One of my greatest powers as a psychiatrist is to gradually remove medication from a regime and watch as the patient recognizes “I guess I didn’t need that” and feel more alive. If I do it very well they say goodbye to me and I consider that the greatest triumph.
People can be helped by use of medications, but frequently they think that continued stability is dependent on the pills. Sometimes it is, sometimes it isn’t. But when it becomes a part of their life that is now stable, they are afraid to remove the scaffolding.
what goes unspoken here, and in Laura Delano‘s book, is that a great deal of this is not just about access to ambiguous resources or support, but, candidly, about money. The kind of real work to come off of and live without psychiatric medications requires both money and the time that money buys. And it may require a family support structure that can provide caregiving assistance—which, again, is about money. it may also require sufficient physical health or, at least, the absence of some other comorbid condition that could be worsened by the neurological effects of withdrawal. Discussions about alternate modes of psychiatric and psychological support have limited relevance to large swaths of the population without acknowledgment of these things. this is to say nothing of the fact that some marginalized people are penalized more harshly for even trying. and personal accounts that don’t touch on these things seem limited, if not a little dishonest.
I agree that access to resources is probably the number one indicator for “success” in ANY treatment/healing/support paradigm (including mainstream psych).
But just to clarify, the frameworks I’m describing are explicitly and necessarily free to access, and like AA, derive their effectiveness in large part BECAUSE they equalize and are accessible w/o regard socio-economic strata
why can’t you just say “money”? you’re doing everything you can not to.
being sick from, and maybe unable to work while, going off of psychoactive medications with neurological and physical side effects requires time and money. you can go to five meetings a day, but if you can’t support yourself and be supported, you might not even get to the meetings in the first place.
What maybe doesn’t come through in the interview is that these mutual aid networks are meant to provide the support (including material support) that might be prerequisite for participation in those networks in the way you describe.
When I first started going to AA, I had no access to money, was physically and mentally incapacitated to the point of disability. The community there provided a great deal more than just meetings: transportation, housing assistance, etc. and AA is far less holistic in its mandate than the networks I’m describing.
It’s not just about meetings and supportive conversations, it’s about directing resources to where they are needed, especially in situations where individuals find themselves estranged from government or familial supports.
This exists already in many places, I’m advocating for its popularization and validity in the eyes of professionals in related fields and service sectors.
Both you and Jaqui make valid points about how difficult this type of work is. But you have to start somewhere. I hope you learn a lot from this venture you have created and change the way that the public view and use drugs to respond to various conditions. People need to feel less passive and more empowered about how to change what they are taking, and more informed and aware of what PROs and CONs are in play when they try a new medication, to prevent a culture of dependency. However, autonomy is a tricky area with severe mental health conditions.
but your wife did, if i recall the profile rachel aviv wrote correctly, and lots of people on this path do. if you want to talk about what is possible, again, money is part of it. a big part of it. WHOSE money, from WHERE, to WHOM, distributed HOW, under what CONDITIONS? all
also, in your example about your own experience, it DID take money, it was just other people’s. which is ok! which is mutual aid! but it wasn’t guaranteed and not every meeting has people with the financial resources who can and will help people.
I was the administrator for HVN in my state for several years, and have a long relationship with many who’ve come through wildflower, and regularly recommend them to people looking for support.
I’m not leaving them out, I’m expressing endorsement for the underlying principles in a more generalized context.
As a psychiatrist, I'm really happy to know about Inner Compass. I'll return to that shortly...
I agree completely that we are over-prescribing and that people spend years trying to find their way out of both mental health issues and dependence on meds that don't help. I was treated for depression with quite a few meds, and more were added when I had side effects (I'm off all but one, which I take for sleep.)
As a psychiatrist, I feel prescribing is so over-determined. As Ray Kloss notes, people are often reluctant to go off meds or depart from the idea that they can be helped by them. Here are some other thoughts:
1) We psychiatrists are now cast as "prescribers." I didn't train to be a prescriber, in fact I did a very psychoanalytic residency, but that's what people now call me. The demand is fueled by the media and public health misinformation campaign which offers treatment as the answer. (One college student told me that he knew "everyone should be in therapy.") It's important to realize that some of us have more flexibility about de-prescribing than others. If you work on an inpatient unit, you might be in trouble if you take someone off their Seroquel.
2) Medical training produces med students and then drs who feel they always need to have the answers, and need to fix things. We are never supposed to admit we don't know what to do, or don't have anything to offer (and if we do, that can be taken as a defeat by patients, who are used to us "knowing.") I have found that psychologists are generally less in "fix-it" mode. But society also doesn't provide a lot of other answers for people who are struggling, i.e, community support, good health benefits that cover alternative treatments, job re-entry programs.
3) Sometimes meds help, so we are never sure when to stop. I just saw a patient who is 82 and has been depressed most of her life. She's tried many meds, a lot of them with me, and we've also done therapy- she's been opposed to other meds. I'd given up and thought she had. On a lark, I suggested Abilify- I did not think she'd be willing, nor did I expect it to help. She called me a week later. "Dr Mahler, it's Happy Laura! You are not going to believe it, but..."
These successes draw us back in. There's always the hope that "this will be the one."
None of these is an excuse for harming patients- it's just the context.
My one issue with your wonderful interview is that I worry that a completely separate, lay industry will fail to draw in psychiatrists who are really sympathetic to this perspective. There are a lot of us, and there will be more if psychiatrists don't feel this industry is "the alternative," rather something with which they can engage, by which they can be educated, and which is their partner in helping people.
The AA analogy was interesting... I don't have a lot of time for AA myself, having read many critiques of them, but it is true that they have mainstream credibility as a patient led movement, and it makes sense that a patient led initiative could have similar credibility in the psych field.
I know as med students we were told to lie if patients asked us if we had lived experience (and the psychs were doing likewise) - just an example of the lack of authenticity that is the norm in psychiatry, and the one patient who did ask my registrar if she'd had lived experience was clearly desperate for an authentic connection.
I think the interlocutor seems to have a binary either/or attitude to drugs/psychiatry... As in drugs or working on the self, the idea that drugs might actually be a precondition for working on the self doesn't seem to have occurred to him... That they can turn your raving lunatic into a clear headed, thoughtful attender of long term therapy doesn't seem to be in his world view... I wonder what his familiarity is with severe manic psychosis... I'm sceptical that there is some naivety there in his worldview, antipsychiatry is far more effective with borderline than truly manic patients
I'd actually support a patient led initiative, in that in my experience in a psych placement in ED, there was very little genuine psychiatric illness that presented to the ED, most of what presented as mental health was "shitty life syndrome" aka life difficulties or the odd drug induced psychosis... And the life difficulties I don't think belong under the mental illness umbrella, even if the person is acutely suicidal at the moment, I would agree that it sends the wrong message to the "patient" that their difficulties need to be medicalised etc etc... though there may be other aspects to a patient led initiative that are valuable/critically important in addition to those highlighted here
I’m remembering standing before a skeptical doctor, having been dragged there by my mother and sister, and looking tongue tied and dozy before her. I could feel her exasperation and impatience as she scanned me and spoke to me as you would to a complete attention seeking timewaster who was getting in the way of her real patients. I was prescribed an antipsychotic and sent on my way after my relatives doing all the talking for me. I’ve never been so infantilised as an adult. The truth was that the contents of my thoughts and feelings were indescribably distorted, disturbing and horrific, and I was dumb with terror, trying to receive screaming voices and hallucinations and listen to normal life around me at the same time. I just don’t know how you could possibly tell whether someone is a “genuine” psychiatric case considering the current assessment methods available to doctors. It’s not possible to come to such a conclusion just by looking and listening to someone. It misses so much.
This is a fascinating interview and I really appreciate Cooper’s willingness to share his views in longform like this.
I’m a psychiatrist in long-term recovery from addiction, and I’ve written about the intellectual and cultural history of addiction, recovery, and mutual help organizations. I wanted to comment on the mutual aid angle specifically, without getting too deep into the many other important issues raised. To clarify some of my own priors: I’m very concerned about overmedicalization, essentialism, reductionism, and related currents in mental health and addiction treatment. I share @Susan Mahler’s concern about overprescribing as well as inadequate support for people tapering off medications.
That said, I think there's some conceptual vagueness in the repeated references to mutual aid here, and one fundamental issue is the term “mutual aid” is a bit slippery. The term has been used across disciplines—sociology, political theory, public health, and various corners of the addiction/SUD world—with different meanings. It can mean everything from anarchist organizing to a sort of reactive assumption that 12-step groups are the ideal. So it may be worth clarifying what it means to apply the “principles of mutual aid”. ICI seems to be drawing on some but not all principles of 12-step groups—Cooper’s main reference point in this interview. But which ones, how, and why? Again, not that AA is necessarily the correct or ideal model, but there are some comparisons worth considering,
To be clear, I’m not speaking for, against, or on behalf of any recovery tradition or organization; I just mean to make some observations based on what I’ve studied and observed, more on the sociological and organizational level.
