Over the past several years, psychiatrist Awais Aftab has cultivated a public image of being an open-minded critic of his own profession, and as a result, he is now regularly the go-to source for media reports on challenges to psychiatric treatments and its diagnoses. However, this public persona obscures the fact that he is serving the interests of his profession, protecting its authority over this domain of our lives, and regularly doing so by attacking critics of psychiatry.
Normally I don’t pay any attention to his writings, even when a Substack post may send a few slings and arrows my way and at Mad in America, but his latest, titled “The Szaszian Heart of MAHA Psychiatry,” comes at a time when discussion of the merits of psychiatric medication has entered the “news cycle,” and thus I think it would be helpful to write a response. It provides me with the opportunity to make clear the nature of Mad in America’s “critique” of psychiatry, and, at the same time, to let readers see, through a deconstruction of his post, the rhetorical methods he employs when defending psychiatry from its “critics.”
Here is how the news cycle unfolded. On May 4, the MAHA Institute hosted a daylong event titled “The Mental Health and Overmedicalization Summit,” which was organized in large part by Laura Delano and her Inner Compass organization. At the end of that event, RFK Jr announced that HHS would seek to curb the overuse of psychiatric medications and provide support for patients to safely taper from their drugs, and also promote non-pharmaceutical therapies.
The New York Times then published an article by Daniel Bergner on May 15 titled “The Strange Alliance Trying to Remake Psychiatry.” He treated the May 4 event in an inquisitive manner, as opposed to a condemnatory manner, and he contacted me to ask what I thought of the event. I said I applauded Laura for her efforts to “open up a crack in the narrative” put forth by American psychiatry, but I also said that describing the problem as one of “overmedicalization” was a mistake. The “over” language implied that the problem with psychiatric care today was simply one of too much—too many people being diagnosed and treated with drugs, which could be seen as validating the disease model of care. It was not a reform of the disease model that was needed, I told Bergner, but rather a paradigm shift in psychiatric care.
This position is embodied in our Mad in America mission statement on our website.
Mad in America’s mission is to serve as a catalyst for rethinking psychiatric care in the United States (and abroad). We believe that the current drug-based paradigm of care has failed our society, and that scientific research, as well as the lived experience of those who have been diagnosed with a psychiatric disorder, calls for profound change.
Then, on May 16, Aftab published a post that was set up as a response to Bergner’s article. Here is how his piece unfolds in regard to me and Mad in America.
The title of Aftab’s post is “The Szaszian Heart of MAHA Psychiatry” and his first paragraph states that the NY Times article “obscures what is most distinctive, and most contestable, about the Moncrieff-Whitaker-Delano brand of psychiatric critique.”
Now, I have to confess I was quite surprised to find myself named in the opening paragraph of a post so titled. What was I possibly doing here?
The implication, of course, is that I have contributed to MAHA psychiatry (whatever that means) and that I am a follower of Szasz, a psychiatrist who wrote The Myth of Mental Illness more than 60 years ago. Both of these associations are designed to immediately discredit the “critics,” as though the criticism is arising from MAHA politics and a denial that mental disorders are “real.”
Here is a fact-check that Aftab might have considered before naming me in his opening paragraph. I have not had any involvement with the MAHA initiative. While I think a societal discussion of the merits of psychiatric drugs is much needed, I personally think that doing so under the MAHA umbrella is problematic, as the critique will be conflated in the public mind with MAHA’s anti-vaccine efforts and Trump’s anti-science agenda.
As for Szasz, while I have written about his place in the history of psychiatry, I have never adopted his The Myth of Mental Illness ideas as my own. Here is my usual comment about psychiatric disorders: “The biology of psychiatric disorders remains unknown.” I am quite sure there are some biological pathways to psychiatric symptoms, and I am also sure that such difficulties may arise from what we call the “social determinants” of health—poverty, lack of housing, trauma, family difficulties, and so forth.
In sum, I do not have a Szaszian heart and I am not a contributor to MAHA psychiatry, and yet, by naming me in the opening, he is putting me into that camp. It’s a common rhetorical device: define your “opponent” in a way that will invite disdain, regardless of whether he or she belongs in that camp.
The second problem with his opening is that he links all three of us—Moncrieff, Whitaker, Delano—into one lump, as though we all share a common critique. In fact, we took different paths to arrive at our criticisms of psychiatry, and there is no reason to think we all share the same criticisms. Joanna Moncrieff is a psychiatrist who founded the Critical Psychiatry Network, which is populated by psychiatrists and other professionals, and their criticism is rooted in their clinical experience and their deconstruction of the research literature (and their own published research). Laura Delano’s critique is rooted in her personal experience as a patient and the lived experience of thousands of others. Indeed, the Mental Health and Overmedicalization Summit featured the voices of people who have been grievously harmed by psychiatric treatments.
