Psychiatry Has a New Hero

There’s a moment I love, in a recent Substack post by psychiatrist Awais Aftab, that captures well the promise, and challenge, of his far-reaching vision of how the field of psychiatry needs to change.

Aftab, a 38-year old émigré from Pakistan now practicing in Cleveland, is reviewing Unshrunk, the new memoir by anti-psychiatry activist Laura Delano. Much of the review is a deeply empathetic synopsis of her story of feeling mistreated by the mental health establishment, but then Aftab steps back to bring his own perspective on psychiatry to bear. It’s not a defense of the profession exactly—he concedes that psychiatry seems to have done wrong by Delano—but it’s optimistic. It begins from the presumption that the endeavor is worth reforming, and is capable of it.

“I can’t help but wonder,” he writes, “how Delano’s experiences would have turned out had she been offered an accurate explanation of the nature of mental disorders, psychiatric diagnoses, and psychiatric treatment instead of the bullshit story she was fed. Imagine if she had been told: You can recover, you can be well, and even medications may be unnecessary at some point in your life. . . . Mental health problems exist at an intersection of temperament, physiology, development, and interpersonal challenges and cannot be understood in isolation. Descriptive diagnoses are fuzzy and fluid, especially early in life. They can change over time, and professionals often disagree. Diagnostic categories do not capture your essence or your identity. What you are experiencing is maladaptive, but it does not lack meaning. Engage with your psychological pain, understand what it is trying to tell you, and seek a meaningful life. Medications are imperfect tools that can assist you in the process. They have the ability to both help and harm, and we will work closely to address any problems you experience with them. If the balance ever shifts such that the medications are hurting more than they are helping, you have other resources at your disposal. The treatment of mental illness does not substitute for family, work, education, and community as sources of meaning and fulfillment.”

If Aftab is doing something important here, and I believe that he is, it’s not something that’s easy to distill into a simple phrase or concept. The mouthful of a name that Aftab gives to his perspective, which he’ll be fleshing out much more fully in the book he’s now writing for Harvard University Press, is “integrative critical psychiatry.” A simpler way of putting it is simply “pluralism.” Or maybe pluralism plus humility plus wisdom.

The word that came to mind for Allen Frances, one of the major figures of modern psychiatry, when he first met Awais Aftab in 2019, was “throwback.”

Aftab was 31 at the time, and a fellow in geriatric psychiatry at UC San Diego. He’d reached out to Frances, who’d chaired the DSM-IV taskforce for the APA, to see if he’d speak to the fellows and residents at the hospital. Also because Frances, who has spent much of the past two decades leveraging his reputation to criticize the discipline of psychiatry, was a personal hero of Aftab’s.

The two met for drinks, and Frances sensed very quickly that the young man was special. “I knew immediately he was going to be a star in psychiatry,” says Frances. “He was a throwback to the kind of people you saw more in psychiatry 50 years ago, when it was one of the broadest professions in the world, when it encompassed everything about human nature. He was that kind of person at a time when most psychiatric residencies had reduced themselves to teaching medication management.”

A few months after that first conversation, Aftab asked Frances to be his first conversation partner in a series of “Conversations in Critical Psychiatry” that Aftab was launching with Psychiatric Times, the main trade journal of the profession.

Frances agreed, and their conversation, which was conducted in person and then refined via email, was published in May of that year. It was a fascinating dialogue, which touched incisively on many of the critiques that Frances had been levying against his fellow psychiatrists for many years, including the systemic overdiagnosis and overmedication of patients, the philosophical fuzziness of many of even the most widely used categories of mental illness, and profound flaws in recent editions of the DSM, including the DSM-IV, which Frances himself had overseen the development of.

The conversation was also an intellectual coming out for the young Aftab. He was able to keep up with Frances as they traversed decades of disciplinary history and controversies, and to expertly negotiate a critique of psychiatry with a recognition of its virtues. It’s very tough on the discipline, but it’s tough love. He’s talking to his colleagues from the inside, beginning from the premise that most psychiatrists are acting in good faith and doing more good than harm, even if they’re sometimes doing more harm and less good than they should.