One important distinction between ICI and 12-step groups seems to be that 12-step groups have a clearer purpose. AA’s mission is simple and behavioral: to help alcoholics who want to stop drinking, using a “program” and a set of suggested steps—framed in terms of spiritual growth and character development—for how to pursue recovery and flourishing. In contrast, much of ICI’s content seems focused more narrowly on getting off medications and managing withdrawal. I appreciate that Cooper says that they are not just anti-med, but the clear focus of the mission and vision on their webpage is in clearly opposition to what they call the “psychiatric paradigm”, ICI is said to be grounded in the experiences of people who have “depsychiatrized” themselves and “leave behind psychiatric diagnoses and drugs”.
Analogously, there have been a lot of organizations that critique AA, the "disease model," the notion of alcoholism or addiction as an organizing explanation for substance problems, and offer alternative (or “parallel,” if you prefer) paths to recovery. The ones that have more staying power and cohesion tend to be the ones that offer a positive vision that goes beyond opposition to existing models. For example, SMART recovery, a more psychology-focused and secular organization, helps people set “toward’ goals and build happiness and resilience, not just critiques of AA.
I read the ICI principles Cooper linked to, but I didn’t see much clarity about how the mutual aid part of ICI actually works aside from being “the voluntary exchange of support and resources.” I understand there’s the "Exchange" and presumably there are some ground rules but I am talking more about the core principles of how it’s meant to work. Cooper says “You need to have an ideological backbone” but I don’t really see a clear articulation of the core problem of suffering, or the solution, from ICI’s perspective. Their “guiding principles” strike me (and I mean this respectfully) as somewhat anodyne: vague, broadly agreeable, and hard to dispute in the abstract. But that rhetorical softness is at odds with the organization’s deeper orientation, which obviously emphasizes getting off psychiatric meds. It feels a bit conceptually muddled. I wonder—though I’m not sure—is ICI assuming that rejecting psychiatric frameworks or interventions is itself a path to flourishing? This may be true for some—particularly those who were harmed or over-medicated by the system—but it is not a universally sufficient or reliable framework for healing or growth.
12-step groups hold to several organizational traditions, including a tradition to take no opinion on “outside issues”, namely controversial issues such as alcohol reform or religion. That neutrality has helped AA maintain cohesion and focus on its primary purpose. It has also helped protect against internal fragmentation. ICI has more opinions about broader sociological currents.
AA also draws a clear separation between mutual aid and medicine. In official communications, AA recognizes that medicine occupies a distinct and legitimate role in society. AA guidance explicitly caution against unlicensed laypeople “playing doctor,” stating that “all medical advice and treatment should come from a qualified physician: https://www.aa.org/sites/default/files/literature/p-11_0324.pdf This boundary reflects a broader sociological understanding of medicine as a legitimate professional domain, even if flawed. Note that this is a complex relationship—in my writing, I’ve described the “treatment industrial complex”, the multi-billion-dollar industry that has often provided a one-size-fits-all treatment model and in which "true" recovery or sobriety has often been equated with the traditional 12-step model. That system has rightly been criticized. But AA as a fellowship has consistently resisted professionalization, framing itself as a peer-based spiritual process, not a form of medical or clinical care.
With those points in mind, I’m not sure that “parallel” is the right word for ICI. If mutual help and psychiatry are truly parallel, then mutual help groups like ICI wouldn’t need to define themselves in opposition to psychiatry.
It strikes me that some other principles and traditions that are very important to 12-step groups are not present in ICI, and might be hard to institute in ICI. E.g., rotating leadership, group autonomy, and the idea that leaders are trusted servants, not governing. That is just one set of principles on mutual aid, in part inspired by the perspective that when a group develops rigid curricula, charismatic leaders, and the like, it loses something important. Of course, 12-step groups don’t need to be the only model here, as Cooper acknowledges, but at the same time AA is the one mutual aid tradition that he referenced, I have to wonder, which are the principles of mutual aid that are being “leveraged” here, and which ones are discarded, and why?
All that said, I appreciate the motivation behind ICI—to reduce suffering and address very real harms within the mental health treatment system. It's clear that all their hard work comes from painful, personal experiences. I’m grateful to Cooper for sharing his story so openly, and I want to acknowledge the depth of what he’s been through and the immense effort they've put into building something that tries to give people some hope and practical guidance for relieving their suffering.
Thank you, Dr. Fisher, for your thoughtful perspective on the substantial differences between AA and ICI. As you note,
"... much of ICI’s content seems focused more narrowly on getting off medications and managing withdrawal. I appreciate that Cooper says that they are not just anti-med, but the clear focus of the mission and vision on their webpage is in clearly opposition to what they call the “psychiatric paradigm”, ICI is said to be grounded in the experiences of people who have “depsychiatrized” themselves and “leave behind psychiatric diagnoses and drugs...[ICI's] deeper orientation obviously emphasizes getting off psychiatric meds."
In contrast, "...AA guidance explicitly caution[s] against unlicensed laypeople “playing doctor,” stating that “all medical advice and treatment should come from a qualified physician...If mutual help and psychiatry are truly parallel, then mutual help groups like ICI wouldn’t need to define themselves in opposition to psychiatry."
And yet, it seems clear that ICI does indeed define itself in opposition to psychiatry, notwithstanding protestations to the contrary; e.g., Mr. Davis's comment to Dr. Aftab that "We [ICI] are not “anti-psychiatry,” “anti-drug,” or “anti-diagnosis.” With all due respect to Mr. Davis, this seems disingenuous to me, and to others who have read the ICI material.
That said, our profession must accept some responsibility for organizations like ICI and its program. As a psychopharmacology consultant and academic psychiatrist, I acknowledge that ICI arose partly in response to less than adequate training of psychiatrists in recognizing and managing withdrawal syndromes (though I think the risk of severe withdrawal from SSRIs has been overstated; see, e.g., Henssler J, Schmidt Y, Schmidt U, et al. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry. 2024;11(7):526-535. ]
Indeed, historically, many psychiatrists, in my experience, have not been using long enough tapering periods, and this is a point I have made in my own published writing [see, e.g., Pies RW. Antidepressant Discontinuation: A Tale of Two Narratives. J Clin Psychopharmacol. 2019 May/Jun;39(3):185-188. PMID: 30921098.] (Of course, the vast majority of antidepressant prescriptions are not written by psychiatrists, but by primary care physicians).
But none of our professional inadequacies justify the very clear marginalization of psychiatry that appears to be the aim of ICI, despite claims to the contrary. ICI would do itself and those who consult it a great service by involving and making use of psychiatric expertise, per my previous comments, if ICI is to avoid overstepping appropriate boundaries (what some might call "playing doctor").
Nevertheless, I agree with you that ICI's motivation is to be respected; i.e., "to reduce suffering and address very real harms within the mental health treatment system." We can honor that motivation while still insisting that the goal must be achieved by respecting the central role of medical expertise.
I am troubled by the Inner Compass Initiative. It seems to me that what they do comes perilously close to practicing medicine without a license. According to the New York Times, both Ms Delano and Mr Davis charge about $600 a month for their counseling services. Of course peer support is invaluable, but “lived experience” is no substitute for medical training. I have attended many DBSA meetings as a family member of someone with SMI. In my experience, it’s a true support group, without an ideological agenda. I also have my own lived experience as patient—one which points me in the opposite direction to that espoused by Inner Compass: I wish SSRI medication had been available when I was an undergraduate at Harvard/Radcliffe back in the 1960’s. I managed to make it through, but was severely handicapped by my mood disorder. Later on in life, psychotherapy helped, but only so much. It wasn’t until I overcame my fear of trying an SSRI in 1991 that I made lasting progress. And as a counter-example to bad experiences discontinuing meds—after a terrifying stage 4 lung cancer diagnosis in 2001, I took a clonazepam pill daily for ten years—until it became clear to me the cancer did not seem to be progressing and probably I could do without it. I succeeded in tapering off it with only a few rocky days.
I also believe that the Inner Compass approach doesn’t sufficiently reckon with the problem of anosognosia, which is sadly so common in psychotic disorders. I am a firm believer in the work of the Treatment Advocacy Center, founded by E Fuller Torrey, which works to remove obstacles to treatment for those with SMI, who otherwise too often end up on the streets or in jail. Yes, people should get help coming off medications, and some are misdiagnosed or end up on unneeded drugs. But it seems to me the problem lies not with the medications per se, nor with the doctors, nor even with the DSM, imperfect though it is—but with the whole system for providing psychiatric care. There aren’t enough doctors/mental health providers. The answer is not to de-professionalize
Finally, I am especially concerned about the platforming of what is —when all is said and done—essentially anti-psychiatry position in this era of RFK, Jr. as health secretary, who has already announced his skepticism about psychiatric medications. I understand that copies of Ms Delano’s book have been delivered to members of Congress.
Excellent points, Ms. Wilbur--and thank you for sharing your experience with successful psychiatric medication treatment! By the way, in a recent article, I, too, shared my concern regarding RFK's benighted claims about SSRIs.
