Adventures in Personalized Psychopharmacology: A Conversation with David Mordecai

This interview is part of a series featuring in-depth conversations intended to foster a re-examination of philosophical and scientific debates in the psy-sciences. See #1 with Diane O’Leary and #2 with Richard Gipps. It is a continuation of my prior series, “Conversations in Critical Psychiatry,” but with a broader focus.

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David Mordecai was born in Jamaica and grew up in Jamaica, Trinidad, Guyana, and the USA. Gardening was a childhood interest and he went on to study horticulture in university. He moved to Toronto, Canada in 1993 at 26. David currently runs a small garden business that he founded, and volunteers in mental health service-user-based projects when he is able.

It is a truism in medicine that patients are the best teachers, but the maxim nonetheless works within an epistemically asymmetrical relationship. Patients are the best teachers, as the common understanding goes, because working directly with patients allows one to observe (and therefore learn from) the diversity of clinical presentations, complexities of etiology, the individual variations in treatment response, etc. that cannot be adequately captured by generalizations in textbooks. Few physicians, however, take the radical step of viewing patients as epistemic partners in a shared undertaking, as potential co-creators of medical knowledge, as individuals who can critically analyze their own symptoms and their own responses to treatments, and who can direct their own care in innovative ways that may not only surprise clinicians but that may also lead to better outcomes for patients. When I think of service users from whom I can learn about psychopharmacology in this sense, one of the first people I think of is David Mordecai. In this interview below we discuss his experiences with various psychiatric phenomena and the creative ways in which he has personalized his care in collaboration with his treating physicians. — Awais Aftab

Introductory comments by David Mordecai

You invited me to do a Q & A about my use of psychotropic medication. What you characterized as my “adventures in personalized psychopharmacology” have only been possible because of the advantages I bring to being psychosocially disabled.

My first advantage was a relatively trauma-free, middle-class childhood. I was self-assured enough to cautiously come out as gay at 13 in Jamaica, a violently homophobic place. I consistently experienced validation from key friends, family, and teachers. My parents were unequivocal in their love for me when I came out to them at 15. My youth was romantically lonesome and emotionally intense, but not, overall, unhappy or problematic.

I have not experienced much direct discrimination despite being gay, Black, and disabled. I have never experienced involuntary psychiatric treatment. My experiences of mania and even psychosis have been, in themselves, harmless and, more recently, positively life-transforming. They did not result in physically violent treatment.

From childhood my mother was open about the madness of relatives across several generations of my family. She encouraged me to understand my experiences with pride, as part of a special family heritage. She inoculated me from stigma. She also protected me by resisting a desire by an incompetent psychiatrist to commit me to inpatient treatment; “day hospital” being the compromise.

Lastly, my bipolar states usually present distinctly; mixed states are rare. I think of my mood as viscous. Shifts within a 24-hour period are small and the transition to extreme states will take days or weeks. Mania has always ended after a couple days on a sufficient dose of antipsychotics. Many experiences of bipolarity are more volatile and persistent than mine.

Aftab: Tell us about your experience of psychopathology. What shape and form have your psychiatric problems taken, and what has the pattern been over the course of your life?

Mordecai: When you say “psychiatric problems,” I hear “my problems with psychiatry” or “problems psychiatry has with me.”

I have never taken seriously the idea that my mind is diseased. I understand my brain and, more recently, my self-concept as unusual but not abnormal. Psychiatry belongs to dominant frameworks of understanding. There are other frameworks. I have always known, if sometimes struggled to feel, that my ways of understanding myself and the world are valid. This is one of the reasons I’ve been able to assert control over my medication while maintaining good relationships with my prescribers.

I can be at ease with some psychiatric terms, but my take on those terms is nuanced. Individual experiences of madness can be horrific, but to me, madness is a revelatory social phenomenon; its purpose is to call attention to realities that society is ignoring. Those ignored realities may be social failures such as abuse, poverty, exploitation, and discrimination, or they may be transcendent and mystical ways of being.

