Psychiatry’s Alchemy: Why We Must Question Its Scientific Credibility

By: Tim Kirk, Ph.D.

Psychiatry has had an uncertain place in the pantheon of the sciences for almost 200 years. While the profession has never wavered in the claim that it was just like cardiology or oncology, that it was a medical specialty that will one day discover the biological underpinnings of madness and place mental illness within the same explanatory order as physical disease, the historical record does not match this rhetoric. Psychiatry has never had a cumulative, progressive history. It has been a story of crisis and collapse, shifting definitions and paradigms, and consistent admissions of ignorance. In short, it is a profession that has promised more than it has delivered and whose authority rests more on social need and professional power than scientific breakthrough.

This was the central argument of the researcher Owen Whooley, in his recent book, On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing. He documents over the decades that psychiatry has repeatedly told its audience that it does not know what it is doing and that the map of the brain and of mental disease remains mysterious.^1 From the earliest years of American psychiatry, enthusiasm resulted in disappointment. As the Association of Medical Superintendents of American Institutions for the Insane (AMSAI, what would become today's American Psychological Association, or APA) was founded in 1844 on the optimistic promise that the asylum would cure insanity, within a little over a decade voices both inside and outside the profession were beginning to admit that psychiatry did not know what it was treating. John Charles Bucknill, an English superintendent, reported to his peers in the 1850s that the “widely differing opinions” held among physicians of note about insanity should be evidence that psychiatry had not arrived at the kind of basic consensus that other branches of medicine enjoyed. A decade later, John E. Tyler, one of the first American superintendents, reported to his own peers that definitions of insanity that they had produced were “invariably unsatisfactory and insufficient to mark it off in all cases from some of the forms of health of mind.”^2

This early uncertainty did not diminish as psychiatry progressed. In 1900, the New York superintendent August Hoch gave a pessimistic report to the American Medico-Psychological Association (a renamed AMSAI), admitting that psychiatrists inferred the existence of different diseases “but beyond this we have little knowledge of their real processes. Indeed, such a knowledge seems to be very remote.”^3 One generation later, Harold Gosline made a similar point. Coming out of the initial optimism of World War I, he admitted that psychiatry still remained “in a maze” when it came to psychopathology.^4 In 1924, Thomas Salmon, the sitting president of the American Psychiatric Association, went on record to admit that more than a century of research had “failed to illuminate the darkness that enshrouded the essential nature of disorders of the mind.”^5 By the end of World War II, George Sprague was bracing his colleagues for the realization that even with literally thousands of possibly relevant factors having been identified, psychiatrists still could not say what the exact causes of mental diseases were and still could not even agree on where to look.^6

By the 1970s, the fact of ignorance was put on full display. A chorus of critics, some newly emboldened by the antipsychiatry movement, called out psychiatrists for what they did not know. Memoirs of former patients, best-selling books, and damning exposés were read by the public. Thomas Szasz had argued in The Myth of Mental Illness that “mental illness” was not a medical disease but a cultural fiction.^7 While psychiatrists collectively bristled at this extreme position, even those defending the profession were forced to admit the weakness of their position. The psychiatrist Stephen Reiss was one of those who conceded that “mental illness” was best considered “a hypothetical construct,” that even its most basic concepts “are imprecise.”^8

In 1982, the philosopher Roberto Mangabeira Unger delivered a speech directly to the American Psychiatric Association that put this state of affairs on blast, warning that psychiatry would never progress until it confronted the basic theoretical problems that it habitually minimized or dismissed.^9 Psychiatry, Unger argued, would need to rethink its “basic explanatory structure”: its assumptions about the relationship between biology and psychology, its conception of passion and subjectivity, and even its understanding of what it meant to “explain” something. A few years later, Martin Roth and Jerome Kroll implored their colleagues to avoid overestimating what psychiatry knew or understood.^10 They warned their readers against being seduced by hype, especially around new psychopharmaceutical drugs, but their advice was not heeded. Psychiatry plunged into the psychopharmacology era with promises that Prozac and its cousins would reveal the biology of depression. These promises have not been met. As Roth and Kroll had foreseen, genetics and neuroscience turned out to be far messier than reformers had expected. To this day, psychiatry “has thus far failed to identify a single neurobiological marker that is diagnostic of a mental disorder.”^11

The candor of contemporary psychiatry is perhaps best exemplified by Kenneth Kendler, one of the foremost leaders in the field of psychiatric genetics. Summarizing decades of research, Kendler writes:

We have hunted for big, simple neuropathological explanations for psychiatric disorders and have not found them. We have hunted for big, simple neurochemical explanations… and have not found them. We have hunted for big, simple genetic explanations… and have not found them.^12

Psychiatry has scoured every nook and cranny and has come up empty-handed.