Excellent interview! Thank you, Cooper, for your comprehensive explanation of how mental health treatment might be aided by patient involvement and input. I could give a whole long presentation in my comments here about my personal story, but honestly, every pushback that rose in me while reading this, you addressed in the next answer to Awais, and so I'm impressed. I did have one concern to share. I'm a person who tends to be in the background, desiring to or not, who in a sense gets forgotten, steamrolled by those with loud voices that carry or who somehow build amazingly large online followings. Someone like me might get lost in alternatives that depend on having one's input heard. For instance, I got lots of attention from the "anti-psych" crowd when I was sick and angry and denigrating psychiatry constantly. But now that I don't do that, it's hard to find footing beyond a small group, fine for me as I do get quality interaction. But within a larger group, I'm overlooked. On to one more thing, a hospital I go to, the only one where I want to be inpatient psych, is incorporating more choices that give agency to patients and provide a kinder setting. This is funded by outside sources, then adopted by this hospital which is part of a large healthcare corporation. I've expanded on this in a blog post, if you're interested. The link is: https://rwillowfish.blogspot.com/2025/01/when-crisis-intake-undergoes-beneficial.html - I believe that progressive hospital administration, willing to, can be part of a bridge to better for us all. And again, thanks so much Cooper, and I'm also reading Laura's book now, which is an immeasurably vital read for me, and I don't know about others' feelings, but I'm identifying heavily.
*Also, I was in AA for 20 years, and while it helped, and I did form friendships, again I felt drowned out and so I left after trying and trying to assert myself, my authentic self. Also felt I had to say I was an alcoholic when really it's cannabis addiction, and that's the sort of thing I don't want forced on me or others, meaning this need to conform when that's not fully what you want to conform with, in any kind of help scenario.
As a now retired psychiatrist who specialized in the nature and treatment of mood disorders, I found this interview of great interest. I had the opportunity of reviewing the online material posted on the Inner Compass Initiative website [https://www.theinnercompass.org/about] and would appreciate some clarification from Mr. Davis.
I understand that the ICI model is grounded in "the crowdsourced, layperson wisdom of the thousands of people around the world who, like us, have “depsychiatrized” themselves–in other words, people who’ve decided to leave behind psychiatric diagnoses and drugs, are at various stages of doing so, and are supporting one another free from profit motive."
At the same time, I note that ICI has a disclaimer that states, "The process of reducing or tapering off psychiatric medication is inherently risky and can be especially dangerous and potentially life-threatening if done faster than one’s body can handle..."
Let's stipulate for now that this is an accurate statement, at least with respect to some psychiatric medications under some circumstances. I am wondering if ICI makes use of experts in psychopharmacology as consultants, in the event that a person using ICI 's "step-by-step, self-directed guide for tapering off" medication runs into serious problems while attempting self-tapering of a medication; and then informs ICI of this problem, requesting advice.
For example, a former patient--now fully "depsychiatrized"--reports that "I tried the tapering method on your website but I'm really having serious physical problems with the tapering recommendation. I feel really sick!" Is it ICI's usual practice to consult with an expert in psychopharmacology at that point, or to refer the person to a health care professional with medical training? If so, does ICI have a roster of potential consultants with medical training? If not, what is the rationale for ICI's decision not to make use of this option? (I do understand, per your disclaimer, that the information ICI provides "...does not constitute Inner Compass Initiative’s advice, encouragement, or recommendation that any individual reduce or taper off of his or her intake of psychiatric medication.")
Thank you, Mr. Davis, for clarifying these important issues. Just as you say on your website, "The significance and scale of the issues we’ve touched on here cannot be overstated—they are issues that affect millions of people directly and many millions more indirectly." On that point, we are in total agreement!
To clarify: ICI does not prescribe or treat, nor does ICI claim to provide medical advice. We provide general information, along with access to mutual aid and community support groups.
ICI does not provide any services, and does not provide treatment recommendations.
We are certainly not opposed to clinical guidance and support. In fact, our resources explicitly state that it is optimal to have a collaborative prescriber relationship during the taper process.
One thing that I'd add to the question of anger in ex patient communities, is that you're seeing the end of a very long process. A lot of us spent years, or even decades, trying to engage with medical and psychiatric professionals about our concerns in a respectful manner.
I first got put on SSRI's after breaking down crying in my doctor's office. I was pregnant with my 3rd child and said that I felt like my husband wanted me dead.
Husband later admitted that he was unhappy about having another (planned) kid, and had in fact been fantasizing about me dying during the birth. He did not actually try to kill me, thankfully, but that suppressed hostility had been coming out in various ways.
The situation escalated over the following years. One of the things he would do is hide the pills to slam me with withdrawal effects whenever I started getting too independent.
I tried to get off the antidepressants a few times. I was not able to identify that my relationship was abusive at that point, but I did say that I was struggling to take the medications regularly and felt like they were doing more harm than good.
Instead I was told that I "shouldn't risk it" because I "seemed to be under a lot of stress." Instead they suggested I get checked for ADHD.
That diagnosis came along with stimulants, which destabilized my mental state further, especially given that I was unable to take them regularly.
Any doctor I tried to talk to about this would swap the prescription out for a different dose or a new medication that I "might like better." And of course scold me for not complying with the treatment plan.
Seems like a funny expectation to have, if they really thought I had a neurological disorder that made concentrating and remembering things abnormally difficult.
Later, during the divorce, I went to a psychiatrist and told her I really needed to get off at least the antidepressants, because my abusive husband was using my "mental health issues" to try to take custody of the kids.
I started crying during this conversation. In response, she told me I not only needed to stay on the antidepressants, but tried to put me on "mood stabilizers," i.e. antipsychotics, as well.
Because of the crying.
Again.
By this time I was already on benzos for my anxiety disorder, of course.
Needless to say, I do not (and did not) have any symptoms of psychosis. I've never had it suggested as a possibility by any other provider.
That was around when the Adderall shortage hit. Amazingly, going off mood altering meds suddenly didn't require any planning or medical support at all.
I ended up going off the antidepressants on my own. Dealing with the withdrawal symptoms, without support, while going through a protracted messy divorce, was super fun. Thankfully they weren't nearly as bad as some people experience.
Credit where it's due, the benzos were actually really helpful for keeping myself together during that whole nightmare.
At that point I knew to do my own research, though. I knew how addictive they were, and took way less than I was prescribed, the absolute minimum I needed to deal with flashbacks and court appearances. That also meant I had a backlog in case the supply dried up at a critical time. Tapered myself off without even thinking about trying to get professional support.
I shudder to think what would've happened if I'd gone along with the antipsychotics. I really think I would've lost the kids, and then gotten more "treatment" for the resulting distress, until I ran out of money and got tossed out onto the street.
So, yeah, I'm pretty angry. And somehow I find I'm not super interested in what psychiatrists have to say about that anger.
You seem like a decent guy who is actually trying to improve the situation, so I don't want to come down too hard on you. But I do want to invite you to consider what's behind that reaction.
Do you really read this story and think that my anger, years later, is the problem? That the system would've fixed itself if I'd just asked a little more nicely for a little longer? If 10 years and a dozen different medical professionals isn't enough to justify giving up, what would be?
Remember, my story is nothing compared to what some people have been through.
Thank you for sharing your story. I’m terribly sorry that you went through all this, and I’m disappointed that you were let down so badly by the professionals, and that you were forced to figure things out on your own. Your anger is completely justified, as is the anger of so many others. I don’t see the anger as a problem and I don’t judge/blame anyone for being angry given what they’ve gone through. What I was commenting on was situations where such anger makes constructive online engagement with professionals impossible or very difficult while one is asking for the engagement of the professionals online. Of course, if the goal is simply to express one’s anger and for the anger to be registered, that’s a different story, and I don’t hold that against people. I appreciate that you took the time to engage with me despite your experiences with my colleagues.
This was an interesting interview. I'm glad you made the comments to this open, because there was a point raised that has been a recurring subject on the blog, without much reference to supporting evidence (and I don't have a "Substack Budget"*):
"And then of course, for the many people who really really really want to get off their drugs, they are forced to stay on them to avoid enduring a grueling withdrawal for which they are unable to rely on their prescriber to oversee. In part this is because their prescribers have zero training or education in how to safely taper patients. And in part, it’s because there’s a lack of rigorous research into the prevalence and severity of withdrawal symptoms, leading to a distinct possibility of having withdrawal symptoms improperly understood as a “relapse” of the original condition or the emergence of some new psychiatric malady."
What training do prescribers have in safely tapering drugs, and how strong is the evidence for various tapering schedules and iatrogenic harm? With how widely psychiatric drugs are used, a even the furthest nook of the bell-curve has a non-negligible number of patients, but Phelps's description seems equally consistent with the nocebo effect:
"But here’s the concern, Awais: there are many patients who, despite such measures, will have extreme symptoms every time they reduce the dose, even by small amounts. I had one PhD psychologist patient who took nearly a year to get from 20 mg of citalopram to 5 mg. At 3 mg using a liquid form, she said, “just put me in the hospital and stop it.” She knew she’d be having suicidal thoughts.
"And finally, the data that really drive my thinking are the accounts at SurvivingAntidepressants.org: thousands of what amount to case reports of profound withdrawal symptoms, so many as to overwhelm any skepticism about credibility. For example, some users describe counting the individual beads in venlafaxine capsules so as to reduce their dose by a few beads at a time. Based on such experiences, the site recommends tapering by 10% of one’s current dose each month. Do the math? This takes years."
