Earlier in January, two months after the launch of this newsletter, Psychiatry at the Margins crossed a thousand total subscriptions, and the number has continued to steadily grow!
As a psychiatrist who is passionate about my profession, I find it really disheartening that so many people on Twitter demonise psychiatry and blame psychiatrists for everything that is wrong with mental health care. The same people valorize psychotherapy without any recognition of its limited effectiveness or adverse effects. How do you deal with all the hate and also the negation of your knowledge (i.e., we are fake doctors who give fake drugs and are brainwashed by Pharma)?
It can indeed be really disheartening. Here’s the approach that I have found somewhat helpful: a) I try to understand where the demonization and blame is coming from. A lot of it comes from really terrible and traumatic experiences people have had in mental health systems, and this anger gets expressed in a lot of different ways. In such cases I listen and try to see how we as a profession can do better, even though productive engagement is not always possible. In other cases, it is ideological or motivated for a guild war mindset. In those cases I politely and firmly push back. A big challenge on social media is figuring out what it is meaningful to engage with someone & when it is meaningful to ignore. Some polarizing folks on twitter deliberately post inflammatory content cause that’s the only way they get any attention. In those cases depriving them of our attention and engagement may be the best strategy.
I think it's generally great, there is amazing scientific work being done, and its informing our understanding of the brain and mind in fascinating ways. Things like "REBUS and the Anarchic Brain" (https://pharmrev.aspetjournals.org/content/71/3/316 ), for example. It's unfortunate that this line of research was almost completely shut down by the governments in 80s and 90s. In many ways we are just finding our way back and resuming this. An important consequence of this has been that psychoactive experiences, spiritual and mystical experiences, and Indigenous practices have experienced a revival of academic and scholarly interest as well. Phoebe Friesen recently had a wonderful paper on the historical entanglements of psychosis research and psychedelics research (https://pubmed.ncbi.nlm.nih.gov/36300247/ ).
I'm cautiously optimistic about the therapeutic use of psychedelics in psychiatry. I think there is a lot of potential there, but I am also quite wary of the hype around them and the general underestimation of safety considerations and adverse effects. (Some students working with me recently wrote a general review on safety considerations for Current Psychiatry: https://www.mdedge.com/psychiatry/article/259826/depression/psychedelics-treating-psychiatric-disorders-are-they-safe )
Hello, Awais! Thank you for the work that you do. I never knew about the anti-psychiatry movement until I saw your posts on Twitter. I am a grad student and I perform behavioral experiments in rats. I had an existential crisis when I learned about the reductionist and behaviorist approach that neuroscientists employ in their research. Do you think it is still worth our time and resources to use animals (rodents, non-human primates) to study human psychiatric disorders? Can we really translate the findings of animal behavioral tests such as elevated plus maze or sucrose preference test to mental illnesses such as anxiety or depression?
Thanks JL! A very important question, probably deserves detailed discussion in a post. My sense is that animal models of mental disorders have severe limitations and extrapolating from them is quite problematic. Psychiatric disorders are quite complex and have this distinctive experiential dimension. We can create animal models that mimic that certain aspects of the psychiatric disorders -- a certain behavioral phenotype, or a certain sort of process such as chronic stress or social defeat -- but it's difficult to jump from that to the pathophysiology or treatment of the disorder in humans. Nonetheless, there are some other ways in which animal models could be helpful. A rodent's preference for being in open arms over closed arms in elevated plus maze and how this preference is modified by a pharmaceutical tells us *something* about exploratory behavior, it's neural associations, and the behavioral effects of a pharmaceutical, and we can begin to ask questions like what corresponding behaviors and behavioral effects might look like in humans, and what their therapeutic value might be, but we should resist the urge to assume that this is telling us anything meaningful about anxiety disorders per se.
Thanks, Awais! I agree with you. I look forward to your future post on this topic. Hope you also discuss more valid research methods/models that neuroscientists can consider when studying the biology of psychiatric disorders. More power!
Hi Awais, I'm a soon-to-be psychiatry resident - do you have any must-read books in the next few months before intern year starts? Or will this substack suffice :)?