Whooley masterfully synthesizes these recurring admissions into a structural critique. Psychiatry, he argues, suffers from two dimensions of ignorance. The first is ontological: it does not know what its object is. The profession has shifted its diagnostic labels from madness to insanity, to neurosis, to mental illness, to mental disorder but has never produced a consensus, and every attempt has been fragile. The second is epistemological: it has never agreed on how to study its object. Each generation of reformers has replaced the last with radically different methods—psychoanalysis, behaviorism, neuroscience, genetics—changing not only theories but also the standards of evidence itself. Psychiatry in this way cannot build cumulative knowledge. The constant vacillation from one program to another stymies discovery. Whooley’s conclusion is stark. Psychiatry only exists because society has so far been willing to put up with its practitioners’ admitted ignorance, to take their pronouncements seriously even when it stabs us in the back. He has us all complicit.^13

Psychiatry as Alchemy

This state of affairs is best compared not to the path of the cumulative sciences, but to the pre-scientific periods of chemistry or physics. Before chemistry was stable, it was alchemy: an unstable and contested mixture of mysticism, armchair speculation, and occasional experimental tinkering. Alchemists promised to transform base metals into gold and find the Philosopher’s Stone. They created some useful techniques and sub-disciplines, but their ontology—the belief in something like a “prima materia”—and their epistemology—a unique blend of mysticism and metallurgy—remained too unstable. It was only when Antoine Lavoisier and others replaced the false ontology of phlogiston with the chemical theory of oxygen, and when they stabilized methods around quantification and the laboratory experiment, that chemistry could be considered a science.^14

Today, psychiatry remains in an alchemy phase. Each generation comes into the field on the promise that *this time* the discipline will achieve scientific maturity. First it was the asylum, then psychoanalysis, then psychopharmacology, then neuroimaging, and now genetics and computational psychiatry. Each one of these promises eventually collapses. Psychiatry still has not had its "Lavoisier Moment". It has not stabilized its ontology and epistemology. Instead, psychiatry remains in a state of oscillation, where methods, definitions, and standards change every generation, and where the field is propped up by the inertia of authority and hope rather than cumulative discovery.

The Pushback: Pragmatic Achievements

This is not to say that psychiatry is wholly useless. Certain psychiatric interventions have demonstrated measurable efficacy. Research tells us that Electro Convulsive Therapy (ECT) is one of the most effective treatments for severe depression, even though it is one of the most stigmatized.^15 "The Science" tells us Lithium has been repeatedly demonstrated to reduce suicidal behavior in people with mood disorders.^16 Researchers say Clozapine remains the only reliably effective medication for treatment-resistant schizophrenia.^17 Research also says CBT and other structured psychotherapies have been shown to outperform placebo for depression, anxiety, and PTSD.^18

If true, this is not insignificant. This list of asserted effective interventions is not trivial and cannot be dismissed as wholly unhelpful or damaging--except for the professionals who do.^23 This may be useful knowledge, in part because it might show that psychiatry can sometimes treat suffering. But this body of evidence does not resolve the ontological or epistemological questions that have bedeviled psychiatry as a field. The existence of these interventions do not mean that the other techniques psychiatry has pursued do not also produce important benefits. On the contrary, there is an extraordinary overlap between who is studying which treatments. But this evidence is pragmatic, not scientific. These interventions are islands of efficacy in a sea of uncertainty, and they would be useful not because psychiatry has matured into a cumulative science but precisely because these interventions transcended psychiatry. Core pathology still eludes the effort, say the pathology of suicide, and to this day Psychiatry offers no concrete insight into the origins.

Corruption and the Cockroach Effect

Where psychiatry deviates most sharply from the settled sciences is its extraordinary vulnerability to corruption. In a 2008 NEJM analysis, while 94 percent of published antidepressant trials had positive outcomes, only 51 percent of the actual trials registered with the FDA were positive.^19 Negative studies were buried, or spun in reports until they appeared to be favorable. The published literature created the illusion of overwhelming success while the underlying data was a different story entirely.