Aftab followed the interview with Frances with dozens more installments of the “Conversations” series, talking over the course of two years with an extraordinary range of leaders, reformers, critics, and antagonists of psychiatry, meeting each expert on his or her own terms, bringing to each conversation a fierce desire to understand from almost every conceivable angle what we mean when we talk about things like mental illness, mental health, diagnosis, depression, anxiety, institutionalization, medication, the biological basis of the psyche, the genetic disposition toward mental illness, and the inescapable ambiguity that creeps in whenever we seek to ameliorate the suffering of other human beings.

In an interview with Lithuanian psychiatrist and human rights advocate Dainius Pūras, to give a typical example of Aftab’s method, he spends much of the interview generously positioning Pūras to elucidate his critique of the prevailing approaches to psychiatric care in the west. He also, however, gently pushes him to complicate the critique when it runs the risk of seeming too reductive.

“That [failure] is certainly true of the United States, where the seriously mentally ill experience much higher rates of homelessness and incarceration,” says Aftab. “Conversely, in many other parts of the world, conditions are no better, as reported by the Human Rights Watch. Shockingly large numbers of individuals with mental illness around the world spend their lives chained like cattle. I myself, when I lived in Pakistan, saw an individual with a psychotic illness shackled to a tree in a village, with no access to medical care, and with the family possessing a premedical conception of madness. This suggests to me that focusing exclusively on biomedical diagnoses and treatments as the boogeyman is naïve, and severely underestimates the collective societal effort that is required to ensure humanistic and effective care for the mentally ill. Your thoughts on this dynamic?”

The series ended in 2022. Aftab then launched his Substack newsletter, Psychiatry at the Margins, which now has more than 17,000 readers, among them an impressive array of elite journalists, academics, and clinicians. He’s continued to run in-depth interviews on the Substack, along with long essays and reviews authored by himself and others in the field. He also uses the space as an occasional clearing house for links to interesting research, news, and writing in the world of mental health.

In addition, somehow, he’s published a steady stream of papers in peer-reviewed journals of psychiatry, psychology, and philosophy of science, as well as an anthology from Oxford University Press of the best interviews from the Psychiatric Times series. And this year, he signed a contract to write the big book that clearly has been germinating in his brain over the course of all this work. It’s provisionally titled Remaking Psychiatry: A New Understanding of Mental Disorders.

The effect of all this work is that Aftab has established himself in a unique space at the intersection of academia, journalism, and clinical practice. He’s a highly credentialed clinician who’s been able to ingest pretty much all the relevant realms of academic expertise—genetics, neuroscience, psychiatry, psychology, philosophy, public health—and he’s an extremely lucid and compelling writer who’s very much in touch with the human muddle at the heart of it all.

The Philosophy of Psychiatry

Growing up in Pakistan, Aftab’s first intellectual love was philosophy. He felt restricted, but also stimulated, by the religious and cultural orthodoxies that structured so much of the life around him. He didn’t understand why things were the way they were, nor why the discussion around them seemed so limited and fraught. Philosophy seemed a way into these dilemmas.

“If I had had the right opportunities, I may have gone into academic philosophy,” he says, “but in Pakistan, that was basically not a viable option at all.”

Instead, like his older sister and others in his family, he turned to medicine. In medical school in Lahore he found psychiatry and began a self-directed education in the philosophy of science and medicine, at first just reading on his own and then eventually connecting to other people who were interested in the questions that were preoccupying him.

“The philosophy of psychiatry field is very richly interdisciplinary,” he says. “So you have psychiatrists, psychologists, philosophers, historians, anthropologists, sociologists, and they all talk and discuss these things.”

After finishing medical school, he began his residency in Doha, Qatar, working there for a year while waiting for his U.S. visa to come through, soon moving to America to complete his training at Case Western Reserve University in Cleveland, Ohio. His clinical practice and philosophical exploration continued to feed each other but also began to come into tension.

In the hospital, he was expected to assign his patients a diagnosis, quickly, and then to explain it to them, and their families, as though the words he was using to describe their suffering were scientific, the causes were generally understood, and the treatments were developing steadily toward greater precision. It was a basically orderly conceptual universe.

In the philosophical literature he was reading, on the other hand, everything was uncertain. Basic concepts of disease, disorder, diagnosis, and biology were treated with skepticism. And it wasn’t just the philosophers. Psychiatric insiders like Frances were subjecting the whole edifice of the DSM to withering criticism. And the cutting-edge researchers in the field were coming up short in their efforts to ground psychiatry in a coherent and predictive genetic paradigm. They weren’t locating discrete forms of mental illness in the genome, repeating the cycle of optimism and disappointment that previous cohorts experienced in their efforts to find answers in chemical imbalances, brain scans, and schizophrenogenic mothers.

