims about the knowability of states we call mental illness. For them, mental illnesses are normal, understandable reactions to life circumstances, and we have only failed to recognize it due to the pathologization of these conditions by psychiatry. To my mind, it is this sort of naïve knowability that we must guard against, and that no doubt has been demonstrated by many psychiatrists over the course of history as well.
Whooley laments the tremendous social neglect of the mentally ill, but if we accept that mental illness – and hence the problems of the mentally ill – are unknowable in principle, why would societal neglect not be the direct consequence of this attitude? If we are to entertain giving up on the project of understanding and helping those in states of extreme mental distress, as Whooley would like us to contemplate, why would society not treat the mentally ill, the mad, the neurodivergent as “the other”? Why would they not write them off as lives lost and irredeemable? I don’t see how this doesn’t follow as a conclusion, and this provides an additional strong argument against the mental-illness-is-unknowable position. If we accept mental illness as unknown but knowable, Whooley’s basic thesis collapses. As he himself writes, “If its ignorance is temporary, we might be frustrated by psychiatry’s failures and dead ends, but still hold out hope for the future. We might even admire psychiatry’s doggedness in the pursuit of knowledge.” Indeed, this is precisely the attitude I would advocate.
I have not mentioned previously that Whooley’s analysis is focused on the psychiatric elite: “… I have privileged what historian Richard Noll deems the “literary elite” of American psychiatry, the leaders of the profession who are the prime producers of psychiatric discourse and who, in turn, shape public opinion on matters related to mental distress.” (p 23)
Although I do not view my own position within psychiatry as powerful or influential, I am mindful that I am likely to be characterized by Whooley as either belonging to the psychiatric elite, or close enough to the psychiatric elite that I function in a similar manner, and my response to Whooley’s critique here is likely to be viewed as yet another manifestation of how the psychiatric elite manage their fundamental ignorance and justify the existence of the profession. I am not necessarily averse to this characterization, but I would object to any implications that this delegitimizes anything I have to say here.
Whooley: “Psychiatry does not have a monopoly over the ignorance of mental distress. We all share in it. But, unlike psychiatry, most of us ignore this ignorance and are keen to delegate it to others. Psychiatry, therefore, survives on the basis of a combination of inertia and indifference. Psychiatry benefits from a lack of viable alternatives and from a collective fear toward the patient population over which it maintains unchallenged jurisdiction – individuals with serious mental illness… The malevolent neglect of the mentally ill translates into a type of benign neglect towards psychiatry. The benefit of this neglect is nothing less than psychiatry’s continued existence.” (p 26-27)
I don’t entirely agree with Whooley that a malevolent neglect of the mentally ill translates into a benign neglect towards psychiatry. To some degree, perhaps, but a malevolent neglect of the mentally ill also becomes a malevolent neglect of psychiatry and the stigma that surrounds the profession in many contexts. It is also not the case that psychiatry’s existence would be threatened if society paid more attention to mental illness; in fact, if recent developments are any indications, social attention to mental illness is likely to reinvigorate and bolster the profession.
Whooley: “… psychiatrists emerge from this book not as cynical schemers, nor innocent dupes, nor admirable advocates. Rather, they are revealed to be individuals struggling to make sense of complex phenomena with imperfect tools, subject to enthusiasms, overexcitement, and dismay, achieving the rare insight but mostly succumbing to confusions, capable of startling acts of kindness and disturbing acts of violence. In other words, I reveal a profession that is decidedly and tragically human.” (p 27)
But is not all medicine (and science) decidedly and tragically human? Is that not the conclusion we arrive at by any impartial historical survey of science? Are we as scientists and clinicians not all struggling to make sense of complex phenomena with imperfect tools and subject to overexcitement and dismay? Have medicine and science achieved some superhuman status in the eyes of historians and sociologists than psychiatry has not? Why not extend the same charity to psychiatry, and see the profession as part of the broader medical and scientific effort to understand madness and mental illness, rather than as something distinct and separate from it? (Huxley and Poole also note in their commentary: “Whooley follows the common a priori assumption among critics of psychiatry that the discipline stands outside of, and distinct from, the main body of medicine.”)
