The Psychiatrist at the Edge of the World
Can psychiatry be reformed? And can what we call mental illness be prevented?
Dear and astute friends! Today we’re speaking with Awais Aftab, a psychiatrist in the contentious middle ground between orthodoxy and doubt—between those who defend psychiatry as essential medicine and those who see it as harmful. His Conversations in Critical Psychiatry is a fantastic series of dialogues with some of the most interesting dissenting voices in contemporary psychiatry. I recommend it! I found him to be a clinician with a fascinating global POV—firmly rooted in the psychiatric paradigm, but also willing to question cherished beliefs about how we care for ourselves and others. Aftab is an Assistant Professor at Case Western and publishes the Psychiatry at the Margins newsletter. We spoke about the ethics of treatment, the psychosis of oppression, and what might be done to reduce the enormous suffering all around us.
Jess: I’m curious about how growing up in Pakistan influenced your approach. What was your early exposure to psychiatry?
Awais: I didn't personally know any psychiatrists, or know anyone in my family who had seen a psychiatrist. The profession was pretty stigmatized—mental distress was also stigmatized and poorly understood. There were superstitions around magic, demonic possession, and curses from God. In many TV shows or films, madness was depicted as a punishment inflicted on a character, or as a consequence of guilt from a person realizing they had made terrible choices.
As if mental distress was something they brought upon themselves!
There was also this idea that if you become a psychiatrist eventually you go mad yourself. In Pakistan, the idea of going to a stranger to talk about your life problems was so strange and unacceptable.
During medical school, I visited my father's ancestral village, and I saw an individual who clearly had some kind of chronic psychotic disorder. He was chained to a tree at his family's house and had been for some time. The family didn't understand, and had no means—no access to psychiatric care. Sometimes in the western world, I encounter narratives romanticizing mental illness, and I think, “You have no idea what pre-medical treatment of madness looks like in many parts of the world.”
In Qatar, you saw a very particular kind of distress. What did you see?
While my U.S. visa issues were being sorted out, I had the opportunity to start psychiatric training in Doha. I was there for about nine months. Qatari society is hierarchical in a way that I haven't really seen anywhere else. At the lowest level are unskilled workers, many from South Asia, India, Nepal, Bangladesh, and Pakistan, too. They're doing manual labor under horrible oppressive, harsh conditions. And because of the way the visa system works, they're trapped until they're formally released by their employers.
I was seeing so many of these laborers coming in with acute psychotic symptoms that seemed linked to the harsh working environments. The technical term is “acute and reactive psychosis.” Once I started working in the U.S., I realized how rare it is here. I had seen so many in just a few months in Doha. It left a very lasting impression on me.
How do you interpret what was going on? Does psychiatry understand the mechanism by which stress becomes psychosis?
Unfortunately no. If we did, we’d be in a very different kind of state of the profession. Those environmental stressors play a role in individuals who are vulnerable. But how does this all come together? How does discrimination interact with the brain circuits? We don't have a good model.
This picture is not scientifically correct.
I'm interested in the way language shapes our thinking. Doctors will say that a patient “complains” of a symptom, or “denies” using drugs. These are aggressive and, I’d say, loaded, belittling words. Language is critical in psychiatry, too. Depression used to be called “depressive reaction.” Then a new version of the DSM changed it to “depressive disorder.” How did that language shift the way people thought about depression?
The shift itself was reflective of broader trends toward more descriptive language, that cleared the way for a biologically oriented way of thinking about psychiatry. The use of “reaction” was in alignment with psychoanalytic ideas. The shift to “disorder” first happened in the UK. Internationally, there was a growing recognition in the field that, we actually don't know what the causes are. Should we be using terminology that is perceived to be more neutral?
Interesting. So it was an attempt to become more neutral, but it in fact entrenches a more essentialist, context-free view of these experiences.
The term “disorder” has certain implicit assumptions in the public imagination that just as we have these discrete diseases in neurology and infectious disease, we have brain diseases in psychiatry. The metaphors offered to the public—that depression is a condition “like diabetes” or that antidepressants work “the way insulin works”—reinforced this idea. This picture is not scientifically correct.