Psychiatry seemed to be under protracted siege, and yet Aftab saw very little of this complexity reflected in how his supervisors and clinical colleagues talked to each other and patients about their work.

“There was this huge disconnect,” he says, “between the kinds of really thoughtful, rich conversations that academics and philosophers were having and what the average clinical psychiatrist was getting exposed to. So I felt compelled to do something about it.”

He didn’t yet have a big theory to offer the world of how we should be talking about mental illness, to replace the incoherent ways we were talking about it, but what he did have, he thought, was the capacity to initiate a more useful conversation.

Beyond Tidy Narratives

“He [Aftab] doesn’t inhabit any familiar particular narrative,” says Rachel Aviv, staff writer for The New Yorker and author of the quite wonderful 2022 book Strangers to Ourselves: Unsettled Minds and the Stories That Make Us. “He’s feeling his way through with an independent mind, and reading him makes the idea of these tidy narratives seem obsolete.”

Aviv was first introduced to Aftab’s writing by a good friend of hers, a doctor who writes about issues of public health and medicine. She sent Aviv an email with a link to a post by Aftab with the injunction that Aviv had to read it immediately. Also on the email chain was another friend, a psychiatrist. Now the three of them occasionally share new stuff from Aftab via email or text, usually with a quick prefatory note that says something like, “He did it again.”

What he did–does–is bypass the binary that structures, or imprisons, so much of the conversation and conflict about mental health and illness in America. I sometimes visualize this conversation as a kind of tableau in which two figures are standing on either side of a chasm, glaring across at each other with deep suspicion. The rest of us are huddled down below in the chasm. We’re vastly more numerous but far less organized and far less clear on what we think, and so we defer, uneasily, to the figures above.

One figure is the Scientist, the very model of a modern biological psychiatrist. He’s in his 50s, has an MD-PhD from Harvard, is chair of a department at a major research university, and is the principal investigator on a big, multi-site study of treatment for first episode psychosis. He’s aware in an ambient way that people have suffered, in the past, from the profession’s excessive faith in its own expertise, and that his field has yet to establish a really firm biological understanding of the kinds of distress it treats and studies. This doesn’t, however, inspire in him much skepticism. Instead, his core motivating belief is that by doing the science and treatment better this time around, we can improve people’s lives in small ways in the short term and move inexorably toward truly transformative conceptualizations and treatments for mental illness in the long term.

Opposite him is the Survivor. She’s in her 50s as well. When she was a teenager, she began acting out in ways that so alarmed her parents they brought her to a psychiatrist, who diagnosed her with bipolar disorder I, prescribed her some meds, and conveyed to her and her parents that the best she could probably hope for, long term, was a simple, highly medicated, highly managed life. A half-life, basically, but one that was tolerable. For the next few decades, like so many people with severe mental distress, she rode a roller coaster of dysfunction that involved occasional institutionalizations, periods of relative stability, long stretches of living with her parents, various revisions and additions to her diagnoses, and increasingly complex cocktails of medications. At some point, after reading the right book or finding the right online forum, she decided to get off most or all of her medications, joined a community of fellow survivors with similar stories, and reoriented her identity around a root-to-branch critique of psychiatry, the mental health system, and the medicalization of human distress and neurodiversity.

Both the Scientist and the Survivor are good, caring people. They’re both driven to help others, and they rely on their hard-won insight into the nature of the human psyche and human suffering to aid them in doing so. But they’re each, unfortunately, trapped within a too-rigid framework for understanding the world in which they, and we, live.

One way to conceptualize Aftab’s project, in this schema, is that he’s trying to listen closely to what these two figures have to say, assimilating what’s valuable in their perspective, while adding more voices to the conversation, each with their own valuable but incomplete perspective. A scan of recent posts on his Substack includes: an interview with a researcher integrating psychoanalysis with computational science; a review of a new book by a neuroscientist proposing a new paradigm for how her field will solve “brain disorders”; a brief commentary on a statement from the American Psychiatric Association on the efficacy and safety of psych meds; and a summary of a new peer-reviewed paper that Aftab and a colleague wrote on what they call the “Rumpelstiltskin Effect,” which is about how the act of diagnosis itself can have healing benefits.