And, whether it's a "nocebo-umbrella effect" or some other phenomenon, is it unreasonable to consider the possibility that the perceived need (even if biological/neurochemical) to "count the individual beads in venlafaxine capsules so as to reduce their dose by a few beads at a time," is itself a manifestation of the mental illness the venlafaxine was prescribed to treat?
Thank you! Out of curiosity, how do you conduct these interviews and how much time does it take, including finding/coordinating with interview subjects and editing the interviews for publication?
Unrelated, you referenced Affective Medicine's post "Serotonin Inhibits Emotions - And that's OK," in your post "How Antidepressants Work," so you and other readers may be interested in the followup post Affective Medicine published, a few days ago: https://affectivemedicine.substack.com/p/serotonin-revisited
*Other than for Astral Codex Ten, due to a combination of the circumstances of its creation (Scott needing to leave his group practice, due to the previous, free blog drawing too much negative attention and him using the Substack to subsidize his low-cost tele-psychiatry practice) and its 25% "students and poor people (honor system)" alternative price.
Training in safely tapering drugs: I personally think it's very inadequate. Things are beginning to change now, and there is talk of safe deprescribing in many training programs, but if you go back 5-10 years, this was not on the radar for most training programs. Most people were ignorant of the severity of withdrawal that some experience and of the need for gradual, hyperbolic tapering. Part of the challenge here is that we don't have good empirical data. There is no high quality RCT of tapering methods for antidepressants, so we are guided by clinical experience, patient experience, and speculative ideas about receptor occupancy curves. It'll be really interesting to see what results blinded tapering will produce in an RCT and how patients fare will these slow tapers when they don't know what dose they are getting.
Interviews are usually over email, once in a while they might be on zoom and then transcript edited. It takes considerable effort on my part. Preparation involves several hours of work (sometimes more, if it involves reading a book, for example) and I am careful in who I approach. The interview itself and the editing takes time too. If I had to guess, the range is probably like 5-10 hours for one interview.
I did see the new Affective Medicine post, thank you for sharing.
I completely understand you making an exception for Astral Codex Ten. That was the first substack I subscribed to as well, and for a while, it was the only one :)
I’m sorry for taking so long to respond – I disable cookies, so it’s easy to procrastinate logging back in to Substack.
In case it was unclear, I don’t doubt that tapering schedules are suboptimal and negatively affect a non-negligible minority of patients, but I think that the question of how to interpret the available evidence hasn’t been adequately addressed on the blog, after being raised in at least two interviews: My understanding is that “understudied, biologically plausible, and claimed to have occurred by patients” applies to practically every criticism of standard medical practice. What is the null hypothesis/What should our “priors” be? And, regarding the claim that psychiatrists aren’t trained to taper drugs correctly, how is the inherent uncertainty addressed in training?
As a non-paying subscriber, I doubly appreciate the time and effort put into the interviews! (You didn’t answer my question about the most remunerative type of book purchase, in the last open thread, so I chose in the most convenient way.) Can you elaborate on "I am careful in who I approach?"
Have you considered interviewing David Nutt about what, if anything, he thinks mainstream mental health clinicians/researchers, rather than governments/the general public, get wrong about addiction medicine and recreational drug use? None of the interviewees in the book were addiction specialists (though perhaps I’m forgetting an online-only interview), the connection between psychiatric and recreational drugs is under-discussed (the closest this comes to being discussed by any interviewee in the book is Paul Summergrad saying he was inspired by using LSD in college and Sandra Steingard using the "tortured distinction ... between so-called medical and recreational marijuana" to contrast a "disease-centered" and "drug-centered" approach), and Nutt is a generally interesting interviewee.
(His published work, so far I know, is too far removed from practical application to be meaningfully “critical,” but Karl Friston was kind enough to send me a polite and surprisingly prompt reply to an email - “...it’s interesting that you connect x and y, because there was a paper published on this, two days ago…” - so he may be worth approaching, in case he also has criticisms he'd like to share. If you DO interview Karl, please, PRETTY-PLEASE ask him the following tongue-in-cheek-but-also-completely-serious question:
“A staple of medical humor is portraying orthopedists as unsophisticated and myopically focused on bones, though these portrayals frequently tacitly imply that orthopedists value empiricism more than their jesting counterpart. (1, 2) A 2011 BMJ Christmas Edition study compared the intelligence of 36 orthopaedic surgeons and 40 anaesthetists and found “The mean intelligence test score of orthopaedic surgeons was also statistically significantly greater at 105.19 (10.85) compared with 98.38 (14.45) for anaesthetists.” (3) In the 2024 USA residency “Match,” psychiatry and neurology had a greater match rate than every surgical residency and lower step one 25th, 50th, and 75th percentile scores than every surgical specialty other than obstetrics and gynecology; psychiatry also had lower step two 25th, 50th, and 75th percentile scores than every specialty other than family medicine, while neurology scores were sixth lowest, between pediatrics and physical medicine and rehabilitation. (4)
“As a research psychiatrist who is at the forefront of theoretical neuroscience and frequently regarded as a scarcely-comprehensible genius by other psychiatrists and scientists (5), should we be worried about the possibility that neuroscience isn’t actually difficult, typical psychiatrists and neurologists just aren’t intelligent enough to practice psychiatry and neurology in a scientifically rigorous manner? If so, what is your pitch to highly intelligent prospective surgeons to instead become clinician-scientist psychiatrists and neurologists? If not, what convincing evidence – to the extent that a negative can be proven - is there that psychiatry wouldn’t be more scientifically rigorous and advanced, if spearheaded by clinician-scientists with the intellectual qualities of surgery's Bell family (6), rather than practitioners with the intellectual qualities of mental health’s Freud and Beck families?"
And, yes, I agree that collecting citations for a tongue-in-cheek question that you probably wouldn’t ask someone you probably won’t interview was a silly thing to do, but, like the authors of the best BMJ Christmas Edition papers, I think tongue-in-cheek approaches to serious questions are themselves worth taking seriously - who WOULDN'T want Karl's answer to that question??? I'd ask him myself, but I did not get a polite and surprisingly prompt reply to my follow-up email...)
Thank you, Mr. Davis, for your reply. I infer from it that while your website provides "access to mutual aid and community support groups," ICI does not provide access to community resources specifically staffed by medically trained, mental health professionals, such as psychiatrists or psychiatric nurse practitioners; nor does ICI make use of such medical resources or personnel in the event that former patients run into problems following the self-directed tapering procedures outlined on the ICI website.
This approach is quite puzzling, in my view, since the ICI website does indeed state:
"Any reductions to psychiatric drug dosages should involve careful preparation and are best made in collaboration with a prescriber who is well-informed about a wide range of risk-minimizing approaches to psychiatric drug tapering
In my professional opinion, such a well-informed "prescriber" is most likely a psychiatrist with a strong background in psychopharmacology. Indeed, that was the nature of my own consulting practice for over 25 years.
Davis: When I see people talking about “abolish psychiatry,” I assume they fail to realize that psychiatry, for all its faults, might actually be doing as good of a job as any other alternative traffic controller who might occupy this exceedingly ugly, unwieldy civilizational intersection."
Then you may be imposing a preconceived idea about what that means, what kind of society one could live in, value systems, etc.
When I say "abolish psychiatry" I don't mean just abolishing a single modern institution. I mean abolishing everything *like* society in terms of control systems upon peoples states of mind and being. That includes the official institution of psychiatry but it also includes what amounts to 'folk psychiatry' like one kid pushing another into the mud and saying 'stop being weird'. When people say "abolish capitalism" they are envisioning often a fundamental change in social and economic relations. The abolition of psychiatry should be viewed in a similar way, in fact it's arguably more profound. Though I want to abolish both as well as the state... and as a transhumanist even want to abolish the tyranny of the current human form. Which is all very... difficult but needs to be done because on every level and in every way the current order of things is such that someone who wants to die is not being irrational, they're jut recognizing the gap between the world as it is and a world that is compatible with any decent values system without the hope I have or try to have for changing that.
One of my greatest powers as a psychiatrist is to gradually remove medication from a regime and watch as the patient recognizes “I guess I didn’t need that” and feel more alive. If I do it very well they say goodbye to me and I consider that the greatest triumph.
People can be helped by use of medications, but frequently they think that continued stability is dependent on the pills. Sometimes it is, sometimes it isn’t. But when it becomes a part of their life that is now stable, they are afraid to remove the scaffolding.
what goes unspoken here, and in Laura Delano‘s book, is that a great deal of this is not just about access to ambiguous resources or support, but, candidly, about money. The kind of real work to come off of and live without psychiatric medications requires both money and the time that money buys. And it may require a family support structure that can provide caregiving assistance—which, again, is about money. it may also require sufficient physical health or, at least, the absence of some other comorbid condition that could be worsened by the neurological effects of withdrawal. Discussions about alternate modes of psychiatric and psychological support have limited relevance to large swaths of the population without acknowledgment of these things. this is to say nothing of the fact that some marginalized people are penalized more harshly for even trying. and personal accounts that don’t touch on these things seem limited, if not a little dishonest.
I agree that access to resources is probably the number one indicator for “success” in ANY treatment/healing/support paradigm (including mainstream psych).