The common medical understanding of pathology in terms of deviation from a norm undermines mental wellbeing. Humans are diverse; some of our differences are less common than others. To judge mental differences as abnormal is othering at best, dehumanizing at worst. When psychopathology parses people or even our experiences as abnormal rather than just different, it gives rise to an iatrogenic harm that is sadly endemic to psychiatric treatment.

An equitable psychopathology understands pathology as the relationship between endogenous difference and ill-health. Personal history and social circumstances play a major role in this relationship. Understanding psychopathology in this way can reveal the judgments and norms incorporated in the idea of dysfunction and invites a collective responsibility for mental health.

Having said all of that, childhood signs of what a psychiatrist would diagnose in my late thirties as ADHD were my challenges with follow-through and completion, and an inability to study in conventional ways. Overall, I did well in school, but my performance was hit-or-miss.

I was completely out as gay as soon as I got to university in the US. During the holidays after my first semester, I realized that at the end of my degree, I would be returning to a more constrained life in Jamaica. This realization led to several weeks of profound sadness. As soon as I got on the bus to return to campus, this sadness became elation, then mania, and, within a week, psychosis.

Nothing harmful happened while I was psychotic. What I eventually came to remember is walking for many hours around campus in a state of magical bliss before being taken to hospital by a friend I believed to be Jesus. I was placed on chlorpromazine and made to take a leave. For the first year of that break, my homophobic psychiatrist could not hear or understand the sadness and then elation that preceded psychosis. He misdiagnosed me with schizophrenia. Subsequently, in the day hospital, I was given a more helpful diagnosis of what was still called manic depression.

Throughout my twenties and early thirties, I would cycle within weeks or months between mild depression and hypomania, which I could curtail successfully with benzos.

In 2002, in my mid-thirties, I started a business which proved to be more challenging and depressing than I had anticipated. From 2002 to 2017 I was often mildly depressed and would rarely experience hypomania—this despite sometimes being off daily mood stabilizers for years, and/or using stimulants in an ultimately unsuccessful attempt to address inattentive ADHD.

In early 2017, in a last-ditch attempt to see if I could reap any benefit from stimulants, I took a single 120 mg dose of Biphentin (methylphenidate) without prior titration and while not on daily mood stabilizers. I knew that this might result in mania. It took three days but eventually I found myself experiencing reality as I had after returning to university in January of 1986: blissful, magical, sublime… and suffused with energy. A compelling sense of intense force or energy that is overwhelming and almost impossible to abide is what distinguishes mania from hypomania for me (official diagnostic criteria notwithstanding). Unlike my first experience of mania, this experience did not end in psychosis, and proved to be positive in ways I write about in detail, here.

I both limited and ended that experience with antipsychotics and it was followed by an afterglow. For about nine months, life felt exceptionally rich and meaningful. Then came roughly a year of anhedonia and avolitional depression which was bleak but did not surprise or severely distress me. This depression did not respond to aggressive medication but eventually gave way to exceptional mood stability from 2019 to 2021. Despite COVID and not taking daily mood stabilizers, for three years I felt a deep, stable contentment, if not great happiness.

I had an abrupt, unexpected experience of hypomania between late December of 2021 and January of 2022 which I suspect was linked to using fluticasone daily for four months. This had the unexpected effect of shifting my self-understanding to one of plurality.

Since that experience of hypomania at the end of 2021, and my recognition of our plurality in early 2022, my experience of bipolarity has changed distinctly. I have had more frequent experiences of both euthymia and minor mood elevation, and, until recently, far fewer experiences of low mood. Happiness and pleasure have been more consistently and stably accessible than ever before. There have been several endogenous experiences of hypomania, but these have not progressed as rapidly as in the past. Sleep is more frequently challenging, but markers that used to characterize greater mood elevation take longer to manifest and often do not manifest at all (perhaps because I usually intervene with medication before they can).