You’ve interviewed many of the leading critical voices for Conversations in Critical Psychiatry. How do you define “critical psychiatry”?
Broadly, it’s the ways in which the assumptions and practices of mainstream psychiatry are subject to scrutiny and criticism—concerns about medicalization, that we are taking complicated phenomena and just focusing on neurological effects. Concerns about pharmaceutical influence distorting clinical practice or negatively affecting research. And around the neglect of harms of medication and involuntary psychiatry treatment. This constellation gets referred to as “critical psychiatry.”
Is “critical psychiatry” different from just “psychiatry”? A reflective psychiatrist is probably also asking these questions.
Right? <Laughs.> Yeah. And also people in philosophy, history, anthropology, sociology are asking these questions.
There's also a narrow sense: critical psychiatry is the group of psychiatrists based in the UK who formed a network in the mid 1990s. They're not just critiquing biomedical practices, but also promoting particular positions of their own. Joanna Moncrieff [psychiatrist who challenged the serotonin theory of depression] thinks that something is a medical disorder only if you can show that there is physiological abnormality. In the absence of that, it's just living with a difference. There's a group in critical psychiatry who absolutely reject psychiatry diagnosis.
What allows you to be able to enter these very fraught conversations without defensiveness, and with an open mind?
Opinions will differ on how successful I am! I tend to get critique and sometimes attacks from both ends. Neither side sees me as being fully aligned, and treats me with a degree of suspicion and distrust.
I’ve tried to be intellectually honest and curious. I try to understand why people are making the arguments that they're making, why people get defensive. It’s helped me notice myself getting defensive or angry.
That’s interesting. In The End of Bias, I argue that creating space between stimulus and response is the beginning of freedom. We can choose how to react. When do you notice your own defensiveness or anger coming up?
There is a community of people who have experienced iatrogenic harm and have legitimate grievances, but it's like some of them allow their anger to shape their thinking, “I had terrible withdrawal from antidepressants, and that means that nothing good can be said about them at all.”
I think some of the fiercest critics of psychiatry actually understand the gaps in data much better than the average psychiatrist.
From my colleagues, what annoys me is the tendency to dismiss any critique of psychiatry. They come across as self-absorbed and indifferent and hell-bent on preserving the legitimacy of the profession at any cost.
I think some of the fiercest critics of psychiatry actually understand the gaps in data much better than the average psychiatrist. [Journalist] Robert Whitaker, for instance, has a comprehensive knowledge of the literature on long-term effects of antipsychotics. I think he's wrong, and I've discussed why, but Whitaker knows more about the literature on long-term antipsychotics than an average psychiatrist.
The polarization in the field seems to mirror our larger political polarization, our inability to talk to one another. Have attempts been made to bridge those two camps? Maybe conversations like this?
This gap is partly why I started the Conversations in Critical Psychiatry series, to have these conversations in a manner that the average psychiatrist would be receptive to.
I recently published a New York Times op-ed, and a prominent psychiatrist responded, asking why I wasn't more vocal about the legitimacy of the profession, or emphasize that psychiatry is not corrupt. Those reactions are common—that the public is so gullible, they'll lap up any kind of critique of psychiatry.
I think much of the critique of psychiatry we're seeing, particularly on the right, comes from feeling the full picture has not been presented. The public health messaging mindset—hammering home one simplified message over and over, like “safe and effective”—is actually what engenders mistrust.
I agree with you. Reality is very messy. The scientific process is messy. A medical organization may say, “This is the consensus,” but behind the scenes, people disagree. It used to be the case that the public never got to see the messiness. Something changed during the pandemic. Science around COVID-19 was happening under public scrutiny. This is how it always been.
Psychiatry needs to be more intellectually humble and collaborative and less paternalistic: “These are the gaps, and this is why we recommend what recommend. These are the places where there's room for reasonable doubt.”
What would make the profession more receptive to critique?
Many in the profession do recognize that there are problems and things have gone wrong.