But just to clarify, the frameworks I’m describing are explicitly and necessarily free to access, and like AA, derive their effectiveness in large part BECAUSE they equalize and are accessible w/o regard socio-economic strata
why can’t you just say “money”? you’re doing everything you can not to.
being sick from, and maybe unable to work while, going off of psychoactive medications with neurological and physical side effects requires time and money. you can go to five meetings a day, but if you can’t support yourself and be supported, you might not even get to the meetings in the first place.
What maybe doesn’t come through in the interview is that these mutual aid networks are meant to provide the support (including material support) that might be prerequisite for participation in those networks in the way you describe.
When I first started going to AA, I had no access to money, was physically and mentally incapacitated to the point of disability. The community there provided a great deal more than just meetings: transportation, housing assistance, etc. and AA is far less holistic in its mandate than the networks I’m describing.
It’s not just about meetings and supportive conversations, it’s about directing resources to where they are needed, especially in situations where individuals find themselves estranged from government or familial supports.
This exists already in many places, I’m advocating for its popularization and validity in the eyes of professionals in related fields and service sectors.
Both you and Jaqui make valid points about how difficult this type of work is. But you have to start somewhere. I hope you learn a lot from this venture you have created and change the way that the public view and use drugs to respond to various conditions. People need to feel less passive and more empowered about how to change what they are taking, and more informed and aware of what PROs and CONs are in play when they try a new medication, to prevent a culture of dependency. However, autonomy is a tricky area with severe mental health conditions.
but your wife did, if i recall the profile rachel aviv wrote correctly, and lots of people on this path do. if you want to talk about what is possible, again, money is part of it. a big part of it. WHOSE money, from WHERE, to WHOM, distributed HOW, under what CONDITIONS? all
of this matters.
also, in your example about your own experience, it DID take money, it was just other people’s. which is ok! which is mutual aid! but it wasn’t guaranteed and not every meeting has people with the financial resources who can and will help people.
Would love to read anything you’ve written on the subject or that demonstrates your preferred emphasis
I’m not here to define the parameters of this discourse, I’m just trying to promote the usefulness of this discourse itself to a wider audience.
i’m also interested in why you don’t refer to any of the support networks that do exist, e.g. wildflower alliance and hearing voices.
I was the administrator for HVN in my state for several years, and have a long relationship with many who’ve come through wildflower, and regularly recommend them to people looking for support.
I’m not leaving them out, I’m expressing endorsement for the underlying principles in a more generalized context.
ok. i think mentioning AA and your own organization in a context where you want to connect people who need help is a choice i wouldn’t make.
As a psychiatrist, I'm really happy to know about Inner Compass. I'll return to that shortly...
I agree completely that we are over-prescribing and that people spend years trying to find their way out of both mental health issues and dependence on meds that don't help. I was treated for depression with quite a few meds, and more were added when I had side effects (I'm off all but one, which I take for sleep.)
As a psychiatrist, I feel prescribing is so over-determined. As Ray Kloss notes, people are often reluctant to go off meds or depart from the idea that they can be helped by them. Here are some other thoughts:
1) We psychiatrists are now cast as "prescribers." I didn't train to be a prescriber, in fact I did a very psychoanalytic residency, but that's what people now call me. The demand is fueled by the media and public health misinformation campaign which offers treatment as the answer. (One college student told me that he knew "everyone should be in therapy.") It's important to realize that some of us have more flexibility about de-prescribing than others. If you work on an inpatient unit, you might be in trouble if you take someone off their Seroquel.
2) Medical training produces med students and then drs who feel they always need to have the answers, and need to fix things. We are never supposed to admit we don't know what to do, or don't have anything to offer (and if we do, that can be taken as a defeat by patients, who are used to us "knowing.") I have found that psychologists are generally less in "fix-it" mode. But society also doesn't provide a lot of other answers for people who are struggling, i.e, community support, good health benefits that cover alternative treatments, job re-entry programs.
3) Sometimes meds help, so we are never sure when to stop. I just saw a patient who is 82 and has been depressed most of her life. She's tried many meds, a lot of them with me, and we've also done therapy- she's been opposed to other meds. I'd given up and thought she had. On a lark, I suggested Abilify- I did not think she'd be willing, nor did I expect it to help. She called me a week later. "Dr Mahler, it's Happy Laura! You are not going to believe it, but..."
These successes draw us back in. There's always the hope that "this will be the one."
None of these is an excuse for harming patients- it's just the context.
My one issue with your wonderful interview is that I worry that a completely separate, lay industry will fail to draw in psychiatrists who are really sympathetic to this perspective. There are a lot of us, and there will be more if psychiatrists don't feel this industry is "the alternative," rather something with which they can engage, by which they can be educated, and which is their partner in helping people.
He specifically repudiated the term "alternative" and emphasized why he used the term "parallel" instead.
The AA analogy was interesting... I don't have a lot of time for AA myself, having read many critiques of them, but it is true that they have mainstream credibility as a patient led movement, and it makes sense that a patient led initiative could have similar credibility in the psych field.
I know as med students we were told to lie if patients asked us if we had lived experience (and the psychs were doing likewise) - just an example of the lack of authenticity that is the norm in psychiatry, and the one patient who did ask my registrar if she'd had lived experience was clearly desperate for an authentic connection.
I think the interlocutor seems to have a binary either/or attitude to drugs/psychiatry... As in drugs or working on the self, the idea that drugs might actually be a precondition for working on the self doesn't seem to have occurred to him... That they can turn your raving lunatic into a clear headed, thoughtful attender of long term therapy doesn't seem to be in his world view... I wonder what his familiarity is with severe manic psychosis... I'm sceptical that there is some naivety there in his worldview, antipsychiatry is far more effective with borderline than truly manic patients
I'd actually support a patient led initiative, in that in my experience in a psych placement in ED, there was very little genuine psychiatric illness that presented to the ED, most of what presented as mental health was "shitty life syndrome" aka life difficulties or the odd drug induced psychosis... And the life difficulties I don't think belong under the mental illness umbrella, even if the person is acutely suicidal at the moment, I would agree that it sends the wrong message to the "patient" that their difficulties need to be medicalised etc etc... though there may be other aspects to a patient led initiative that are valuable/critically important in addition to those highlighted here
I’m remembering standing before a skeptical doctor, having been dragged there by my mother and sister, and looking tongue tied and dozy before her. I could feel her exasperation and impatience as she scanned me and spoke to me as you would to a complete attention seeking timewaster who was getting in the way of her real patients. I was prescribed an antipsychotic and sent on my way after my relatives doing all the talking for me. I’ve never been so infantilised as an adult. The truth was that the contents of my thoughts and feelings were indescribably distorted, disturbing and horrific, and I was dumb with terror, trying to receive screaming voices and hallucinations and listen to normal life around me at the same time. I just don’t know how you could possibly tell whether someone is a “genuine” psychiatric case considering the current assessment methods available to doctors. It’s not possible to come to such a conclusion just by looking and listening to someone. It misses so much.
This is a fascinating interview and I really appreciate Cooper’s willingness to share his views in longform like this.
I’m a psychiatrist in long-term recovery from addiction, and I’ve written about the intellectual and cultural history of addiction, recovery, and mutual help organizations. I wanted to comment on the mutual aid angle specifically, without getting too deep into the many other important issues raised. To clarify some of my own priors: I’m very concerned about overmedicalization, essentialism, reductionism, and related currents in mental health and addiction treatment. I share @Susan Mahler’s concern about overprescribing as well as inadequate support for people tapering off medications.
That said, I think there's some conceptual vagueness in the repeated references to mutual aid here, and one fundamental issue is the term “mutual aid” is a bit slippery. The term has been used across disciplines—sociology, political theory, public health, and various corners of the addiction/SUD world—with different meanings. It can mean everything from anarchist organizing to a sort of reactive assumption that 12-step groups are the ideal. So it may be worth clarifying what it means to apply the “principles of mutual aid”. ICI seems to be drawing on some but not all principles of 12-step groups—Cooper’s main reference point in this interview. But which ones, how, and why? Again, not that AA is necessarily the correct or ideal model, but there are some comparisons worth considering,
To be clear, I’m not speaking for, against, or on behalf of any recovery tradition or organization; I just mean to make some observations based on what I’ve studied and observed, more on the sociological and organizational level.
One important distinction between ICI and 12-step groups seems to be that 12-step groups have a clearer purpose. AA’s mission is simple and behavioral: to help alcoholics who want to stop drinking, using a “program” and a set of suggested steps—framed in terms of spiritual growth and character development—for how to pursue recovery and flourishing. In contrast, much of ICI’s content seems focused more narrowly on getting off medications and managing withdrawal. I appreciate that Cooper says that they are not just anti-med, but the clear focus of the mission and vision on their webpage is in clearly opposition to what they call the “psychiatric paradigm”, ICI is said to be grounded in the experiences of people who have “depsychiatrized” themselves and “leave behind psychiatric diagnoses and drugs”.
Analogously, there have been a lot of organizations that critique AA, the "disease model," the notion of alcoholism or addiction as an organizing explanation for substance problems, and offer alternative (or “parallel,” if you prefer) paths to recovery. The ones that have more staying power and cohesion tend to be the ones that offer a positive vision that goes beyond opposition to existing models. For example, SMART recovery, a more psychology-focused and secular organization, helps people set “toward’ goals and build happiness and resilience, not just critiques of AA.
