It's interesting to see from the comments below that your sub-stack is frequented by clinicians and patients alike. It just occurred to me to share it with some of my patients.
There are few forums - are there any others?- that are heterogenous this way, and where a clinician can "come out" as also a patient.
As a psychiatrist who was also pretty depressed, for whom meds and other treatments caused serious problems I also think, like David M, about whether the cure isn't often worse than the disease, and I also try to think about partnering with patients. I think I've actually argued with AA about the validity of diagnosis! I almost never insist that people take medication.
But I was trained in the medical model. It seems like we drs don't feel we have anything to offer unless we are prescribing. We want to feel needed and in control, having worked so hard and acquired so much "knowledge." It's interesting to think about how to re-educate psychiatrists to work in tandem rather than in a top-down model. It runs contrary to medical training.
I definitely feel that there's a way in which I know more as a patient than as a dr, though.
My experience, like David's. has been that, in general, non-MD therapists are more able to see patients as equals; there is less of a polarized dynamic. Of course, MDs also worry about their licenses, litigation, etc. But a real partnership between patient and dr seems unlikely to end badly, in my view.Thanks, as always, for some good reads!
Thanks for these comments, Susan! Yeah, I can’t say that there are a lot of avenues for such clinician-patient encounters. Publications such as Psychiatric Times have become more open to it over time.
There was recently a post on psychology today that hospitalizing for suicidal ideation can cause iatrogenic harm…. My question is why does MH hospitals have to be so degrading? And why should a physicians potential liability trump a patients refusal to be hospitalized? 😢
There are a lot of reasons for why inpatient experience is often so negative. A big reason is that the hospitals/units have been optimized over time for minimizing risk (trying to prevent patient access to things that could be used for self-harm or violence & prevent opportunities for harm), with patient comfort/dignity/autonomy being secondary considerations at best. A second reason is not enough funding or reimbursement for things like decent food or arranging more activities for patients. A third reason is inadequate staffing such that there aren’t enough nurses/aides and people are burnt out. There are many other factors as well but these are some off the top of my head.
I’m full time clinical with an adjunct academic appointment. I worked inpatient at a state psychiatric hospital for several years, mostly with forensic patients, and got to see the dynamics of long-term inpatient care first hand. These days I work in an intensive outpatient and partial hospitalization program and round on inpatient unit on some weekends. I do lectures with med students and residents as part of their didactics, clinically supervise trainees sometimes, and I offer a reading/discussion elective to residents interested in conceptual and critical issues in psychiatry. No formal research these days. Academic writing in between clinical work and in my personal time 😊 What about you?
You've got your hands full, but are also clearly more disciplined with your time than I am. I did private outpatient group practice for a couple years out of residency and started a psychoanalytic training program but stopped, both because they didn't adapt well to virtual during COVID and for various theoretical and institutional-culture reasons. Then I went full inpatient (with some PHP and consults once in a blue moon) in the community and kept a small side practice which is in hibernation for the time being. I do some teaching with APNs and family medicine residents but no psych residents or med students unfortunately. I did lots of teaching in med school and residency and that is one area of academic medicine I really miss. But I'm still a psychotherapy supervisor for PGY2s at my residency, which keeps me plugged into those worlds.
I love reading your work! A few questions – would love to hear your take, and any recommendations you have for articles/books/podcasts/interviews/films etc. on these subjects that you think might be useful:
1) What do you make of Thomas Szasz’s idea that mental illnesses are not "illnesses/diseases" but issues of insufficient/misaligned incentives? I understand that profound neurological changes take place in addiction, depression, and other conditions, but I find Szasz’s take to be optimistic in that it A) suggests (much like IFS) that you are not ‘broken’ or wrong for enacting a maladaptive coping mechanism – it is a functional response to the horrors of contemporary life, B) charts a potential path out of a cycle of victimization/helplessness in that it meaningfully differentiates between diseases without a cure (cancer) and mental conditions that may respond to therapeutic intervention and C) in so doing emphasizes the human capacity for change.
2) Do you feel like we have arrived at a moment where affective labor has become too medicalized, in the sense that therapeutic relationships are becoming valorized over simply having a robust friend group?
3) Do you feel like, given the a-political nature of therapy, it has the potential to be truly transformative? In other words, to what extent are our "bad feels" the result of internal cognition/ideation and to what extent are they the result of structures of inequity/capital/social life that make people feel bad?