But is not all medicine (and science) decidedly and tragically human? Is that not the conclusion we arrive at by any impartial historical survey of science? Are we as scientists and clinicians not all struggling to make sense of complex phenomena with imperfect tools and subject to overexcitement and dismay?
On applying this sort of understanding to science generally, consider this excellent exchange between Lorraine Daston and Samuel Loncar on the history and philosophy of science:
Lorraine Daston: … you’ve got to historicize science, you’ve got to understand it in its own terms, you’ve got to understand it not in terms of what we think now—in which latter case, the history of science is merely a history of errors. You’ve got to imagine yourself into the rational, if exotic, mindset of the alchemist of the seventeenth century or Aristotle thinking about falling bodies. That kind of historicist program, which has transformed the history of science and made it genuinely historical, has, of course, alienated the scientists because that is not the story they wish to hear.
Samuel Loncar: … For people who maybe don’t know, by historicism, we’re talking about placing anything, including science, in its own historical context in which you understand it based on that context, based on the way the actors understood themselves and could have understood themselves rather than by, say, standards that are present to us now, but unavailable to them. And when we do that, you end up getting this vertiginous experience in the history of science, much as you do in cultural anthropology, in which you recognize that people weren’t just precursors of our current ways of thinking. It’s not some linear, progressive history of either people messing up to get to us or helping us get to where we are.
Lorraine Daston: Problem number two are the philosophers, who have never risen to the challenge of rethinking what truth might mean if our highest standard for the truths we have—and this I would certainly subscribe to—are scientific truths. That’s our highest standard. But those truths change. So we need a philosophical remake of the concept of truth that does justice to the historical dynamism of science. It’s not surprising if the philosophers cling to a Platonic, theological notion of eternal, immutable truth, and the poor scientists don’t know what to do in terms of reconciling their absolutely sincere belief that they are looking for the truth with the empirical experience of the truth being constantly, as Weber said, surpassed as science progresses.
I quote this second point by Daston about truth and historical dynamism of science because historians and sociologists too are frequently guilty of holding on to outdated and inadequate yardsticks by which to judge scientific progress. For instance, the failure to find biomarkers that are diagnostically specific to DSM categories is seen as a devastating failure for the whole of psychiatry, and it is a failure of sorts, but why should we privilege biomarkers in this manner to frame this judgment as a failure of psychiatric science itself. Why should we not see the development of a more complex scientific understanding of the relationship between brain and behavior as a story of progress? Or take the charge that psychiatry has been unable to pin down the essence of mental illness. Should we be so devoted to the essentialism inherent in this assertion? Is talk of “essences” the best way to characterize the object of psychiatric inquiry? Should we not take into account the burgeoning philosophical literature on the metaphysics of psychopathology (Zachar, 2014) that challenges such essentialism and characterizes psychopathology as an imperfect community lacking an essence, and adjust the historical and sociological questions we ask accordingly?
Is talk of “essences” the best way to characterize the object of psychiatric inquiry? Should we not take into account the burgeoning philosophical literature on the metaphysics of psychopathology (Zachar, 2014) that challenges such essentialism and characterizes psychopathology as an imperfect community lacking an essence, and adjust the historical and sociological questions we ask accordingly?
Whooley: “Such a history reveals an unnerving lack of progress. However, this is not to suggest that psychiatry has not progressed at all, that it has been static, entombed in its own inescapable ignorance. Psychiatry has evolved, particularly in the means by which subsequent reformers have achieved their reinventions.” (p24)
Statements that there has been an unnerving lack of progress or that claims of progress in psychiatry are not credible are very strong claims whose extraordinary nature cannot simply be attenuated by ‘oh, yeah, I’m not saying psychiatry hasn’t progressed at all.’ If psychiatry has progressed over the last century – as I believe it has and for which there is an extraordinary amount of clinical and scientific evidence – then what is the significance of this progress? How should the sociological narrative of ignorance in psychiatry take this progress into account. Whooley is not too dissimilar here from Andrew Scull, another sociologist/historian who has perfected the act of ignoring psychiatry’s progress into an artform.