Recently (since March 2023) I have had a series of distressing experiences that have led to some depression between periods of euthymia and mild mood elevation.

Aftab: What sort of experiences have you had working with psychiatric clinicians? Has it been the full range of the good, the bad, and the ugly?

Mordecai: My first encounter with a psychiatrist happened in Jamaica, when I was 15. My parents suggested it after I came out to them. In a single appointment he spoke with me, determined that nothing was wrong with me or my life, and simply cautioned me to act carefully given how violently homophobic Jamaican culture can be.

Unfortunately, when I returned from university after my manic-psychotic experience, I did not see the same psychiatrist (cost may have been a factor), but another who, along with his work as a doctor, was also a Baptist minister. He was virulently homophobic, such that he was unable to engage with the history preceding my psychotic experience. I’m not sure what informed his diagnosis of schizophrenia. For the subsequent year, he treated me aggressively and harmfully with increasing doses of trifluoperazine, butriptyline, benztropine, and the occasional benzo or adjunct antipsychotic for sleep.

I continued to see him and take the medication prescribed because I wanted to get back to university. His treatment made me sicker and eventually he gave up. I became a day-patient at a nearby psychiatric hospital. My psychiatrist there decided to stop the antipsychotics and started me on lithium. For the first time I had a diagnosis, manic depression, that better fit with my experience. Within a month I was able to start and keep a basic job, and within six months I was back at school.

In 1987 when I recounted my treatment in Jamaica to the in-house psychiatrist at Cornell University, he admitted to me that psychiatrists do not know how medications help, but sometimes they do, and sometimes diagnosis is based on what medications prove helpful. He told me that the only way to find what works is to try. This simple, humble exchange was the most helpful encounter I have had with a psychiatrist. Based on his admission I determined that I would approach taking medication as an experiment, but because of my earlier mistreatment, I would be in charge.

Mordecai: In 1987 when I recounted my treatment in Jamaica to the in-house psychiatrist at Cornell University, he admitted to me that psychiatrists do not know how medications help, but sometimes they do, and sometimes diagnosis is based on what medications prove helpful. He told me that the only way to find what works is to try. This simple, humble exchange was the most helpful encounter I have had with a psychiatrist. Based on his admission I determined that I would approach taking medication as an experiment, but because of my earlier mistreatment, I would be in charge.

I was so successful at preventing a recurrence of mania that eventually new doctors sought to revise my diagnosis—bipolar 2, cyclothymia, “bipolar spectrum.” It’s bizarre that doctors implicitly understand some diagnoses in terms of treatment failure. This can curtail the very support that has kept someone well. Unlike my doctors, I never doubted that I had experienced mania and psychosis and might again, but I did gradually question my need for daily medication.

Over thirty years living in Toronto, I have seen eleven psychiatrists. Five for consultations, six for attempts at ongoing talk therapy. Two of the psychiatrists I consulted were fairly distinguished.

The first well-known psychiatrist rudely interrupted me as he observed his fellow taking my history. He asserted with clear annoyance that I was doing poorly, despite my (and my long-term doctor’s) assessment that my mood was stable. Presumably he made this determination because I was not taking daily mood stabilizers at the time. I was seeing him for input on managing ADHD in the context of bipolarity. The only thing that stopped me from making a loud complaint was recognizing that at some future point I might be at this psychiatrist’s mercy in an emergency. He was the most arrogant (as opposed to ignorant) clinician I have ever encountered, and his arrogance was maddening.

The second, a renowned psychopharmacologist, met helpfully with me three times over several years. He conceded with brief frustration that he could only advise me. He acknowledged that I would make my own choices, and his concession quickly forged an alliance. I had brought him a list of medications I might want to try. He went through them, offered his thoughts, and suggested other approaches. He set the parameters within which my prescribing physician and I experimented for years.