Right now there's a polarized dynamic. Many in the profession take an unreflective reductionistic stance—“Oh, depression, anxiety, schizophrenia, they're all obviously brain disorders. Neuroscience is going to give us the answers.” At the other extreme, you have folks who reject neuroscience offering any kind of utility. It keeps the debate stuck. It makes patients and families feel they either have to become mainstream advocates, like NAMI, or aligned with a critical faction.
When parents bring their children in, their expectation is for me to treat the kid. But the problem is not the kid in isolation, but the interaction.
I think certain critiques are ill-informed. There's a whole Scientology critique. Many criticizing psychiatry online belong to the psychiatric survivor movement, patients who have had terrible medication side effects or prolonged withdrawal, sexual dysfunction, or terrible involuntary inpatient experiences. They're angry at psychiatry, and coming at it from an emotionally charged place.
But I see that same emotional charge from the pro-psychiatry side. I’m no RFK fan, but in his congressional hearing, he proposed investigating a potential link between SSRIs and violence. Senator Tina Smith got extremely emotional. She explained that she’d been helped by SSRIs, and said he was implying that people who take SSRIs are dangerous.
It was not only a logical fallacy, but she seemed unable to accept that a drug that truly helped her could possibly harm others. There's so much emotion on both sides.
The reality of psychiatric treatment, like all medical treatment, is that they help some people tremendously. Other people, they help somewhat. Some are not helped at all, and some people are harmed. The people who are harmed tend to think that most people are being harmed. People who are helped tend to think most people are being helped.
I have also been thinking about the term “side effects,” which seems to be a label we give to effects we don’t want, in the way that “weeds” are the plants in our garden we don't want.
If someone is taking a neuroleptic and develops a motor problem, it's not really a “side effect,” is it? It's literally the effect of this drug that is working on some motor aspect of the brain.
Factually speaking, medications produce a range of effects, and they don't come classified into “intended” and “not intended.” That’s a human judgment.
I think it also generalizes: from my perspective, the distinction between what is normal and what is disordered ends up being human-dependent. There's nothing in the nature of these conditions that tells us one thing is a medical condition and another is not.
How does that philosophical question affect your work with patients?
It invites the question: why is this experience a problem and for whom? Why are we even treating this? For example, when parents bring their children in, for example, their expectation is for me to treat the kid. But the problem is not the kid in isolation, but the interaction.
And how do you handle that, within our flawed American medical system?
There were parents who had a daughter who was adopted. There were behavioral issues. It became clear to me that how the parents were reacting was contributing to the problem. I tried to have an open discussion with the mom about this, and she got offended at the possibility. I never saw them again. They presumably went to someone else who didn't tell them what they didn't want to hear.
I have friends in the Hearing Voices Network—people who were diagnosed with schizophrenia or schizoaffective disorder at some point, but found they were able to live more productively outside the psychiatric paradigm. Is there room for something like the Hearing Voices Network within psychiatry?
I think they have unfortunately been somewhat in opposition. I don't think there's any fundamental incompatibility. I think the Hearing Voices movement can coexist with psychiatry in the same way as Alcoholics Anonymous coexists with addiction medicine. Someone who hears voices may be able to function well without medical services if they have the right kind of peer support. I think many people who hear voices and who are on the schizophrenia spectrum don't just have an issue with hearing voices, there are delusions or disorganized behaviors or other things.
When people make broad statements about over-treating or over-medicalizing, they're missing the suffering of the individual patient.
To be clear, folks that I know in this network don't accept the label of schizophrenia. They live without that label.
Labels are to a certain extent, superficial. What really matters is whether we are recognizing what's happening in terms of symptoms. Voice hearing by itself is fairly common in the population. When they do community studies, it shows up.
It's interesting and even normalized in certain churches—hearing the voice of God. Or hearing the voice of an ancestor.
Yes.
This might be a spicy question. We think of depression and anxiety as maladaptive. Could they actually be fully adaptive, in that they’re the body’s message that something that needs to change? I know someone who was in a very bad life situation, but was able to tolerate the situation when they took an SSRI. At times, could mainstream psychiatric treatment impede the process of making a necessary change?