I read the ICI principles Cooper linked to, but I didn’t see much clarity about how the mutual aid part of ICI actually works aside from being “the voluntary exchange of support and resources.” I understand there’s the "Exchange" and presumably there are some ground rules but I am talking more about the core principles of how it’s meant to work. Cooper says “You need to have an ideological backbone” but I don’t really see a clear articulation of the core problem of suffering, or the solution, from ICI’s perspective. Their “guiding principles” strike me (and I mean this respectfully) as somewhat anodyne: vague, broadly agreeable, and hard to dispute in the abstract. But that rhetorical softness is at odds with the organization’s deeper orientation, which obviously emphasizes getting off psychiatric meds. It feels a bit conceptually muddled. I wonder—though I’m not sure—is ICI assuming that rejecting psychiatric frameworks or interventions is itself a path to flourishing? This may be true for some—particularly those who were harmed or over-medicated by the system—but it is not a universally sufficient or reliable framework for healing or growth.
12-step groups hold to several organizational traditions, including a tradition to take no opinion on “outside issues”, namely controversial issues such as alcohol reform or religion. That neutrality has helped AA maintain cohesion and focus on its primary purpose. It has also helped protect against internal fragmentation. ICI has more opinions about broader sociological currents.
AA also draws a clear separation between mutual aid and medicine. In official communications, AA recognizes that medicine occupies a distinct and legitimate role in society. AA guidance explicitly caution against unlicensed laypeople “playing doctor,” stating that “all medical advice and treatment should come from a qualified physician: https://www.aa.org/sites/default/files/literature/p-11_0324.pdf This boundary reflects a broader sociological understanding of medicine as a legitimate professional domain, even if flawed. Note that this is a complex relationship—in my writing, I’ve described the “treatment industrial complex”, the multi-billion-dollar industry that has often provided a one-size-fits-all treatment model and in which "true" recovery or sobriety has often been equated with the traditional 12-step model. That system has rightly been criticized. But AA as a fellowship has consistently resisted professionalization, framing itself as a peer-based spiritual process, not a form of medical or clinical care.
With those points in mind, I’m not sure that “parallel” is the right word for ICI. If mutual help and psychiatry are truly parallel, then mutual help groups like ICI wouldn’t need to define themselves in opposition to psychiatry.
It strikes me that some other principles and traditions that are very important to 12-step groups are not present in ICI, and might be hard to institute in ICI. E.g., rotating leadership, group autonomy, and the idea that leaders are trusted servants, not governing. That is just one set of principles on mutual aid, in part inspired by the perspective that when a group develops rigid curricula, charismatic leaders, and the like, it loses something important. Of course, 12-step groups don’t need to be the only model here, as Cooper acknowledges, but at the same time AA is the one mutual aid tradition that he referenced, I have to wonder, which are the principles of mutual aid that are being “leveraged” here, and which ones are discarded, and why?
All that said, I appreciate the motivation behind ICI—to reduce suffering and address very real harms within the mental health treatment system. It's clear that all their hard work comes from painful, personal experiences. I’m grateful to Cooper for sharing his story so openly, and I want to acknowledge the depth of what he’s been through and the immense effort they've put into building something that tries to give people some hope and practical guidance for relieving their suffering.
Thank you, Dr. Fisher, for your thoughtful perspective on the substantial differences between AA and ICI. As you note,
"... much of ICI’s content seems focused more narrowly on getting off medications and managing withdrawal. I appreciate that Cooper says that they are not just anti-med, but the clear focus of the mission and vision on their webpage is in clearly opposition to what they call the “psychiatric paradigm”, ICI is said to be grounded in the experiences of people who have “depsychiatrized” themselves and “leave behind psychiatric diagnoses and drugs...[ICI's] deeper orientation obviously emphasizes getting off psychiatric meds."
In contrast, "...AA guidance explicitly caution[s] against unlicensed laypeople “playing doctor,” stating that “all medical advice and treatment should come from a qualified physician...If mutual help and psychiatry are truly parallel, then mutual help groups like ICI wouldn’t need to define themselves in opposition to psychiatry."
And yet, it seems clear that ICI does indeed define itself in opposition to psychiatry, notwithstanding protestations to the contrary; e.g., Mr. Davis's comment to Dr. Aftab that "We [ICI] are not “anti-psychiatry,” “anti-drug,” or “anti-diagnosis.” With all due respect to Mr. Davis, this seems disingenuous to me, and to others who have read the ICI material.
That said, our profession must accept some responsibility for organizations like ICI and its program. As a psychopharmacology consultant and academic psychiatrist, I acknowledge that ICI arose partly in response to less than adequate training of psychiatrists in recognizing and managing withdrawal syndromes (though I think the risk of severe withdrawal from SSRIs has been overstated; see, e.g., Henssler J, Schmidt Y, Schmidt U, et al. Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry. 2024;11(7):526-535. ]
Indeed, historically, many psychiatrists, in my experience, have not been using long enough tapering periods, and this is a point I have made in my own published writing [see, e.g., Pies RW. Antidepressant Discontinuation: A Tale of Two Narratives. J Clin Psychopharmacol. 2019 May/Jun;39(3):185-188. PMID: 30921098.] (Of course, the vast majority of antidepressant prescriptions are not written by psychiatrists, but by primary care physicians).
But none of our professional inadequacies justify the very clear marginalization of psychiatry that appears to be the aim of ICI, despite claims to the contrary. ICI would do itself and those who consult it a great service by involving and making use of psychiatric expertise, per my previous comments, if ICI is to avoid overstepping appropriate boundaries (what some might call "playing doctor").
Nevertheless, I agree with you that ICI's motivation is to be respected; i.e., "to reduce suffering and address very real harms within the mental health treatment system." We can honor that motivation while still insisting that the goal must be achieved by respecting the central role of medical expertise.
Regards,
Ron
Ronald W. Pies MD
Thanks for the comment and the link to your paper! I look forward to checking it out
Thank you, Carl--much appreciated!
Best regards,
Ron
I am troubled by the Inner Compass Initiative. It seems to me that what they do comes perilously close to practicing medicine without a license. According to the New York Times, both Ms Delano and Mr Davis charge about $600 a month for their counseling services. Of course peer support is invaluable, but “lived experience” is no substitute for medical training. I have attended many DBSA meetings as a family member of someone with SMI. In my experience, it’s a true support group, without an ideological agenda. I also have my own lived experience as patient—one which points me in the opposite direction to that espoused by Inner Compass: I wish SSRI medication had been available when I was an undergraduate at Harvard/Radcliffe back in the 1960’s. I managed to make it through, but was severely handicapped by my mood disorder. Later on in life, psychotherapy helped, but only so much. It wasn’t until I overcame my fear of trying an SSRI in 1991 that I made lasting progress. And as a counter-example to bad experiences discontinuing meds—after a terrifying stage 4 lung cancer diagnosis in 2001, I took a clonazepam pill daily for ten years—until it became clear to me the cancer did not seem to be progressing and probably I could do without it. I succeeded in tapering off it with only a few rocky days.
I also believe that the Inner Compass approach doesn’t sufficiently reckon with the problem of anosognosia, which is sadly so common in psychotic disorders. I am a firm believer in the work of the Treatment Advocacy Center, founded by E Fuller Torrey, which works to remove obstacles to treatment for those with SMI, who otherwise too often end up on the streets or in jail. Yes, people should get help coming off medications, and some are misdiagnosed or end up on unneeded drugs. But it seems to me the problem lies not with the medications per se, nor with the doctors, nor even with the DSM, imperfect though it is—but with the whole system for providing psychiatric care. There aren’t enough doctors/mental health providers. The answer is not to de-professionalize
Finally, I am especially concerned about the platforming of what is —when all is said and done—essentially anti-psychiatry position in this era of RFK, Jr. as health secretary, who has already announced his skepticism about psychiatric medications. I understand that copies of Ms Delano’s book have been delivered to members of Congress.
Excellent points, Ms. Wilbur--and thank you for sharing your experience with successful psychiatric medication treatment! By the way, in a recent article, I, too, shared my concern regarding RFK's benighted claims about SSRIs.
https://www.psychiatrictimes.com/view/the-ongoing-movement-against-psychiatric-medications
Best wishes,
Ronald W. Pies, MD
Excellent interview! Thank you, Cooper, for your comprehensive explanation of how mental health treatment might be aided by patient involvement and input. I could give a whole long presentation in my comments here about my personal story, but honestly, every pushback that rose in me while reading this, you addressed in the next answer to Awais, and so I'm impressed. I did have one concern to share. I'm a person who tends to be in the background, desiring to or not, who in a sense gets forgotten, steamrolled by those with loud voices that carry or who somehow build amazingly large online followings. Someone like me might get lost in alternatives that depend on having one's input heard. For instance, I got lots of attention from the "anti-psych" crowd when I was sick and angry and denigrating psychiatry constantly. But now that I don't do that, it's hard to find footing beyond a small group, fine for me as I do get quality interaction. But within a larger group, I'm overlooked. On to one more thing, a hospital I go to, the only one where I want to be inpatient psych, is incorporating more choices that give agency to patients and provide a kinder setting. This is funded by outside sources, then adopted by this hospital which is part of a large healthcare corporation. I've expanded on this in a blog post, if you're interested. The link is: https://rwillowfish.blogspot.com/2025/01/when-crisis-intake-undergoes-beneficial.html - I believe that progressive hospital administration, willing to, can be part of a bridge to better for us all. And again, thanks so much Cooper, and I'm also reading Laura's book now, which is an immeasurably vital read for me, and I don't know about others' feelings, but I'm identifying heavily.
