On the Heels of Ignorance: A Conversation With Owen Whooley

The fundamental concerns of American psychiatry – articulating madness, understanding mechanisms responsible for mental distress – have always eluded it. As Owen Whooley argues in On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing, the history of the field is a history of ignorance, and a cyclical record of disappointment and reinvention.

On the Heels of Ignorance begins with psychiatry’s origins in the 1840s, and moves through nearly two centuries of periodic understanding, doubt, and reinvention. Whooley creates a unique and coherent framework to grasp the chaotic history of psychiatry, with ignorance emerging as the unifying thread. On the Heels of Ignorance not only succeeds in clarifying a blurry subject, but also points to a new direction for the field, and for the discipline of intellectual history.

BackStory spoke with Owen Whooley about his book, the hype-disappointment cycle, and the known unknown of psychiatric ignorance.

BackStory: You talk about psychiatry as a narrative character that keeps reinventing itself, it keeps changing. You have this quote, “Historians of the same period, often using the very same data, can arrive at wildly different portrayals.” How did you reckon with this in your own writing in the book?

Whooley: There’s a fundamental challenge to anyone who’s examining psychiatry or psychiatric practice from an academic intellectual perspective. The field itself is very polemical. On one side you have apologist histories, often written by former psychiatrists themselves. Then on the other side you have research that is more of the anti-psychiatry vein. So it becomes hard to enter into that conversation with nuance. I think a fundamental challenge that I had in writing this book is, I don’t want this to be an anti-psychiatry screed. I don’t want, for example, Scientologists taking the book up in support of their arguments. But on the other hand, I want to remain critical of psychiatry because frankly, it’s hard to look at the history of psychiatry and not be critical. There’s a lot of abuses there.

I try to walk this fine line, I think it’s a difficulty when the title of your book has “ignorance” in it because that suggests a certain kind of critical standpoint, which I do indeed take, but I hope that, for example, psychiatrists who might actually read the book would find it to be a critical, yet more balanced account.

Often when we write about professions, or write about scientific endeavors, we have a tendency to slide into narratives of progress. That’s another thing I’m constantly trying to work against. Not to say that there hasn’t been progress, not to say that people don’t get better from contemporary treatments, but to really push against these professional narratives that psychiatry is getting better and better all the time. Because I think when you look at the history of psychiatry, you don’t see a linear progression. What you see are these repeated cycles that I call reinvention. 

BackStory: You talk about psychiatry’s stance towards the future and this necessary fundamental optimism that it has. What does that say about psychiatrists’ own conception of their history?

Whooley: So, one thing to note about the book is, the data I’m working with can tell you about psychiatric elites, or what other historians have called aspirational psychiatry. These are the leaders of the profession, who are articulating a vision of the profession. Now, my other research would suggest that psychiatry is unique, or perhaps extreme in the ways in which everyday practice might be divorced from what’s happening among these elites.

So what happens in this cycle? Well, psychiatry faces some sort of crisis when their ignorance gets exposed, often in a very public way. And so, reformers during those periods of crisis begin to articulate a new vision for psychiatry. They then hype up this new vision. Whether it’s psychoanalysis, or today you hear a lot of hype around neuroscience, they create a lot of expectations in order to secure resources to help them revise, or reform as a profession. Part of what they need to do to explain away the crisis that they’re trying to solve is to paint those who came before them as fundamentally misguided. I think this is important. It’s not just that they were wrong. They were fundamentally misguided in the ways they articulated and understood mental illness.

What I argue is in doing so, these reformers then create a break from the past. It’s almost like they acknowledge this history, they acknowledged these problems, but they domesticate it into the past, relegate it to the past, and then articulate a new kind of direction that is fundamentally different from that past. And so that lets them off the hook. That yes, psychiatrists have done horrible things in the past, and you talk to any psychiatrist and they will acknowledge the lobotomies, they will acknowledge the problems of the mental hospitals. They’ll frame those historical developments almost as if they’re the other. We’ve now moved beyond that. We put that in the past and now we’re headed towards that future.

BackStory: I really like this idea of the cycle, that’s something that you also see outside of psychiatry to some extent. 

Whooley: Yeah. And I’m taking here from models of this hype-disappointment cycle that come out of sociological work on technology. Venture capitalists in Silicon Valley use this exact same kind of logic in promoting the next big, transformative, disrupting technology. And you know, very rarely do those technologies actually end up fundamentally disrupting social fabrics. Not to say that some don’t, but if you look at the rhetoric of Silicon Valley, you often see this kind of logic playing out.

BackStory: Why is ignorance so embedded in this field, and is it really that embedded only in psychiatry, or are there also ways that we can expand that to how we look at the history of science more broadly?

Whooley: Yes, I think these dynamics play out in certainly every profession. In the back of my mind, there’s always a comparative framework with medicine proper because that’s what my first book was on.