It’s not spicy. Low mood and anxiety evolved as adaptive signals to indicate that something is going on, in the same sense as pain is an adaptive signal. The maladaptive part is where the severity of those signal is so out of proportion to what is happening that they're overwhelmed or unable to function. They cannot take action. Or the body is stuck producing those signals—a person is anxious all the time, and there’s nothing in their life that would suggest that.
As the clinician, you're trying to figure out if a person's reaction is out of proportion. It seems quite subjective!
It is. I regularly work with people experiencing depression and anxiety and stuck in a really stressful, terrible job. But they don’t have a choice of leaving this job right now. Do I just tell them, “It's your job. I can't help you. Go deal with it”?
It can be the case that medications can allow unhelpful situations to persist by blunting their distress signal. But who should be making that decision? Should I as a doctor say, “You don't deserve to reduce your suffering. You should get a divorce, and I'm not going to give you an antidepressant”? It presents ethical challenges.
When people make broad statements about over-treating, they're missing the suffering of the individual patient.
Yes.
When people make broad statements about over-treating or over-medicalizing, they're missing what's happening in the clinical encounter. They're missing the suffering of the individual patient. They're missing that clinicians, by and large, can't change a person's job or marriage. So the treatments we have are individual-centered.
The best outcome happens when a person uses those treatments as a way of making changes, whereas previously they didn't have the energy or cognitive wherewithal to, say, contact a lawyer or find an alternative living situation.
Ultimately every patient has to figure that out themselves. Some people do want to use the tools to distract and suppress. It's also problematic to say that we should withhold treatment from those individuals.
A friend of mine once said the extent to which psychiatric medications are helpful or harmful depends on the extent to which the patient understands what the medication is doing and why.
Yes.
We know that adverse childhood experiences, ACEs, are risk factors for having mental health challenges later in life. What do we know about the mechanism?
There are promising leads. We know that often people with early childhood adversity can have low-grade chronic inflammation. Chronic inflammation can affect the development of the brain, certain genetic processes. Under chronic stress, the hippocampus—which is involved in learning and memory and one of the only parts of the brain where new neurons are generated—is disrupted. New neurons are not generated in the same manner. Neuroplasticity—reorganization of the connections between neurons—is affected. These are linked with trauma and adversity. But we still don't have a definitive theory of how everything ties together.
If we know that these stresses have these consequences, should there be more of an emphasis in psychiatry on prevention at the social level, before the damage is done?
The challenge is that these things are not specific to mental illness particularly, but involve making society better for everyone.
Exactly.
There's a large body of research showing how housing accessibility improves health for everyone, both mental and physical. Transportation, access to education. There are clear policy implications, but there's little political appetite for them.
What if we just laser-focused on child abuse prevention, as a way to improve mental health in adults?
I think we don't understand quite how to prevent trauma in a broader sense.
The problem becomes very large.
There's going to be suffering. There's going to be divorce, cancer, adversity. But more extreme situations, like children growing up in extreme poverty? I think if we improve society collectively, fewer children would be abused. Usually when people come to clinical attention, the trauma has happened. We're dealing with the consequences.
If you could fix the American medical system so people could get the help they need, what would you change?
Universal basic income would free a lot of people from being trapped in miserable working conditions. Accessible housing. Social structures that facilitate social interaction—designing buildings with playgrounds and courtyards. That would relieve a lot of loneliness. This would make a massive difference at the societal level.
I do think there are internal psychological dynamics as well, unresolved conflicts and insecurities. And then there are physiological and other factors too. But these social changes will relieve a lot of misery.
The End of Bias: A Beginning, about how people become measurably less biased, is out in paperback.
Right! We do know a lot about what would make society healthier, broadly speaking. But all of the western world is stuck in this political trend where we make things worse and worse. Politicians shouldn't be allowed to GET AWAY with saying that they take mental health seriously and want to do something about it while, at the same time, they make all these decisions that predictably gives us more and worse mental health problems.
“I think some of the fiercest critics of psychiatry actually understand the gaps in data much better than the average psychiatrist.”
Thank you, Dr. Aftab, for your fair and measured views.