Excerpt from “On the Heels of Ignorance” by Owen Whooley
October 10 is #WorldMentalHealthDay, with the overall objective of raising awareness of mental health issues around the world. In honor, we’d like to share a short excerpt from the introduction to On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing by Owen Whooley. His well-researched history begins with psychiatry’s formal inception in the 1840s and moves through two centuries of constant struggle to define and redefine mental illness as well as the best ways 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 to get to where it is today.
The history of American psychiatry is a history of ignorance. Underlying psychiatry’s curious past—its repeated crises and dramatic transformations, its faddish theories and epistemic somersaults, its occasional achievements and egregious abuses—is a stubborn, inconvenient fact. Psychiatrists lack basic knowledge regarding mental illness. Madness evades articulation. Charged with the quixotic, perhaps doomed, mandate to impose reason on madness, psychiatrists have searched for an understanding of the mechanisms that produce mental distress, be they psychological, neurological, genetic, or social. These searches have been in vain. The most fundamental questions regarding their object remain unanswered.
Psychiatry’s critics have been more than happy to point out its knowledge gaps. But to their general credit, the most consistent chroniclers of this ignorance have been psychiatrists themselves. One might think that psychiatrists would try to suppress their ignorance through conspiracies of silence, campaigns of misinformation, and sweepings under the rug. Indeed, such attempts have been made. However, psychiatrists have long balanced denial with sober acknowledgments of all that they do not know.
Confessions of ignorance resound throughout American psychiatric discourse. The establishment of American psychiatry as a profession dates to 1844, with the founding of the Association of Medical Superintendents of American Institutions for the Insane (AMSAII). Armed with a reforming ethos and inﬂated statistics, superintendents justiﬁed their new profession on the curative promise of the asylum. But a mere thirteen years after the founding of AMSAII, John Charles Bucknill, an English superintendent, threw cold water on the hyperbole of his American peers. Comparing psychiatry to other branches of medicine, Bucknill found it wanting: “The widely differing opinions which have been entertained by the ablest physicians respecting the pathology of insanity clearly show that there is some difﬁculty at the bottom of the question, greater than that which has existed with regard to the nature of other classes of disease.” Eight years later, John E. Tyler urged his fellow superintendents to admit a troubling lack of consensus regarding the nature of insanity. “Without doubt, any person who has read as much and thought as much upon the subject of insanity as each one of you, gentlemen, has done, realizes fully how difﬁcult a thing it is to enunciate, in any short formula of words, or to make it clear by any brief description, what insanity is,” Tyler told his colleagues. “And you cannot have failed to feel that the deﬁnitions which have been given by various and learned writers, have by no means been perfect deﬁnitions; that is, they have by no means distinguished insanity from everything else.”
Were it not for their persistence, these early admissions of ignorance might be shrugged off as the growing pains of a young ﬁeld. But they have continued ever since. Over the next ﬁve decades, the comparisons between psychiatry and the rest of medicine grew even less favorable. In response to the laboratory revolution that swept medicine proper, psychiatry could offer only frustrating stasis. In a 1900 paper to the now rechristened Ameri-can Medico-Psychological Association (AMPA), New York superintendent August Hoch expressed pessimism regarding psychiatry’s future: “But while we infer the existence of different diseases, we have little knowledge of their real processes. Indeed, such a knowledge seems to be very remote.” Twenty years later, the prognosis remained just as grim. Dampening the puffed- up pretensions of psychiatry after World War I, Harold Gosline cautioned that “in the matter of psychopathology we are still in a maze.” In 1924, Thomas Salmon, the inﬂuential president of the once again rechristened American Psychiatric Association (APA), admitted that decades of study had “failed to illuminate the darkness that enshrouded the essential nature of disorders of the mind.” Near the end of World War II, during the acme of psychiatry’s prestige, George Sprague, a prominent New York psychiatrist, voiced his disappointment at psychiatry’s enduring difﬁculties in cracking mental illness. With so many factors to consider, “thousands of possibly relevant items,” psychiatrists were still unable to identify the “exact causes” of mental diseases. Even knowing where to look for insight was unclear.
By the 1970s, psychiatric ignorance was on full display. A chorus of criticism, unleashed in damning exposés, best- selling novels, and frank memoirs by former patients, threw into sharp relief all that psychiatrists did not know. An emboldened antipsychiatry movement questioned the very existence of mental illnesses, imperiling psychiatry’s existence like never before. Psychiatrists were unable to mount an effective response to this challenge, hamstrung as they were by the obviousness of their failures and an atrophying psychoanalytic paradigm. In response to Thomas Szasz’s provocative book The Myth of Mental Illness, psychiatrist Stephen Reiss conceded that while Szasz’s critique had gone too far in calling mental illness a myth, the term “mental illness” “is best considered as a hypothetical construct,” and that “basic psychiatric concepts are imprecise.” In a 1982 address to the APA, Roberto Mangabeira Unger warned that psychiatry would never “progress without confronting certain basic theoretical problems that it has habitually minimized or dismissed.” Chiding his colleagues for long neglecting these conceptual issues, Unger called upon them to reconsider “the basic explanatory structure of psychiatry: psychiatry’s image of the relationship between biological and psychological accounts, its background conception of the fundamental reality of passion and subjectivity, and even its tacit assumptions about what it means to explain something.”
From the founding of the APA in 1844 to today, psychiatrists have struggled with ignorance. What was unknown before is unknown now. An understanding of the causal mechanisms of mental illness, what historian Gerald Grob calls psychiatry’s “holy grail,” remains beyond psychiatrists’ grasp. The hunt goes on. 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.
And yet, despite the intransigence of its ignorance, psychiatry survives.