Hi Kai! Congrats on your residency. From a more practical standpoint, familiarizing yourself with symptoms for some of the common disorders and treatment guidelines (eg from UpToDate) is probably the most useful. The months before intern year are a good time to read up on some of the popular book about psychiatry. That will give you a sense of the broader social, critical, and historical context in which we are operating. Gary Greenberg's The Book of Woe, Allen Frances's Saving Normal, and Anne Harrington's Mind Fixers are good options. I'd also recommend The Examined Life by Stephen Grosz and Strangers to Ourselves by Rachel Aviv. (I am forever grateful that I read Derek Bolton's What is Mental Disorder? before I started my psychiatric training. Bolton's book changed the way I think about mental illness. It's a philosophical work, however, and trainees don't always find it easy to read.)
Hi Awais, i am a reader from North Macedonia so i would rather ask a different question. As a first year psychiatry resident myself, what is the only advice you would have given to every psychiatry resident on their first day of residency?
Welcome! My advice would be something along the lines of: psychiatry is a disciplines that exists at the intersection of the medical and social sciences. To be a good psychiatrist, to have an expert grasp on the nuances of our field, we have to read critically and widely, and engage in a dialogue with multiple disciplines, including history, psychology, philosophy, neuroscience, and mad studies. This requires curiosity and humility. It is not enough to remain in the academic silo of our field, to read nothing but psychiatry textbooks and psychiatry journals, and attend psychiatry lectures.
As a person with lived experience, I'm now organizing the first-in-nation Eating Disorders Awareness Week in Korea. In so doing, I came to the realization that the whole experiences of ours are, without exception, narrowed down to a disease to be cured and the insignificant rest, that are excuses of patients who aren't motivated enough to be cured to the medical authorities. A psychiatrist told me the other day, "They need to know that eating disorder patients are not strange people but can get better with medical treatment." I can agree on her first argument, but the second one? I received the impression that, to some psychiatrists, what matters is that simple legacy system where they take authority firmly or to confirm medical consumers that their services are still the most effective.
The medical model is surely an efficient tool, but how can we do better in keeping patients' life experiences from being dismissed? How can we set the tone of our collective discourse so that the psychiatric authorities won't regard our questioning as an attack upon them?
Hi Jeannie! You are completely right that that is a problem. It's a problem across medicine, but it leads to a lot more damage in psychiatry. It's also a problem that is worse is countries/cultures where physicians are a lot more patriarchal and are threatened by any sort of questioning by the patient. I grew up in Pakistan so I understand this sort of attitude quite well. It's a complex multifaceted problem that requires physicians to appreciate that i) how we conceptualize psychiatric problems matters, and it matters a great deal, and traditional medical conceptualizations have severe limitations; and ii) adopt an attitude of epistemic humility and be a lot more democratic in how they interact with patients and the public. This requires a radical cultural change in the profession and in all likelihood will be an effort that spans generations.
Hi Awais, I’m always inspired by and excited about your thinking. I’m curious: what’s your relationship to psychodynamic theory? And how do you conceptualize and/or relate to the notion of ‘unconscious’ processes?
I was fortunate that my psychiatry residency program had a robust psychodynamic component. with a lot of teaching devoted to it and long-term psychotherapy clinic with a psychoanalytic supervisor. Practicing psychodynamic psychotherapy opened my eyes to forms of clinical interaction and conceptualization that I hadn't quite appreciated before. My view of psychodynamic psychotherapy is therefore quite positive and the general principles make a lot of sense to me, as described, eg, by Nancy McWilliams or Jonathan Shedler. When it comes to details of psychoanalytic theory, some of it gets rather arcane and obscure, and I lose interest (eg Lacan).
I approach the notion of "unconscious" both psychodynamically and neuroscientifically. Some of what goes on seems to be processes akin to unconscious wishes, and desires, and ego defenses, etc, and some of the other seems to be processes like assumptions, inferences, predictions, and computations. I am drawn to the approach of neuropsychoanalysis taken by Mark Solms.
