On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing by Owen Whooley (review)

In his second book, On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing, sociologist Owen Whooley turns the sociology of knowledge approach on its head to study what effects the absence of knowledge can have on a medical specialty—in this case, our persistent ignorance about the fundamental mechanisms of mental illnesses. Unlike other successful disciplines and professions, he contends, American psychiatry was "shaped less by the knowledge it has secured and more by the ignorance it cannot resolve" (p. 197).

The result, Whooley suggests, has been a cycle of professional crisis and reinvention, which he categorizes as five linear periods: the nineteenth-century asylum era; the psychobiological period of the early twentieth century; Freudian psychoanalysis after World War II; community psychiatry after John F. Kennedy signed the Community Mental Health Act in 1963; and, in the 1980s, the neo-Kraepelinian revolution rooted in revisions to the specialty's Diagnostic and Statistical Manual (DSM-III). He concludes that these epochs indicate an enduring pattern of epistemic crises and corresponding professional reinventions designed to mask or manage ignorance.

In a systematic examination of the American Journal of Psychiatry, from its inception in 1844 (under various titles) to the present, Whooley observes that psychiatrists have long grappled openly with epistemological uncertainty. In Chapter 1, he suggests that asylum superintendents employed optimistic rhetoric to mask ignorance, which produced a "cult of curability" and gave them "absolute psychiatric authority" (p. 53) in the nineteenth century. Chapter 2 describes the reinvention of psychiatry in the next century under Adolf Meyer's program of psychobiology, which "promised to resolve ignorance by pursing it in all directions" until such efforts "coalesced into a complete picture of mental illness" (p. 64). While psychobiology did not fulfill its promise, Whooley reckons, it gave rise to the discipline's habit of reinventing itself when faced with epistemological crises. After World War II, he argues in Chapter 3, psychoanalysts successfully sold their well-defined theory as an antidote to open-ended approaches, but in due course psycho-sexual reductionism gave rise to new crises. Chapter 4 flirts with a multifactorial explanation of the emergence of community psychiatry in the 1960s (e.g., the advent of anti-psychotic drugs and team-based approaches in medicine; changes in welfare policy that favored noninstitutional measures; reportage that exposed the failings of state hospitals; and, significantly, federal legislation mandating the creation of Community Mental Health Centers)—but, staying on message, Whooley ultimately concludes that deinstitutionalization resulted from psychiatrists' professional imperative "to mitigate psychiatric ignorance by diluting it" (p. 157). Chapter 5 describes how neo-Kraepelinians successfully pursued reinvention as an overt strategy by promoting the revised DSM-III as proof of a paradigm shift within the discipline, from psycho-dynamically to somatically oriented. Classification, they promised, was the solution to ignorance. According to Whooley, the conviction of that promise contrasts sharply with its failure today, and recent debates about DSM-V once again showcased psychiatrists' "lack of mastery" and "nervous fiddling" over that ever-elusive question: what are the mechanisms of mental illnesses?

The strength of the monograph—in addition to its superbly crafted narrative and exposition—is its original frame and research questions. Whooley rightly asks: If professional authority rests upon a discipline's claim to esoteric knowledge, how did psychiatrists successfully professionalize and exercise power without ever achieving a basic understanding of their object(s) of study? Undoubtedly, historians of psychiatry and their students will find it valuable to join the author as he grapples with this question. What they won't find is new information about asylums, psychobiology, psychoanalysis, deinstitutionalization, or DSM; all of this Whooley deals with superficially even as he shows us new ways to consider these carefully-studied developments. Importantly, this is a sociology of American psychiatry, not a history of it, that relies principally on prescriptive and declarative statements made by psychiatrists—to...