*Also, I was in AA for 20 years, and while it helped, and I did form friendships, again I felt drowned out and so I left after trying and trying to assert myself, my authentic self. Also felt I had to say I was an alcoholic when really it's cannabis addiction, and that's the sort of thing I don't want forced on me or others, meaning this need to conform when that's not fully what you want to conform with, in any kind of help scenario.
As a now retired psychiatrist who specialized in the nature and treatment of mood disorders, I found this interview of great interest. I had the opportunity of reviewing the online material posted on the Inner Compass Initiative website [https://www.theinnercompass.org/about] and would appreciate some clarification from Mr. Davis.
I understand that the ICI model is grounded in "the crowdsourced, layperson wisdom of the thousands of people around the world who, like us, have “depsychiatrized” themselves–in other words, people who’ve decided to leave behind psychiatric diagnoses and drugs, are at various stages of doing so, and are supporting one another free from profit motive."
At the same time, I note that ICI has a disclaimer that states, "The process of reducing or tapering off psychiatric medication is inherently risky and can be especially dangerous and potentially life-threatening if done faster than one’s body can handle..."
Let's stipulate for now that this is an accurate statement, at least with respect to some psychiatric medications under some circumstances. I am wondering if ICI makes use of experts in psychopharmacology as consultants, in the event that a person using ICI 's "step-by-step, self-directed guide for tapering off" medication runs into serious problems while attempting self-tapering of a medication; and then informs ICI of this problem, requesting advice.
For example, a former patient--now fully "depsychiatrized"--reports that "I tried the tapering method on your website but I'm really having serious physical problems with the tapering recommendation. I feel really sick!" Is it ICI's usual practice to consult with an expert in psychopharmacology at that point, or to refer the person to a health care professional with medical training? If so, does ICI have a roster of potential consultants with medical training? If not, what is the rationale for ICI's decision not to make use of this option? (I do understand, per your disclaimer, that the information ICI provides "...does not constitute Inner Compass Initiative’s advice, encouragement, or recommendation that any individual reduce or taper off of his or her intake of psychiatric medication.")
Thank you, Mr. Davis, for clarifying these important issues. Just as you say on your website, "The significance and scale of the issues we’ve touched on here cannot be overstated—they are issues that affect millions of people directly and many millions more indirectly." On that point, we are in total agreement!
Sincerely,
Ronald W. Pies, MD
Professor Emeritus of Psychiatry
Editor-in-Chief Emeritus, Psychiatric Times
Great question, Ron. I’ve alerted Cooper to it as well.
Thank you, Awais. I'll hope for a response from Cooper soon.
Regards,
Ron
Hello Dr. Pies,
To clarify: ICI does not prescribe or treat, nor does ICI claim to provide medical advice. We provide general information, along with access to mutual aid and community support groups.
ICI does not provide any services, and does not provide treatment recommendations.
We are certainly not opposed to clinical guidance and support. In fact, our resources explicitly state that it is optimal to have a collaborative prescriber relationship during the taper process.
Thank you for your interest!
Cooper Davis
Executive Director
Inner Compass Initiative
One thing that I'd add to the question of anger in ex patient communities, is that you're seeing the end of a very long process. A lot of us spent years, or even decades, trying to engage with medical and psychiatric professionals about our concerns in a respectful manner.
I first got put on SSRI's after breaking down crying in my doctor's office. I was pregnant with my 3rd child and said that I felt like my husband wanted me dead.
Husband later admitted that he was unhappy about having another (planned) kid, and had in fact been fantasizing about me dying during the birth. He did not actually try to kill me, thankfully, but that suppressed hostility had been coming out in various ways.
The situation escalated over the following years. One of the things he would do is hide the pills to slam me with withdrawal effects whenever I started getting too independent.
I tried to get off the antidepressants a few times. I was not able to identify that my relationship was abusive at that point, but I did say that I was struggling to take the medications regularly and felt like they were doing more harm than good.
Instead I was told that I "shouldn't risk it" because I "seemed to be under a lot of stress." Instead they suggested I get checked for ADHD.
That diagnosis came along with stimulants, which destabilized my mental state further, especially given that I was unable to take them regularly.
Any doctor I tried to talk to about this would swap the prescription out for a different dose or a new medication that I "might like better." And of course scold me for not complying with the treatment plan.
Seems like a funny expectation to have, if they really thought I had a neurological disorder that made concentrating and remembering things abnormally difficult.
Later, during the divorce, I went to a psychiatrist and told her I really needed to get off at least the antidepressants, because my abusive husband was using my "mental health issues" to try to take custody of the kids.
I started crying during this conversation. In response, she told me I not only needed to stay on the antidepressants, but tried to put me on "mood stabilizers," i.e. antipsychotics, as well.
Because of the crying.
Again.
By this time I was already on benzos for my anxiety disorder, of course.
Needless to say, I do not (and did not) have any symptoms of psychosis. I've never had it suggested as a possibility by any other provider.
That was around when the Adderall shortage hit. Amazingly, going off mood altering meds suddenly didn't require any planning or medical support at all.
I ended up going off the antidepressants on my own. Dealing with the withdrawal symptoms, without support, while going through a protracted messy divorce, was super fun. Thankfully they weren't nearly as bad as some people experience.
Credit where it's due, the benzos were actually really helpful for keeping myself together during that whole nightmare.
At that point I knew to do my own research, though. I knew how addictive they were, and took way less than I was prescribed, the absolute minimum I needed to deal with flashbacks and court appearances. That also meant I had a backlog in case the supply dried up at a critical time. Tapered myself off without even thinking about trying to get professional support.
I shudder to think what would've happened if I'd gone along with the antipsychotics. I really think I would've lost the kids, and then gotten more "treatment" for the resulting distress, until I ran out of money and got tossed out onto the street.
So, yeah, I'm pretty angry. And somehow I find I'm not super interested in what psychiatrists have to say about that anger.
You seem like a decent guy who is actually trying to improve the situation, so I don't want to come down too hard on you. But I do want to invite you to consider what's behind that reaction.
Do you really read this story and think that my anger, years later, is the problem? That the system would've fixed itself if I'd just asked a little more nicely for a little longer? If 10 years and a dozen different medical professionals isn't enough to justify giving up, what would be?
Remember, my story is nothing compared to what some people have been through.
Thank you for sharing your story. I’m terribly sorry that you went through all this, and I’m disappointed that you were let down so badly by the professionals, and that you were forced to figure things out on your own. Your anger is completely justified, as is the anger of so many others. I don’t see the anger as a problem and I don’t judge/blame anyone for being angry given what they’ve gone through. What I was commenting on was situations where such anger makes constructive online engagement with professionals impossible or very difficult while one is asking for the engagement of the professionals online. Of course, if the goal is simply to express one’s anger and for the anger to be registered, that’s a different story, and I don’t hold that against people. I appreciate that you took the time to engage with me despite your experiences with my colleagues.
This was an interesting interview. I'm glad you made the comments to this open, because there was a point raised that has been a recurring subject on the blog, without much reference to supporting evidence (and I don't have a "Substack Budget"*):
"And then of course, for the many people who really really really want to get off their drugs, they are forced to stay on them to avoid enduring a grueling withdrawal for which they are unable to rely on their prescriber to oversee. In part this is because their prescribers have zero training or education in how to safely taper patients. And in part, it’s because there’s a lack of rigorous research into the prevalence and severity of withdrawal symptoms, leading to a distinct possibility of having withdrawal symptoms improperly understood as a “relapse” of the original condition or the emergence of some new psychiatric malady."
Tapering protocols were also part of your February discussion with Jim Phelps: https://www.psychiatrymargins.com/p/medication-treatment-challenges-in
What training do prescribers have in safely tapering drugs, and how strong is the evidence for various tapering schedules and iatrogenic harm? With how widely psychiatric drugs are used, a even the furthest nook of the bell-curve has a non-negligible number of patients, but Phelps's description seems equally consistent with the nocebo effect:
"But here’s the concern, Awais: there are many patients who, despite such measures, will have extreme symptoms every time they reduce the dose, even by small amounts. I had one PhD psychologist patient who took nearly a year to get from 20 mg of citalopram to 5 mg. At 3 mg using a liquid form, she said, “just put me in the hospital and stop it.” She knew she’d be having suicidal thoughts.
"And finally, the data that really drive my thinking are the accounts at SurvivingAntidepressants.org: thousands of what amount to case reports of profound withdrawal symptoms, so many as to overwhelm any skepticism about credibility. For example, some users describe counting the individual beads in venlafaxine capsules so as to reduce their dose by a few beads at a time. Based on such experiences, the site recommends tapering by 10% of one’s current dose each month. Do the math? This takes years."