Perhaps the question shouldn't only ask what psychoanalysis and psychodynamic therapy can do for the therapist but what their (absolute and relative) value to patients is. How do they fair against sham therapy? What's their cost-benefit ratio? How do they compare with other treatments, particularly for cyclical (e.g., depression) and self-limited (e.g., PTSD) disorders? Do they prevent relapses? Is there quality assurance - is one therapist as good as the next - like they compare brand and generic meds?
I love your newsletter and am grateful for the thoughtful, rigorous, humble approach you model! I would love if you gave attention in the future to "constructive" approaches (following Femi Taiwo) and affirmative visions of mental health care, as well as the political economy of mental health care more broadly (joining Chapman and others; i.e. following the money). Would also be great to have more about political organizing among mental health clinicians (see Isabel Perera on how psychiatrists in France organized in unions and helped secure public money vs. privatization/fragmentation in US). And would love a post on how and why inpatient units became so carceral and punitive, following up on your interview about managed care and psych with Psych Times. Just some ideas from a fan :) -Jeremy Levenson MD and PhD Candidate Anthro/Social Medicine
Thank you Jeremy! All excellent directions to pursue. I loved Olúfẹ́mi O. Táíwò's Elite Capture. Robert Chapman's book is in the works and eagerly awaited. I'm not familiar with Isabel Perera's work and have to look into that. What happened to inpatient units definitely deserves a detailed look.
Thank you! You are so thoughtful about the intersection of philosophy, science and medicine. What’s one emerging thing in any or all of those realms that you are particularly excited about?
Thank you Nicole! It seems to me that there is a growing appreciation across these fields regarding the limit of reductionism and there is this new intellectual energy around trying to figure out what scientific pluralism should look like without degenerating into eclecticism. Work on multi-level causal interactions and complex, dynamic systems seems exciting. I am also excited by the rise of enactivism/4E thinking in neuroscience along with approaches inspired by the Free Energy Principle, and I am very curious as to what sort of synthesis would emerge from this.
Hello Awais,
As a psychiatrist who is passionate about my profession, I find it really disheartening that so many people on Twitter demonise psychiatry and blame psychiatrists for everything that is wrong with mental health care. The same people valorize psychotherapy without any recognition of its limited effectiveness or adverse effects. How do you deal with all the hate and also the negation of your knowledge (i.e., we are fake doctors who give fake drugs and are brainwashed by Pharma)?
It can indeed be really disheartening. Here’s the approach that I have found somewhat helpful: a) I try to understand where the demonization and blame is coming from. A lot of it comes from really terrible and traumatic experiences people have had in mental health systems, and this anger gets expressed in a lot of different ways. In such cases I listen and try to see how we as a profession can do better, even though productive engagement is not always possible. In other cases, it is ideological or motivated for a guild war mindset. In those cases I politely and firmly push back. A big challenge on social media is figuring out what it is meaningful to engage with someone & when it is meaningful to ignore. Some polarizing folks on twitter deliberately post inflammatory content cause that’s the only way they get any attention. In those cases depriving them of our attention and engagement may be the best strategy.
As they say about lawyers, everyone hates and makes jokes until they need them.
Hello Awais, what do you make of the current 'renaissance' of interest and work around psychedelics in psychiatry?
I think it's generally great, there is amazing scientific work being done, and its informing our understanding of the brain and mind in fascinating ways. Things like "REBUS and the Anarchic Brain" (https://pharmrev.aspetjournals.org/content/71/3/316 ), for example. It's unfortunate that this line of research was almost completely shut down by the governments in 80s and 90s. In many ways we are just finding our way back and resuming this. An important consequence of this has been that psychoactive experiences, spiritual and mystical experiences, and Indigenous practices have experienced a revival of academic and scholarly interest as well. Phoebe Friesen recently had a wonderful paper on the historical entanglements of psychosis research and psychedelics research (https://pubmed.ncbi.nlm.nih.gov/36300247/ ).