My other experiences with psychiatrists have been benign, if rarely very helpful. Of the six psychiatrists I have seen as possible talk therapists, I chose to continue with four. One was good as both a therapist and prescriber, the other three less so as therapists. The worst of these eventually started to fall asleep in sessions. My three most effective talk therapists were not psychiatrists.

Although I cannot recount it here, I also had one distressing and revealing experience with a well-meaning psychiatrist who was a colleague, not my doctor.

Aftab: How do you keep an eye on your mood to detect mania or depression at an early stage? What changes are you looking out for?

Mordecai: Endogenous depression always presents first for me as lethargy. If there are circumstantial factors, typical emotions like sadness, despair, and helplessness will occur and sometimes precede and precipitate lethargy and depression.

My appetites are another early sign. I crave carbohydrates when tending towards depression. When my mood starts to rise, I crave proteins, if I remember to eat at all. I have never been ashamed of sex, and it is one of the few pleasures I can find when depressed. So less sexual preoccupation is an early sign of rising mood for me—which I know is atypical. However, romantic interest becomes pronounced and actionable when my mood is significantly elevated.

The most peculiar early sign of rising mood, even before sleep becomes a problem, is that I lose the ability to park my car parallel to things. I will think I am parallel and discover I am parked at an angle. When my mood stabilizes, even at a more elevated level, the ability to park parallel returns.

Before my>our plural self-understanding of early 2022 my indicators of rising mood would often overlap and increased ideation was a later sign. My plural experience of these indicators is more distinct, more gradual and clearly sequential, and the order has changed. This separation and reorganization of indicators has enabled me to create a ten-point scale and use an app to track my mood. Below 1 is suicidal, above 10 would be psychosis. Later states of elevated mood will include earlier signs.

10 - Force majeure (mania)

9 - Living profundity (hypomania–includes emerging synchronicity and a keen sense of interconnectedness)

8 - Sensitivity to beauty (sub-hypo)

7 - Emerging ideas (sub-hypo)

6 - Can find pleasure (euthymic)

5 - Hmmm

4 - Meh

3 - Lethargic

2 - Avolitional

1 - Hopeless

The scale speaks to my mental state. Sleep challenges may emerge at any point and indicate my shifting physiological experience of bipolarity. When I feel energetic after a sleepless night, no matter where I might be on the scale, I know that I need to intervene with medication if I am not prepared to experience a more elevated mental state.

Aftab: What is your approach to the pharmacological management of bipolarity? What works best for you?

Mordecai: I have tried roughly 30 psychotropic medications to date to find the half-a-dozen for which the benefits outweigh the adverse effects and long-term risks.

My year on chlorpromazine and then trifluoperazine taught me that daily antipsychotics can suppress cycling but for me the result is a flattening on the depressive side, sometimes severely so. This has been true even on daily aripiprazole or lurasidone, supposedly helpful with depression. Antipsychotics are also too harmful a choice as maintenance medications for me.

When I started lithium in 1987, high daily doses (2,400 mg) would bring me only to the very bottom of the therapeutic serum range. I also experienced intolerable adverse effects before mood cycling stopped. For those reasons, I took lithium in doses that kept me below the ideal serum range and my mood would cycle over weeks or months. At more stressful times I would titrate my dose upwards but still below 2,400 mg daily. I made these changes myself, promptly informing my doctor and getting blood tests if I stayed at the new dose for more than a week.

I diligently took lithium and other medications for the first ten years after my diagnosis, out of fear of the disruption of psychotic mania. Based on my experiences, first at high doses then coming off of lithium, I suspect that lower lithium doses promoted my rapid cycling while limiting the extremes of mood.

I learned early on to use an adjunct (flurazepam, then diazepam, then triazolam, and for the past twenty years, clonazepam and sometimes an antipsychotic) for times when sleeplessness became a problem.