1) Szasz made a lot of problematic claims, about how "illnesses" should be defined, the nature of medical authority, and the nature of mental health problems. There is certainly value in characterizing mental health problems as "functional responses" but it only applies to a subset of mental health problems, and Szasz is neither unique nor distinctive in that regard. Psychoanalysis and psychodynamic thinking, for example, look for hidden and non-obvious forms of functioning underlying the apparently obvious. Some discussion of it in these posts:
2) In a manner of speaking, yes. A lot of people experience loneliness and social isolation, and some of them end up trying to use psychotherapy as a way of having a meaningful human connection. (But it's usually not as simple as that, because prolonged loneliness and social isolation often generate or exacerbate other mental health problems, which do warrant clinical treatment.)
3) I don't think it has the potential to be socially transformative. Psychotherapeutic and psychiatric treatments are not going to change whatever sociopolitical dysfunctions exist in our society, and it is unreasonable to expect them to do that. As I wrote in a prior post (https://www.psychiatrymargins.com/p/people-are-stumbling-from-one-misguided )
"I agree that most medical and psychiatric interventions are focused on the individual, but that is not because the “medical model” fails to understand context, but because the manner in which we as a society organize and reimburse healthcare makes it impossible for clinicians to do anything about the context of a person’s life other than acknowledge its relevance. The clinic often treats individual effects of sociopolitical dysfunction, but the clinic is powerless to treat the sociopolitical dysfunction itself. If we want political change, we have to undertake the difficult, messy work of politics. No model applied in the clinic will do that for you."
For any relevant professional still reading this thread:
1. Is it just me, or is there a suspicious amount of overlap between the epidemiology and symptoms of syndromes frequently claimed to be psychosomatic (e.g., fibromyalgia, chronic fatigue, functional this, dysautonomic that...) and known autoimmune disease?
2. What neurological differences between males and females could account for disparate rates of psychosomatic illness, the way immune system differences account for disparate rates of autoimmune disease? (If you point to disparate rates of depression and anxiety between sexes, you merely rephrase the question: What neurological features of depression and anxiety cause somatic symptoms not caused by other mental illnesses?)
I'm a medical student doing an ED term on the very team that screwed me over so disastrously as a patient... Prof misdiagnosed manic psychosis as borderline in crisis and his treatment plan was don't admit, as a result the police took me to ED 5x in 6 days saying she's psychotic, the ED psychiatrist literally wrote in my notes she doesn't have a psychiatric illness, police think she's psychotic, they need to be told she's not, her issues are purely behavioural... A month in a locked ward and three forensic psych reports later all agreeing florid manic psychosis for the time period the ED psychiatrists were adamant there was nothing wrong with me... Oh yeah, and that I didn't have a personality disorder...
No-one on the current team was there then except for my treating psychiatrist who I've managed to avoid, but it's strange seeing how it would have played out, and our current prof isn't great, I'll just say my psych doesn't have very complementary things to say about him... And watching him make personality disorders diagnoses of patients when in crisis, which was the mistake made about me... Being pimped about ideas of reference and thinking I've got this one, it's when people on the TV talk directly to you, and being told no, it's when they talk about you, not to you... And thinking damn I'll have to pay out my treating psych for not telling me my ideas of reference were atypical.... It's so frustrating not being able to have intelligent conversations with the doctors because they assume I'm much more ignorant than I am! Clinically I'm a novice, but from my treating psychiatrist... I know more about bipolar than some psychiatrists... I've got a solid theoretical basis... And I even educated prof on valproate restrictions in the UK which he was unaware of. Anyway, any thoughts on humane psychiatry electives for our 4th year program? That don't cost an arm and a leg and a prosthesis??? Being a single parent of a child with a disability and all...
A bpd patient criticised her care providers and got pathologised for her pains, I kept my mouth firmly shut but I thought she made some cogent points and that they were profoundly pathologising and invalidating of her (she didn't like her doctors and to be honest, if I was a patient, I wouldn't have either!) (and made other legitimate criticisms that were ignored) - but if I had peeped that I had agreed with her this would have been seen as splitting, not as a genuine problem with the way we perceive people with bpd. She did have problematic behaviours, but that's not a reason to discredit everything someone says. Grrr.
It is terrible that you had this experience Heather, I’m so sorry. A crisis situation isn’t the right context for a new diagnosis of a personality disorder, and even if someone has a personality disorder, the crisis deserves an appropriate response.