The historian Jonathan Sadowsky writes in his review of Andrew Scull’s Psychiatry and Its Discontents:
“On page 2, after stating his opposition to “progress narratives” of the history of psychiatry, Scull assures us that he does not deny that any advances have been made. But what are they? … All of Scull’s views have some merit. The question is whether there is more to the story. There is, I dare to say, some evidence that some psychiatric treatments relieve suffering, even if they all have flaws. (Most medical treatments have flaws.) Criticism of the pharmaceutical industry is warranted, but do we really want a world without any psychiatric medications? Odds are good that a lot of people reading this right now are on one. We can blame this on psychiatric overreach if we want, but if you are one of those people, and feel a benefit, don’t you want that represented in the historiography? There is also plenty of evidence that psychotherapy works—even including the psychodynamic therapy inspired by that dead Viennese horse we keep flogging. I dislike hagiographic history as much as the next person. But medical historians have a responsibility to give some weight to therapeutic benefits of what we study.” (Sadowsky, 2021)
The historical and sociological critique of psychiatry has powerful lessons for us — lessons of humility, of transparently acknowledging the limits of our knowledge, of avoiding the cycles of hype and disappointment that have characterized the field’s development. I previously wrote in article for Psychiatric Times and I still stand by these words:
“Psychiatry has been vulnerable to diagnostic fads… Psychiatric theory has been vulnerable to “single-message mythologies” and zealous reductionism… The state of science is what it is; we can make conditions conducive to scientific research, but discoveries and breakthroughs cannot be rushed or forced. While acknowledging the state of psychiatric science should lead to an attitude of humility, many psychiatrists in positions of power and influence have often made grandiose claims—and at times have displayed stunning arrogance.”
It is also, however, the case that analyses of the sort exemplified by Whooley can end up attributing too much agency to psychiatry. Broader social and scientific developments have inevitably shaped the practice of the profession. Psychiatry’s knowledge and scientific agendas have always been constrained and restricted by forces outside of the profession’s control. Any analysis of psychiatry’s failures cannot be divorced from these larger questions of what psychiatry could’ve done differently but didn’t, what psychiatry wasn’t allowed to do, and what psychiatry could not have done because the conceptual and scientific methods required had not yet been developed. I am fond of quoting George Engel, who in his discussion of the biopsychosocial model in 1977 had the foresight to say: “nothing will change unless or until those who control resources have the wisdom to venture off the beaten path of exclusive reliance on biomedicine as the only approach to health care.” The history of those of who control resources and their wisdom (or lack of it) is usually missing from the stories we tell about psychiatry.
Whooley writes: “[I am interested] in exploring how psychiatrists, in search of answers and authority, have negotiated their ignorance, with their livelihoods on the line, and in doing so, created ways for patients to be mentally ill.” (p 22) (my emphasis)
Psychiatry exists because mental illness — madness, mental disability, psychopathology, mental distress, whatever you want to call it — exists. It exists because of the suffering, impairment, disruption, and harm that accompanies madness, something that each and every society has had to find ways to navigate. Psychiatry exists as the medical and scientific response to madness; psychiatry exists as a part of, and not something distinct from, or over and above, medicine and science. To contemplate a world without psychiatry is to contemplate a world in which our response to madness is something other than through the framework of healthcare. To contemplate a world in which mental illness is inherently unknowable is to contemplate a world in which psychological science is impossible and the lives of the mad are forever lost to despair.
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Whooley admits that “the most consistent chroniclers of this ignorance have been psychiatrists themselves.”
Whooley eventually chooses not to take a firm position: “Mental distress has been, and remains, unknown. Of course, this could change tomorrow with some groundbreaking discovery. This possibility cannot be rejected out of hand, although psychiatry’s track record would suggest it is unlikely. And neither can its opposite – that mental distress is fundamentally unknowable – be dismissed… I leave the issue as to the essential nature of mental disorders to the unfolding of time or to others more brazen than myself.” (p 22)