The above evolved into an approach that I now see as “meeting force with force.” As my mood rises, I increase my level of intervention with medication, informing my doctor after the fact. I never allow myself more than two nights with absolutely no sleep. This approach with lower doses of lurasidone (40–80 mg) enabled sporadic sleep during my experience of mania in 2017, but it took two days of lurasidone at 160 mg to bring the experience to an end.

For me it seems to be as or more effective to match an upward change in mood with a change in medication as to rely on just a fixed dose of a daily mood stabilizer. Antidepressants don’t lend themselves to brief, as-needed use in response to falling mood. Stimulants do, but having taken them in various combinations for years, I don’t enjoy their side-effects and can’t imagine a doctor prescribing them for that purpose. Intuition says ketamine and psychedelics would be unwise for me.

After a decade on lithium, I became concerned about organ damage and switched to lamotrigine. Eventually, I tried coming off a daily mood stabilizer completely and medicating only around sleep. My prescriber of 20 years and I agree that since he has known me, daily mood stabilizers have not made a clear positive difference. What is critical is prompt, effective interventions around sleep.

I am careful to restrict my use of clonazepam to three days a week, ideally much less, despite the fact that clonazepam provides an immediate improvement in mood stability (for both upward or downward shifts) in addition to enabling sleep. Recently, as sleep has become a more frequent challenge, I will reluctantly use an as-needed nightly dose of 20 - 40 mg ziprasidone as an alternative to 0.5 - 1.5 mg clonazepam. Zopiclone does nothing for me.

In May 2023, my increased challenges with sleep even when euthymic led me to resume taking a daily mood stabilizer: 200 mg lamotrigine. This does seem to lessen my need for medication for sleep, but life circumstances continue to be depressing so it’s hard to know what is causing what.

Antidepressants were helpful for short periods prior to 2017. I noticed that all antidepressants stopped working in three to six months. The antidepressive effects of daily lurasidone or high dose lamotrigine (400 mg per day, suggested by a consultant psychopharmacologist) lasted less than two weeks. The severe and protracted depression I experienced after mania in 2017 did not respond to antidepressants that had previously helped, nor to creative new strategies (adding daily aripiprazole and modafinil—again suggested by a consultant psychiatrist).

During summertime heat, prior to 2017, I used to consistently experience lethargy which led to seasonal summer depression. Drinking electrolytes daily seemed to help.

Depression has always been harder for me to manage with medication than elevated mood. Now that I am more consistently experiencing euthymic or slightly higher mood states, antidepressants seem an unwise choice. Therapy, self-compassion, radical acceptance, thought-challenging records, connecting with a sense of life purpose and peer-support seem to be my best current options for coping with depression.

Aftab: You once tweeted: “I have taken a dozen antidepressants, and all have worked for me… for three to six months. Tachyphylaxis is a thing. After 20 years of different meds I picked my favourite three and cycled through them. All worked again after a holiday.” This seems like a creative and rational strategy in light of your experiences. Since this sort of practice isn’t endorsed by practice guidelines—mainly because it hasn’t been studied in trials—and this isn’t something psychiatrists are formally taught, many practitioners are likely to lack the imagination and courage to propose a regimen like this. The mainstream approach tends to be to find a medication through trial and error that is beneficial and tolerated, then stay on it for maintenance until it stops working, and then repeat the trial and error. The possibility of cycling through short-term use of three “favorite” antidepressants isn’t something that would come naturally to a lot of physicians I know. Perhaps that is precisely the problem: contemporary psychiatric practice is too rigid, too unimaginative, too scared even, and needs the sort of playful spirit that you exemplify?

Aftab: The possibility of cycling through short-term use of three “favorite” antidepressants isn’t something that would come naturally to a lot of physicians I know. Perhaps that is precisely the problem: contemporary psychiatric practice is too rigid, too unimaginative, too scared even, and needs the sort of playful spirit that you exemplify?