I'm cautiously optimistic about the therapeutic use of psychedelics in psychiatry. I think there is a lot of potential there, but I am also quite wary of the hype around them and the general underestimation of safety considerations and adverse effects. (Some students working with me recently wrote a general review on safety considerations for Current Psychiatry: https://www.mdedge.com/psychiatry/article/259826/depression/psychedelics-treating-psychiatric-disorders-are-they-safe )
Hello, Awais! Thank you for the work that you do. I never knew about the anti-psychiatry movement until I saw your posts on Twitter. I am a grad student and I perform behavioral experiments in rats. I had an existential crisis when I learned about the reductionist and behaviorist approach that neuroscientists employ in their research. Do you think it is still worth our time and resources to use animals (rodents, non-human primates) to study human psychiatric disorders? Can we really translate the findings of animal behavioral tests such as elevated plus maze or sucrose preference test to mental illnesses such as anxiety or depression?
Thanks JL! A very important question, probably deserves detailed discussion in a post. My sense is that animal models of mental disorders have severe limitations and extrapolating from them is quite problematic. Psychiatric disorders are quite complex and have this distinctive experiential dimension. We can create animal models that mimic that certain aspects of the psychiatric disorders -- a certain behavioral phenotype, or a certain sort of process such as chronic stress or social defeat -- but it's difficult to jump from that to the pathophysiology or treatment of the disorder in humans. Nonetheless, there are some other ways in which animal models could be helpful. A rodent's preference for being in open arms over closed arms in elevated plus maze and how this preference is modified by a pharmaceutical tells us *something* about exploratory behavior, it's neural associations, and the behavioral effects of a pharmaceutical, and we can begin to ask questions like what corresponding behaviors and behavioral effects might look like in humans, and what their therapeutic value might be, but we should resist the urge to assume that this is telling us anything meaningful about anxiety disorders per se.
Thanks, Awais! I agree with you. I look forward to your future post on this topic. Hope you also discuss more valid research methods/models that neuroscientists can consider when studying the biology of psychiatric disorders. More power!
Hi Awais, I'm a soon-to-be psychiatry resident - do you have any must-read books in the next few months before intern year starts? Or will this substack suffice :)?
Hi Kai! Congrats on your residency. From a more practical standpoint, familiarizing yourself with symptoms for some of the common disorders and treatment guidelines (eg from UpToDate) is probably the most useful. The months before intern year are a good time to read up on some of the popular book about psychiatry. That will give you a sense of the broader social, critical, and historical context in which we are operating. Gary Greenberg's The Book of Woe, Allen Frances's Saving Normal, and Anne Harrington's Mind Fixers are good options. I'd also recommend The Examined Life by Stephen Grosz and Strangers to Ourselves by Rachel Aviv. (I am forever grateful that I read Derek Bolton's What is Mental Disorder? before I started my psychiatric training. Bolton's book changed the way I think about mental illness. It's a philosophical work, however, and trainees don't always find it easy to read.)
Hi Awais, i am a reader from North Macedonia so i would rather ask a different question. As a first year psychiatry resident myself, what is the only advice you would have given to every psychiatry resident on their first day of residency?
Welcome! My advice would be something along the lines of: psychiatry is a disciplines that exists at the intersection of the medical and social sciences. To be a good psychiatrist, to have an expert grasp on the nuances of our field, we have to read critically and widely, and engage in a dialogue with multiple disciplines, including history, psychology, philosophy, neuroscience, and mad studies. This requires curiosity and humility. It is not enough to remain in the academic silo of our field, to read nothing but psychiatry textbooks and psychiatry journals, and attend psychiatry lectures.
As a person with lived experience, I'm now organizing the first-in-nation Eating Disorders Awareness Week in Korea. In so doing, I came to the realization that the whole experiences of ours are, without exception, narrowed down to a disease to be cured and the insignificant rest, that are excuses of patients who aren't motivated enough to be cured to the medical authorities. A psychiatrist told me the other day, "They need to know that eating disorder patients are not strange people but can get better with medical treatment." I can agree on her first argument, but the second one? I received the impression that, to some psychiatrists, what matters is that simple legacy system where they take authority firmly or to confirm medical consumers that their services are still the most effective.