My path to becoming a “critic” of psychiatry was borne from my career as a journalist. After the American Psychiatric Association published DSM III in 1980, it told the public a narrative of great progress, that researchers had discovered that chemical imbalances were the cause of major psychiatric disorders, and that it now had medications to fix those chemical imbalances, like insulin for diabetes. However, as I discovered while researching both Mad in America (2002) and Anatomy of an Epidemic (2010), psychiatry’s own record of research findings, which could be found in studies funded by the NIMH over the course of six decades, told a very different story.
The research literature told of how the chemical imbalance theory of mental disorders had been investigated in the 1980s and 1990s and had not panned out. Indeed, the literature told of how psychiatric drugs, rather than fix a chemical imbalance, perturbed the normal transmission of chemical messages in the brain, and that in response to that perturbation, the neurons went through a series of compensatory adaptions in an effort to maintain a “homeostatic equilibrium.” As NIMH director Steven Hyman wrote in 1996, at the end of this compensatory process, the brain is operating in a manner that is both “quantitatively and qualitatively different than normal.”
As for the efficacy of psychiatric drugs, the research literature tells of how SSRIs and atypical antipsychotics, which were heralded as “breakthrough medications” when they first arrived on the market, provide a very small benefit over the short term, so small that the drug-placebo difference doesn’t rise to the level of a “minimum clinically important difference.” As for their long-term impact, there is abundance evidence that psychiatric drugs increase the risk that a person will become chronically ill and functionally impaired. In fact, the handful of researchers that have dared to acknowledge this worsening of outcomes have pointed to the brain’s compensatory adaption to the drugs, which is known as “oppositional tolerance,” as a likely cause.
Thus, in short, my two books led to this conclusion: American psychiatry has told the public a story that is out of sync with its own research. Instead of serving as an honest communicator of its own research, American psychiatry—as an institution—told a story that served its guild interests and the interests of the pharmaceutical companies. As Lisa Cosgrove and I detailed in Psychiatry Under the Influence, this was a classic case of “institutional corruption.”
After Anatomy of an Epidemic was published, I turned my personal Mad in America website into a webzine, and I did so with the purpose of continuing this journalistic effort, of making known research findings that belie the narrative that American psychiatry has told to us ever since it published DSM III.
As can be seen, my “critique” of psychiatry is the product of a journalistic effort, and as such, I don’t even think of myself as a “critic” of psychiatry. You can even find that in MIA’s mission statement: it is “scientific research, together with the voices of those with lived experience, that calls for profound change.”
I should also note that Mad in America, while sounding that call for profound change, publishes blogs that espouse a variety of opinions on the shortcomings of psychiatry today and of possible solutions. We want to be a forum for a societal discussion for “rethinking psychiatry.” As evidence of this, please see our MIA Radio podcast this past week, which featured an interview with G. Eric Jarvis, a prominent psychosis expert and Editor-in-Chief of Transcultural Psychiatry. Even among MIA editors, there is no set dogma that we all agree on, and we often publish blogs that one or more editors—and that includes me—heartily disagree with.
Having set up his MAHA-Szaszian foil for defining the critics of psychiatry, Aftab then asserts that while the critics are caught up in a simplistic binary way of thinking, he and his peers have a nuanced and philosophically rich understanding of mental disorders, as well as a keen appreciation of the science. The disease model may have been promoted in the 1980s, but even when DSM III was published in 1980, much of psychiatry, he writes, was already moving on to a rich bio-psychological-social model.
You know what else was published in 1980, by the way? George Engel’s “The clinical application of the biopsychosocial model” in the American Journal of Psychiatry. The “medical model” that Bergner places as having taken over psychiatry in 1980 was already, in 1980, being articulated in a form quite different from the one [Bergner] describes.
As I have written before, there is a long-standing public confusion in which the medical model is identified with the idea that all psychiatric conditions are discrete biological disease entities of the brain. This caricature isn’t true even of much of general medicine, which routinely deals with multifactorial syndromes, problems shaped by environment and trauma, conditions defined by symptom clusters without identifiable biomarkers, and it certainly isn’t true of psychiatry. What we call the “medical model,” properly understood IMO, is an aspiration to extend the conceptual and practical tools of general medicine to mental health problems: classification and diagnosis, attention to natural history, multi-level causal explanation, and the use of a wide treatment armamentarium that includes, but is by no means exhausted by, pharmacotherapy. It is also a model that, in theory, comfortably exists in a broader pluralism of clinical and non-clinical approaches.