The problem goes far beyond selective publication. Ghostwritten articles have been discovered, most prominently in the case of SSRIs and antipsychotics, where industry-hired writers had prepared manuscripts that were later signed by prominent academics.^20 Analyses of the committees that wrote DSM-IV and DSM-5 revealed that many members had financial ties to pharmaceutical companies, particularly in the categories where medication sales were most profitable.^21 Trials have been shown to change their primary endpoints midstream in order to call attention to more favorable results.^22

These are not random acts of misconduct by a few bad apples. These are structural camouflage techniques. Psychiatry’s ontological and epistemological fragility make it more dependent on the creation and maintenance of the illusion of progress than other fields. If cardiology or oncology are distorted by financial conflicts of interest, they are still distortions at the margins. The basic science, ontology, and epistemology are still stable. But psychiatry, where the object itself is unstable and the methods keep changing, needs corruption to prop up the very appearance of legitimacy.

The metaphor of cockroaches is apt. For every scandal we know about—for every ghostwritten paper or buried trial—we can be sure that there are likely many more that we do not. If psychiatry were really a robust field, it would not need this degree of manipulation. The very need for so much corruption is itself evidence of fragility.

Conclusion: Why Caution Is Essential

Psychiatry has never stabilized its object or its methods. It remains defined by ontological uncertainty and epistemological vacillation. Its history is a history of confessed ignorance from the asylum era of the nineteenth century all the way to the genetic research of the twenty-first. It is still a field that has never settled on what it means to “explain” something. It persists, despite its admitted ignorance, not because it has solved mental illness, but because society needs it to believe that it will.

Its pragmatic interventions might show that psychiatry can sometimes and in some cases treat suffering. But these pragmatic achievements do not resolve the larger credibility crisis. They are exceptions that prove the rule.

The persistent need for ghostwriting, selective publication, and financial conflicts of interest suggests that psychiatry’s scientific authority is based on curated appearances rather than cumulative discovery. Like alchemy in the employ of royal patronage, it will survive not because it is scientifically sound but because it fulfills an important social function.

For this reason, we should be more careful than ever in granting it the credibility of a science. Its history, its internal confessions, and its patterns of corruption all point to the same conclusion. Psychiatry remains in its alchemy phase, a discipline still defined by ignorance, sustained by illusions, and propped up by the complicity of those who take it seriously. Until it stabilizes its ontology and epistemology, until it can withstand honest reporting without the need to collapse, we must be more careful than ever in granting it the credibility of a science. For better or worse, it has never been both settled, and settled in the right place at the same time.

Notes

1. Owen Whooley, On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing (Chicago: University of Chicago Press, 2019), 2.

2. Ibid., 17–19.

3. Ibid., 55.

4. Ibid., 58.

5. Ibid., 64.

6. Ibid., 67.

7. Thomas S. Szasz, The Myth of Mental Illness (New York: Harper & Row, 1961).

8. Whooley, On the Heels of Ignorance, 143.

9. Ibid., 159.

10. Martin Roth and Jerome Kroll, The Reality of Mental Illness (Cambridge: Cambridge University Press, 1986), 7.

11. Ibid., 11.

12. Kenneth Kendler, quoted in Whooley, On the Heels of Ignorance, 212.

13. Whooley, On the Heels of Ignorance, 233.

14. Hasok Chang, Inventing Temperature: Measurement and Scientific Progress (Oxford: Oxford University Press, 2004), 45–67.

15. Charles Kellner et al., “Efficacy of Electroconvulsive Therapy in Treatment-Resistant Depression: A Meta-Analysis,” Journal of ECT 28, no. 1 (2012): 3–10.

16. Cipriani et al., “Lithium in the Prevention of Suicide in Mood Disorders: Updated Systematic Review and Meta-Analysis,” BMJ 346 (2013): f3646.

17. Kane et al., “Clozapine for the Treatment-Resistant Schizophrenic: A Double-Blind Comparison with Chlorpromazine,” Archives of General Psychiatry 45, no. 9 (1988): 789–796.

18. Butler et al., “The Empirical Status of Cognitive-Behavioral Therapy: A Review of Meta-Analyses,” Clinical Psychology Review 26, no. 1 (2006): 17–31.

19. Erick H. Turner et al., “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy,” New England Journal of Medicine 358, no. 3 (2008): 252–260.

20. David Healy and Dinah Cattell, “Interface between Authorship, Industry and Science in the Domain of Therapeutics,” British Journal of Psychiatry 183 (2003): 22–27.

21. Lisa Cosgrove et al., “Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry,” Psychotherapy and Psychosomatics 75, no. 3 (2006): 154–160.

22. Ben Goldacre, Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients (London: Fourth Estate, 2012).

23.Tucker Carlson, YouTube, SSRIs and School Shootings, FDA Corruption, and Why Everyone on Anti-Depressants Is Totally Unhappy, https://www.youtube.com/watch?v=UnhT77W9mtQ