The medical model is surely an efficient tool, but how can we do better in keeping patients' life experiences from being dismissed? How can we set the tone of our collective discourse so that the psychiatric authorities won't regard our questioning as an attack upon them?
Hi Jeannie! You are completely right that that is a problem. It's a problem across medicine, but it leads to a lot more damage in psychiatry. It's also a problem that is worse is countries/cultures where physicians are a lot more patriarchal and are threatened by any sort of questioning by the patient. I grew up in Pakistan so I understand this sort of attitude quite well. It's a complex multifaceted problem that requires physicians to appreciate that i) how we conceptualize psychiatric problems matters, and it matters a great deal, and traditional medical conceptualizations have severe limitations; and ii) adopt an attitude of epistemic humility and be a lot more democratic in how they interact with patients and the public. This requires a radical cultural change in the profession and in all likelihood will be an effort that spans generations.
Hi Awais, I’m always inspired by and excited about your thinking. I’m curious: what’s your relationship to psychodynamic theory? And how do you conceptualize and/or relate to the notion of ‘unconscious’ processes?
I was fortunate that my psychiatry residency program had a robust psychodynamic component. with a lot of teaching devoted to it and long-term psychotherapy clinic with a psychoanalytic supervisor. Practicing psychodynamic psychotherapy opened my eyes to forms of clinical interaction and conceptualization that I hadn't quite appreciated before. My view of psychodynamic psychotherapy is therefore quite positive and the general principles make a lot of sense to me, as described, eg, by Nancy McWilliams or Jonathan Shedler. When it comes to details of psychoanalytic theory, some of it gets rather arcane and obscure, and I lose interest (eg Lacan).
I approach the notion of "unconscious" both psychodynamically and neuroscientifically. Some of what goes on seems to be processes akin to unconscious wishes, and desires, and ego defenses, etc, and some of the other seems to be processes like assumptions, inferences, predictions, and computations. I am drawn to the approach of neuropsychoanalysis taken by Mark Solms.
Perhaps the question shouldn't only ask what psychoanalysis and psychodynamic therapy can do for the therapist but what their (absolute and relative) value to patients is. How do they fair against sham therapy? What's their cost-benefit ratio? How do they compare with other treatments, particularly for cyclical (e.g., depression) and self-limited (e.g., PTSD) disorders? Do they prevent relapses? Is there quality assurance - is one therapist as good as the next - like they compare brand and generic meds?
Aren't we curious?
I love your newsletter and am grateful for the thoughtful, rigorous, humble approach you model! I would love if you gave attention in the future to "constructive" approaches (following Femi Taiwo) and affirmative visions of mental health care, as well as the political economy of mental health care more broadly (joining Chapman and others; i.e. following the money). Would also be great to have more about political organizing among mental health clinicians (see Isabel Perera on how psychiatrists in France organized in unions and helped secure public money vs. privatization/fragmentation in US). And would love a post on how and why inpatient units became so carceral and punitive, following up on your interview about managed care and psych with Psych Times. Just some ideas from a fan :) -Jeremy Levenson MD and PhD Candidate Anthro/Social Medicine
Thank you Jeremy! All excellent directions to pursue. I loved Olúfẹ́mi O. Táíwò's Elite Capture. Robert Chapman's book is in the works and eagerly awaited. I'm not familiar with Isabel Perera's work and have to look into that. What happened to inpatient units definitely deserves a detailed look.
Thank you! You are so thoughtful about the intersection of philosophy, science and medicine. What’s one emerging thing in any or all of those realms that you are particularly excited about?
Thank you Nicole! It seems to me that there is a growing appreciation across these fields regarding the limit of reductionism and there is this new intellectual energy around trying to figure out what scientific pluralism should look like without degenerating into eclecticism. Work on multi-level causal interactions and complex, dynamic systems seems exciting. I am also excited by the rise of enactivism/4E thinking in neuroscience along with approaches inspired by the Free Energy Principle, and I am very curious as to what sort of synthesis would emerge from this.