It’s a chorus of voices and overlapping ways of understanding and approaching the mind and its discontents, not a single paradigm or silver bullet. “Psychiatry has had a tendency to rely on single answers based on different kinds of faddish paradigms,” says Aftab. “Pretty early in my career, I realized that that’s not going to take us anywhere meaningful. So we have to do two things. One, we give up the search for simple answers and embrace complexity in a meaningful way. Secondly, we embrace a very strong form of humility. We recognize that scientifically speaking, we are in a very premature state. We are just scratching the surface of these questions, and we can look at mental health phenomena through a variety of lenses and perspectives. Each brings with it a certain advantage or disadvantage, and sometimes they’re contradictory in interesting ways or incompatible, but we are not yet in a position to sort them out.”

It’s not, on the surface, a radical way of looking at a topic that everyone concedes is immensely complex. What’s radical in it, perhaps, is the revision that truly, madly, deeply adopting it would demand to psychiatrists’ sense of themselves and their way of being with patients.

Aftab gets at this in the introduction to his 2024 anthology, when he draws a parallel between psychiatry and policing. Both professions, he writes, deal with humanity at its worst and most vulnerable. Both are authorized to exercise control over people to an unusual degree. Both have a checkered history of abuse and error. Both, even at their best, produce a lot of “unhappy customers.” And both seem to be necessary, unavoidable, to the adequate functioning of society.

The result, in both cases, is that they attract a constant and often quite intense barrage of scrutiny and criticism. This often feels unfair to their practitioners, and no doubt much of it is unfair. The key point for Aftab, though, is that in a global sense it’s utterly fair that psychiatrists (and police too, surely) receive this level of skepticism. It’s simply the job, with all its privileges and burdens. Psychiatrists are paid well, accorded high social status, legally vested with the power to prescribe psychoactive drugs, and charged with managing profound decisions about not just what kinds of lives many of us will lead but the very terms by which we will understand them. How could it be otherwise?

To be a psychiatrist in America in 2025, then, isn’t a bad thing to be, but it’s complicated. And the ethical demand is to honor that complexity, within pragmatic reason, to the best of your ability.

What this looks or sounds like is highly context dependent. It will look different in a cozy office with a worried-well patient than in a hospital ER confronting someone with severe psychosis, and different yet again in the pages of an academic journal of philosophy of science. To read Aftab over time, however, is to get an increasingly strong sense of the feel of it.

Above all, perhaps, it feels literary, devoted at its core to representing the beauty, uncertainty, and poignancy of the human condition, and—more pragmatically—to maximal flexibility when it comes to the right diction, or genre, for the occasion and patient.

Such an approach would’ve felt very familiar to Sigmund Freud and William James, the fathers of modern psychiatry and psychology, respectively, both of whom were deeply influenced by literature and were themselves exceptional writers. But it’s not, to say the least, the current vibe of how 21^st century psychiatry or psychology imagines itself. It’s also, too often, not what the rest of us want from the discipline. We want answers, categories, diagnoses, science.

In “You aren’t in the DSM,” a recent essay of his for the journal Asterisk, Aftab addresses this challenge: “In my own clinical work, I often find myself attempting to deflate the power of these categories. I remind patients not to lean too heavily on the label I’m offering. Not because the label is meaningless, but because the problems it captures are typically imprecise, shifting, deeply contextual. I describe symptom patterns in relation to broader psychological structures, early experiences, temperament, and life stressors.

“My hope in these conversations with patients is to plant a seed of resistance, to offer an account of suffering that acknowledges complexity, contingency, and context beyond categories. I try to say, in effect: this pattern of symptoms reflects something meaningful about your psychological life, but it doesn’t define you. It shouldn’t be the scaffold upon which you build your entire self. You’re free to acknowledge it, even to use it as a lens, but don’t let it confine you. Do not let it determine your story.”

It’s a tall ask, in other words, not just of the profession of psychiatry but of the rest of us as well, that we accept that we’ll have to live, and suffer, without the kind of certainty that clean diagnoses or hard science seem to promise. The best case for choosing to step into this uncertain world is simply that it’s the actual world we live in, and we’ll be best equipped to navigate it, generally speaking, if we can be honest about that. And maybe have the help of some smart, humane people along the way.