Mordecai: I hesitate to suggest too much from my experience. I have never noticed withdrawal effects on any medication. This is another way in which I am fortunate and has facilitated my experimentation. If my bipolarity were more labile and I was less observant or adept at negotiating my care with my doctors, this would be a different history. My involvement in my treatment with medication is part of why medication has been helpful to me, but that may not be true or desirable for others. And how many people have access to the same prescribing physician for regular, often weekly, talk therapy over twenty years? Not to mention a doctor who is comfortable not prescribing anything at all.

I agree that fear is a barrier to doctors responding as mine have; I doubt the solution is playfulness. Courage, perhaps. Although guidelines can protect patients, practicing outside of guidelines also makes doctors vulnerable, and not just to accusations of malpractice. Hidden by guidelines are doctors’ fears about competence and efficacy. My decades-long success at avoiding psychosis and self-harm no doubt reassures my doctors. Without it they might be more coercive in my treatment.

Other observations that may be widely applicable:

My best doctors have always acknowledged my freedom to make choices contrary to what they would recommend. I, in turn, have been sensitive to my doctors’ discomfort when I assert control of my medication. I keep them informed of my choices, my rationale, and significant changes. I learn about the adverse effects of my meds and make clear that I know them.

Mordecai: My best doctors have always acknowledged my freedom to make choices contrary to what they would recommend. I, in turn, have been sensitive to my doctors’ discomfort when I assert control of my medication.

We usually discuss the parameters within which I might adjust what I am taking in advance. Sometimes this is very explicit. I will talk about how I want to take a medication and why. If my doctor is willing to prescribe it at all, his response has been “I can prescribe this recommended dose; I realize that you might choose to take it this way instead.” I usually choose less, rather than more, medication and this approach allows my doctor to adhere to guidelines while recognizing my autonomy. If there are risks to certain choices I might make, my sharing how I might actually take medication enables my doctor to make these risks clear (for example, do not abruptly stop and start lamotrigine, or antidepressants). I also check risks with my pharmacists. There are certainly times when I yield to my doctor’s advice. Unusual medication choices only happen after consulting a psychiatrist.

I have had bipolar friends become frustrated when their prescriber insists on being consulted prior to medication changes, delaying intervention, and forcing a choice between promptly controlling rising mood and staying on good terms with their prescriber. Preemptively negotiating parameters within which people can promptly change their medication on their own is probably a helpful approach in most cases.

Aftab: What has been your experience with psychotherapy, or combination of medication and psychotherapy?

Mordecai: My return to Cornell as an undergraduate was conditional on regular talk therapy and ongoing psychiatric care. I have continued therapy, usually weekly, for thirty-two of the last thirty-six years. I have never undergone psychoanalysis, but therapy has addressed attachment and self-esteem challenges and given me tools for coping. Regular therapy can also somewhat anchor my mood by creating a frame in which to present myself consistently.

My current 20-year therapeutic relationship has been with what, in Canada, we call a GP- or MD-psychotherapist. He is also my prescriber. It is through our work together that I recognized my durable sense of self-worth and developed a separate understanding of self-esteem. These developments were key to resisting grandiosity during mania in 2017. During that experience, my MD-psychotherapist was careful not to pathologize what I was going through. At my request he stayed in touch with a close friend and ensured that I was not acting in dangerous ways, but he resisted naming or judging my experience when interacting with me. He also did not express any judgment about the medication experiment that led to mania.

My friend became involved because when my mood becomes very elevated I tend to misplace the medications that limit it. My friend filled my lurasidone prescriptions and held some in reserve in case I misplaced what I had been given.

When my 2017 experience was over, my MD-psychotherapist said to me (paraphrasing): “now that you have experienced mania without harm or psychosis, you do not need to let your fear of it govern your life anymore.”

Society has handed psychiatry and medicine immense power in managing madness. Skilled doctors can set this power aside, and indeed act to protect us from its harmful effects. Those doctors who can step outside the frame of pathology and work with us as people, not patients, can offer immediate relief from mental distress, and sometimes a path to healing that does not depend on medication at all. I like to say that for psychosocially disabled people, hope is health. One of the fundamental roles of a clinician is to offer hope. And doctors can do so in every encounter by seeing your patients first as people.