If we stay with that comparison, medicine proper has, unlike psychiatry, almost unambiguous successes to point to in its path. And so, while I think other scientific endeavors, other professions are dealing with similar dynamics, I see psychiatry as an extreme case. Now the question is, why is psychiatry such an extreme case? This is where I think I back off on the anti-psychiatry in that I have sympathy for the task which we’ve given psychiatrists. Mental illness is just a really complicated, protean thing. We think it involves an organ of the body that we still don’t understand very well. That organ, the brain, is constantly interacting and being shaped by, and shaping its environment and social context. And then you add in interpersonal relationships, developmental psychology… Mental illness is just a really tough nut to crack.

And if you look at the universe of things that we’ve given to psychiatry, they’re often quite different things. Psychiatrists have to figure out what we understand to be severe and chronic mental disorders, like bipolar type one or schizophrenia. They also have to figure out depression, anxiety, more of these kind of problems, or these things that affect functioning and daily living. They’re also charged with dealing with paraphilias. They’re charged with dealing with personality disorders. And so we tend to label all of these things under the rubric of mental disorders, but are they really of the same kind of thing fundamentally? So to put it most succinctly, I think ignorance is such a problem for psychiatry because their object, the thing that they’re supposed to treat and understand is inherently a very complicated object.

Now, I don’t know, maybe in the future, developments in neuroscience will get a better grasp on these kinds of things. But if you look over the course of the history of psychiatry, mental illness has been a slippery thing. And just when you think you have a grasp on one aspect of it, it slips through your fingers. And you know, all scientists in all professions have these challenging questions. What I think sets psychiatry apart as an extreme case is the very fact that mental illness is incredibly, incredibly hard to understand.

And it gets even a little bit more difficult for psychiatry because it turns out, when we do come up with a biomedical explanation of a condition under psychiatry’s purview, we tend to take it away from psychiatry. 

Most famously general paresis, which is the end state of chronic syphilis, which in the 19th century, early 20th century is a huge part of what asylum or mental hospitals are dealing with. Well, once we understand that that has a bacterial origin, we take that out of psychiatry’s hands. So even when we’ve figured some of these things out, we then take them from the province of psychiatry and delve them or distribute them to other medical specialties. Once again, leaving psychiatry with the puzzles we don’t really understand.

Psychiatry has always been the awkward stepchild of medicine. I don’t think it’s any kind of grand insight to say, yeah, psychiatry’s always been an outlier when it comes to other medical specialties. But going back to your original question on this line of thinking, I would argue that ignorance is the driving force of the professional trajectory of psychiatry, and I think that is singular. I do think you would find similar dynamics on a smaller scale within any kind of medical profession or any kind of scientific endeavor.

BackStory: When you identify ignorance as this driving force throughout psychiatry’s history, I like that way of lending coherence, or at least some way of viewing, or holding this object, when it’s so slippery by nature.

Whooley: The other thing about psychiatry, in terms of its exemplary character, is that these reinventions aren’t just transforming the profession, they’re transforming the very object of the profession. So mental illness itself, or how we understand it, how we frame it, how we approach it, changes with each reinvention. Once again, going back to this shift from psychoanalysis to the contemporary era. Well those two eras have completely different understandings of what fundamentally, and essentially, mental illness is.

On the one hand, there is the innate complexity of this thing we call mental illness. And on the other hand is this repeatedly shifting fundamental way in which we understand and frame that ineffable or difficult to understand thing.

When we talk about ignorance, there’s this newish field in sociology called the sociology of ignorance. And one of the things it’s trying to do, or one of its major mandates, is pointing out different kinds of ignorance. Because we label something ignorant, but you could be ignorant of something for a variety of different reasons. I would put the fundamental dynamic driving psychiatry’s dealing with ignorance as follows: Psychiatric ignorance is what’s called a known unknown. We know that we don’t know it. Now, sometimes people might deny that. Sometimes people might say, “Well, we kind of know it,” but generally speaking, even psychiatrists themselves will attest that there’s just so much we don’t know.

So that’s not the question. What’s at stake in the question is whether mental illness is knowable. Whether there’s something inherent about mental illness that is fundamentally unknowable, or whether or not we just haven’t figured out how to know it.

Now what my history shows is that, to date, mental illness has been unknowable. But I do want to stress that I’m not suggesting that it’s fundamentally unknowable. I would have no logical or philosophical warrant to support such a claim. It could very well be that tomorrow there’s some major neuroscientific breakthrough that unlocks the key. Now having written this history and marinated in this hype-disappointment cycle, I would think that would be highly unlikely, but I don’t want to say it’s impossible.

Owen Whooley is associate professor of sociology at the University of New Mexico and the author of “On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing.”