The binary of disease-based reductive psychiatry on one side and “critical psychiatry” on the other nudges us to assume there is nothing in between. In fact, the space between is large and well populated. Various strands of explanatory and methodological pluralism and theoretical developments like embodied cognition, enactivism, complex dynamic systems, phenomenological psychopathology, psychodynamic psychiatry, social determinants of health, etc . . . these are not minor footnotes. They are scientifically grounded, neuroscientifically and psychologically informed, philosophically aware, humanistically oriented, and deeply skeptical of reductionism.
The critics of psychiatry depend on this binary being invisible. If the only choices on offer are 1980s neuro-reductionism on one side and a self-righteously critical, anti-medical posture on the other, then anyone disenchanted with the first is shepherded toward the second. Once you see the binary, you see that the rhetorical machinery of critical psychiatry runs on it.
Two comments in response.
First, this presentation of psychiatry’s history, dating back to the 1980s, is a form of historical gaslighting. American psychiatry, of course, promoted a disease model to the American public following the publication of DSM III, with this model presented to the public by Nancy Andreasen, a long-time editor-in-chief of the American Journal of Psychiatry, in her bestselling 1984 book The Broken Brain. The chemical imbalance story stood at the heart of that disease model: the pathology was known, and the profession now had drugs that fixed that pathology. Indeed, many psychiatrists began calling themselves psychopharmacologists, and ever since then, the profession’s primary activity has been prescribing psychiatric drugs.
What American psychiatry has not been doing since 1980 is promoting non-drug therapies to the public or embracing environmental alternatives like Soteria House. As a profession, it has not been operating in the “space between” that Aftab ascribes to himself and his peers.
Second, notice his comparison of the intellectual merits of the critics versus those who live in the “space between.” The critics are depicted as simpletons, stuck in a binary form of thinking, and who are, in terms of their character, “self-righteous and antimedical,” while he describes himself and his peers in psychiatry as “scientifically grounded, neuroscientifically and psychologically informed, philosophically aware, humanistically oriented, and deeply skeptical of reductionism.”
All I can say, after reading that litany of self-praise, is wow. I’m tempted to write something snarky in response, about thumbing through my DSM and looking for diagnoses associated with delusions of grandeur, but best I just let his self-description speak for itself.
After telling of the intellectual failings of the critics, Aftab writes this: “As I’ve written previously, the Whitaker-Moncrieff version of critical psychiatry, at its core, is a philosophically and scientifically exhausted movement.”
I had no idea what he might be referring to, and so I looked up the post he had linked to.
I am not mentioned by name in the post, and neither is Moncrieff. Nor is there any description of my particular critique of psychiatry, that American psychiatry has not been a reliable narrator of its own research. Instead, it is just a lengthy diatribe against critics of psychiatry, describing them as zealots who are feeding into societal conspiracy theories, while describing his own (mild) criticisms of psychiatric thought and practices as the true path of the rigorously skeptical mind.
I guess Aftab assumed that nobody would bother to click on the link.
However, it is the type of commentary that the American Psychiatric Association apparently appreciates, as it Board of Trustees recently gave Aftab its “Distinguished Service Award” for “exceptional meritorious service to psychiatry and the APA.”
As I wrote in the opening to this post, there were two reasons that I was moved to respond to Aftab’s post, and the surrounding news events.
The first was to make known the nature of the “Whitaker/MIA” critique. It arises from a very straightforward journalistic effort, which provides a documented account of how our society has organized its thinking around a narrative told by American psychiatry that is out of sync with its own research.
The second was to provide a deconstruction of Aftab’s post. As the media now regularly turns to him for a comment on psychiatric matters, he has become a prominent figure within American psychiatry, and thus, to a large extent, his post can be seen as an example of how psychiatry, as an institution, responds to its critics.
I should add that I am sure that Moncrieff and Delano, if they were so inclined, could provide their own deconstruction of Aftab’s post.
I titled this post “Psychiatry’s Attack Dog Is at It Again.” The “at it again” in the title expressed my weariness at having to respond to criticisms of this sort, which have been ever present since I published Mad in America and E. Fuller Torrey, in a review of the book, described me as apparently having fallen under the influence of Scientologists. The title also implied that Aftab’s post was not to be taken seriously, that this was just more of the same. Indeed, to be honest, when I came to the part where he described himself and his peers with an ode to their collective brilliance, I laughed out loud. So this is how, when they look in the mirror, they see themselves!
But with that Attack Dog title in mind, I am thinking of summing up my response with a quip, keeping a note of humor present in this reply, and with one that brings his post and my response full circle.
So call it, Man Bites Dog.