Aftab: What do you make of all the skepticism around efficacy of psychopharmacological interventions that is common in critical circles?

Mordecai: Psychotropic medications are unusually and strangely powerful. They are not always helpful and even when helpful they can have significant adverse effects. Unlike other medications, very few prescribers have taken the most powerful psychotropics for more than a single dose out of curiosity. Prescription of psychotropics often occurs with a casualness and lack of fully informed consent that can be disastrous.

I am very sympathetic to those who have experienced harm from meds. I gradually developed very unpleasant akathisia on lurasidone and a psychopharmacologist has warned me that I may be in the initial stages of tardive dyskinesia (a risk I try to mitigate with vitamin E). I will be dealing with metabolic syndrome for the rest of my life. I am thankful that none of these harms came as surprises to me.

Psychotropics are risky band-aids, an often-poor substitute for eliminating poverty, abuse, and discrimination, and accommodating disability. If psychosocially disabled people did not have to worry about adequate financial and social support, what we now call mental illness would look very different for most. I like to think that if I didn’t have to work and fulfill other responsibilities such as caregiving, I could come off medication. Certainly, if I did not have to work, I would take less.

A pharmacologically circumscribed practice of psychiatry often arises and functions as a stop-gap in failing societies. Instead of psychiatrists standing in solidarity with marginalized people rebelling against societal ills, bio-psychiatry placates or restrains us with pills. This cynical take overlooks the individual benefits medication can offer to people like me, but reveals that on a macro level, when psychiatric treatment is limited to prescribing medication and coercively policing madness, it is complicit in the illnesses it seeks to treat.

Succinctly, not everyone experiences the benefits of medication, and those who instead experience harm see psychiatry’s shortcomings very clearly.

Mordecai: Not everyone experiences the benefits of medication, and those who instead experience harm see psychiatry’s shortcomings very clearly… At the same time, antipsychiatry can marginalize the realities of those of us who do benefit and knowingly choose to use toxic drugs in order to cope.

At the same time, antipsychiatry can marginalize the realities of those of us who do benefit and knowingly choose to use toxic drugs in order to cope. Some antipsychiatry elides endogenous differences—what some call neurodivergence—in attacking psychopathology. It is possible to take medications and not see them as cures. However, it is one thing to do this with informed choice. It is quite another to be forced or seduced into doing so by narratives around mental ill health that fail to reckon with its societal components and the real harms of the medications offered as treatments.

Aftab: What do you think of my piece “A Psychopharmacology Fit for Mad Liberation?” for Asylum Magazine? Any substantial points of disagreement? Or any important points that you think I should’ve touched on?

Mordecai: I found it impressively comprehensive, if still implicitly operating under a traditional understanding of psychopathology. You do a thorough job of addressing the power dynamics and pitfalls of prescribing. You insightfully propose constructive alternatives. Would that more doctors apply your manifesto in practice.

Mordecai: Mad liberation for me comes back to the power that society has handed to medicine to pass judgment on and control madness. I don’t expect that state of affairs to last forever, but I’m not as keen to overturn it as some because I fear what might replace it.

Mad liberation for me comes back to the power that society has handed to medicine to pass judgment on and control madness. I don’t expect that state of affairs to last forever, but I’m not as keen to overturn it as some because I fear what might replace it. Doctors who are humble and who can set their power aside, or better yet, use it to confront sanism, can collaborate more equitably with Mad people in our care. Such doctors are rare. They can be open to and affirm our unusual experiences in ways that validate us and enable hope and healing. This potential healing validation is why psychiatric care should never be limited to or conditional on prescribing. If more doctors understood the dehumanizing dangers of psychopathology, and worked skillfully to counter them, outcomes of psychiatric care would improve, perhaps with less of a need to rely on psychopharmacology.

Aftab: Thank you!

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