And, whether it's a "nocebo-umbrella effect" or some other phenomenon, is it unreasonable to consider the possibility that the perceived need (even if biological/neurochemical) to "count the individual beads in venlafaxine capsules so as to reduce their dose by a few beads at a time," is itself a manifestation of the mental illness the venlafaxine was prescribed to treat?
Thank you! Out of curiosity, how do you conduct these interviews and how much time does it take, including finding/coordinating with interview subjects and editing the interviews for publication?
Unrelated, you referenced Affective Medicine's post "Serotonin Inhibits Emotions - And that's OK," in your post "How Antidepressants Work," so you and other readers may be interested in the followup post Affective Medicine published, a few days ago: https://affectivemedicine.substack.com/p/serotonin-revisited
*Other than for Astral Codex Ten, due to a combination of the circumstances of its creation (Scott needing to leave his group practice, due to the previous, free blog drawing too much negative attention and him using the Substack to subsidize his low-cost tele-psychiatry practice) and its 25% "students and poor people (honor system)" alternative price.
Training in safely tapering drugs: I personally think it's very inadequate. Things are beginning to change now, and there is talk of safe deprescribing in many training programs, but if you go back 5-10 years, this was not on the radar for most training programs. Most people were ignorant of the severity of withdrawal that some experience and of the need for gradual, hyperbolic tapering. Part of the challenge here is that we don't have good empirical data. There is no high quality RCT of tapering methods for antidepressants, so we are guided by clinical experience, patient experience, and speculative ideas about receptor occupancy curves. It'll be really interesting to see what results blinded tapering will produce in an RCT and how patients fare will these slow tapers when they don't know what dose they are getting.
Interviews are usually over email, once in a while they might be on zoom and then transcript edited. It takes considerable effort on my part. Preparation involves several hours of work (sometimes more, if it involves reading a book, for example) and I am careful in who I approach. The interview itself and the editing takes time too. If I had to guess, the range is probably like 5-10 hours for one interview.
I did see the new Affective Medicine post, thank you for sharing.
I completely understand you making an exception for Astral Codex Ten. That was the first substack I subscribed to as well, and for a while, it was the only one :)
I’m sorry for taking so long to respond – I disable cookies, so it’s easy to procrastinate logging back in to Substack.
In case it was unclear, I don’t doubt that tapering schedules are suboptimal and negatively affect a non-negligible minority of patients, but I think that the question of how to interpret the available evidence hasn’t been adequately addressed on the blog, after being raised in at least two interviews: My understanding is that “understudied, biologically plausible, and claimed to have occurred by patients” applies to practically every criticism of standard medical practice. What is the null hypothesis/What should our “priors” be? And, regarding the claim that psychiatrists aren’t trained to taper drugs correctly, how is the inherent uncertainty addressed in training?
As a non-paying subscriber, I doubly appreciate the time and effort put into the interviews! (You didn’t answer my question about the most remunerative type of book purchase, in the last open thread, so I chose in the most convenient way.) Can you elaborate on "I am careful in who I approach?"
Have you considered interviewing David Nutt about what, if anything, he thinks mainstream mental health clinicians/researchers, rather than governments/the general public, get wrong about addiction medicine and recreational drug use? None of the interviewees in the book were addiction specialists (though perhaps I’m forgetting an online-only interview), the connection between psychiatric and recreational drugs is under-discussed (the closest this comes to being discussed by any interviewee in the book is Paul Summergrad saying he was inspired by using LSD in college and Sandra Steingard using the "tortured distinction ... between so-called medical and recreational marijuana" to contrast a "disease-centered" and "drug-centered" approach), and Nutt is a generally interesting interviewee.
(His published work, so far I know, is too far removed from practical application to be meaningfully “critical,” but Karl Friston was kind enough to send me a polite and surprisingly prompt reply to an email - “...it’s interesting that you connect x and y, because there was a paper published on this, two days ago…” - so he may be worth approaching, in case he also has criticisms he'd like to share. If you DO interview Karl, please, PRETTY-PLEASE ask him the following tongue-in-cheek-but-also-completely-serious question:
“A staple of medical humor is portraying orthopedists as unsophisticated and myopically focused on bones, though these portrayals frequently tacitly imply that orthopedists value empiricism more than their jesting counterpart. (1, 2) A 2011 BMJ Christmas Edition study compared the intelligence of 36 orthopaedic surgeons and 40 anaesthetists and found “The mean intelligence test score of orthopaedic surgeons was also statistically significantly greater at 105.19 (10.85) compared with 98.38 (14.45) for anaesthetists.” (3) In the 2024 USA residency “Match,” psychiatry and neurology had a greater match rate than every surgical residency and lower step one 25th, 50th, and 75th percentile scores than every surgical specialty other than obstetrics and gynecology; psychiatry also had lower step two 25th, 50th, and 75th percentile scores than every specialty other than family medicine, while neurology scores were sixth lowest, between pediatrics and physical medicine and rehabilitation. (4)
“As a research psychiatrist who is at the forefront of theoretical neuroscience and frequently regarded as a scarcely-comprehensible genius by other psychiatrists and scientists (5), should we be worried about the possibility that neuroscience isn’t actually difficult, typical psychiatrists and neurologists just aren’t intelligent enough to practice psychiatry and neurology in a scientifically rigorous manner? If so, what is your pitch to highly intelligent prospective surgeons to instead become clinician-scientist psychiatrists and neurologists? If not, what convincing evidence – to the extent that a negative can be proven - is there that psychiatry wouldn’t be more scientifically rigorous and advanced, if spearheaded by clinician-scientists with the intellectual qualities of surgery's Bell family (6), rather than practitioners with the intellectual qualities of mental health’s Freud and Beck families?"
“1. Bones: An Orthopedic Surgeon’s Perspective https://gomerblog.com/2014/09/bones/
“2. Orthopedics vs Anesthesia https://www.youtube.com/watch?v=q0S5EN7-RtI
“3. Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study https://www.bmj.com/content/343/bmj.d7506
“4. https://www.yousmle.com/most-competitive-nrmp-residencies/
“5. God Help Us, Let’s Try To Understand Friston On Free Energy https://slatestarcodex.com/2018/03/04/god-help-us-lets-try-to-understand-friston-on-free-energy/
“6. https://en.wikipedia.org/wiki/Benjamin_Bell#Bell's_contributions_to_surgery”
And, yes, I agree that collecting citations for a tongue-in-cheek question that you probably wouldn’t ask someone you probably won’t interview was a silly thing to do, but, like the authors of the best BMJ Christmas Edition papers, I think tongue-in-cheek approaches to serious questions are themselves worth taking seriously - who WOULDN'T want Karl's answer to that question??? I'd ask him myself, but I did not get a polite and surprisingly prompt reply to my follow-up email...)
Wow this is a really inspiring and awesome interview. Weve been talking about developing mutual aid networks for yeas and it looks like Inner Compass has some resources to make it happen. https://icarusprojectarchive.substack.com/p/lessons-from-aa-for-peer-support?utm_source=publication-search
Thank you, Mr. Davis, for your reply. I infer from it that while your website provides "access to mutual aid and community support groups," ICI does not provide access to community resources specifically staffed by medically trained, mental health professionals, such as psychiatrists or psychiatric nurse practitioners; nor does ICI make use of such medical resources or personnel in the event that former patients run into problems following the self-directed tapering procedures outlined on the ICI website.
[https://www.theinnercompass.org/taper]
This approach is quite puzzling, in my view, since the ICI website does indeed state:
"Any reductions to psychiatric drug dosages should involve careful preparation and are best made in collaboration with a prescriber who is well-informed about a wide range of risk-minimizing approaches to psychiatric drug tapering
[https://www.theinnercompass.org/taper]
In my professional opinion, such a well-informed "prescriber" is most likely a psychiatrist with a strong background in psychopharmacology. Indeed, that was the nature of my own consulting practice for over 25 years.
Respectfully,
Ronald W. Pies, MD
Material reviewed:
https://www.theinnercompass.org/about
https://www.theinnercompass.org/taper
https://www.theinnercompass.org/taper/sample-implementation-making-and-cutting-liquid-mixture
Davis: When I see people talking about “abolish psychiatry,” I assume they fail to realize that psychiatry, for all its faults, might actually be doing as good of a job as any other alternative traffic controller who might occupy this exceedingly ugly, unwieldy civilizational intersection."
Then you may be imposing a preconceived idea about what that means, what kind of society one could live in, value systems, etc.
When I say "abolish psychiatry" I don't mean just abolishing a single modern institution. I mean abolishing everything *like* society in terms of control systems upon peoples states of mind and being. That includes the official institution of psychiatry but it also includes what amounts to 'folk psychiatry' like one kid pushing another into the mud and saying 'stop being weird'. When people say "abolish capitalism" they are envisioning often a fundamental change in social and economic relations. The abolition of psychiatry should be viewed in a similar way, in fact it's arguably more profound. Though I want to abolish both as well as the state... and as a transhumanist even want to abolish the tyranny of the current human form. Which is all very... difficult but needs to be done because on every level and in every way the current order of things is such that someone who wants to die is not being irrational, they're jut recognizing the gap between the world as it is and a world that is compatible with any decent values system without the hope I have or try to have for changing that.