I’d suggest looking into options for electives in medical humanities, narrative medicine, or medical ethics. You could also look into a psychodynamic psychiatry elective at Austin Riggs if traveling was an option. An elective at a first episode psychosis program might be good too.
What do you make of the claim that mental health discourse has the unintended effect of inducing sociogenic mental illness (commented on by Scott Alexander in a few posts, e.g., https://www.astralcodexten.com/p/book-review-crazy-like-us, https://www.astralcodexten.com/p/book-review-the-geography-of-madness)? It's certainly not a great leap from "mental illnesses can be socially mediated and ontologically dependent on social constructs" to "mental illness can be sociogenic," but the latter is difficult to prove.
Also, if it were correct and if it was found that there is an unavoidable trade-off between reducing under-diagnosis/under-treatment and avoiding sociogenic mental illness, would you be a cold, calculating utilitarian focused on minimizing QALYs lost to mental illness policy, or would you prioritize one goal over the other?
These are challenging questions that I am still wrapping my head around. I’m inclined to think that there is a degree of plasticity in psychological distress and impairment such that whether they take the form of an illness or not does depend partly on sociocultural conceptualization. Our scientific understanding of this is very rudimentary at the moment. I suspect there is an optimal balance between recognizing suffering and creating mass illness, and my guess is that it requires epistemic pluralism and it requires talking about mental health problems without reification of categories. I hope to write more about this. Great question, thank you.
Hi Awais, thanks for the AMA and I have appreciated your nuanced and thoughtful takes! You seem to have a diverse readership, which is great. But almost as great is the generative cross-dialogue between this blog and other clinicians, philosophers, psychiatrists, service users and advocates on adjacent newsletters and platforms. So it feels like a node of sorts helping to connect people closer to the center with people "at the margins" of psychiatry.
I know there has been some disagreement and infighting recently, which makes it harder to know what to take entirely at face value. But it looks to be a useful overview of the big issues and concerns.
More generally, I would love to see posts devoted to OCD or related issues, as this is a remarkably heterogenous condition that often gets shoved into a box, and in my experience leaves many sufferers falling through the cracks. The "gold standard" of exposure therapy is not as gold as many would have you believe (though obviously very helpful for some), and psychodynamic approaches simply dismissed. Psychedelic research aside, the field can feel narrow and insular, with little awareness of critical or conceptual issues. But I think it lends itself to philosophical questions and really deserves more qualitative accounts (Dana Fennell's recent book is a rare exception). It was great to see the Rose Cartwright article come up here.
I read that first post on Mad in the UK, and I was rather annoyed by it. I find it increasingly difficult to take MITUK seriously. I have rather pro-neurodiversity, but I have some reservations about aspects of neurodiversity myself, and it might be good to discuss this in more detail.
I think you're doing really thoughtful, sensitive work here, Awais . I'm especially intrigued by the discursive interchange on "psychiatry's ignorance" you joined alongside Ikkos, Poole, and Huxley. It has stoked my curiosity about Whooley's book. I'll admit, I find myself largely in agreement with many of his critiques, though as a clinician, I think back to residency and my days in psych emerg, and I immediately want to wag my finger and say, "yes, but." On the ground, it's just so much more complicated, and as you do such fine work exploring, the layers of subtlety surrounding psychiatric--and adjacent--theory and practice are endless. Ultimately, I think clinical humility, as you write, takes us a long way toward doing good and doing well. And a little more engagement with the humanities and social sciences, certainly.
Depression can be quite resistant to treatment with existing options and I recall you making the point of just how much progress is still needed in the treatment of mental illness in general. It boggles the mind then that newer paradigms like TMS aren’t be deployed with much greater urgency…
As a (much more amateur) psychiatrist-philosopher myself, I'm in awe of your capacity to think so deeply, and to take the time to write so thoughtfully. Do you have a clinical practice too? How do you find the time?
I wonder if you've thought about (or have already written about) the psychiatric generalist. I mean psychiatrists, myself included, who offer both medication and psychodynamic psychotherapy. (I see medication and CBT more of a piece, and thus a less interesting question, both being focused primarily on manifest symptoms.)
"If all you have is a hammer, everything looks like a nail." Thus your comment here that "many psychiatrists have little to offer beyond meds," and the common criticism that psychiatrists overmedicate. Perhaps any controversy over a "bigger toolbox" relates to the mixed feelings in our field about eclecticism, and how this term seems, to me, conflated with dilettantism. But I'd love to read your thoughts on this.
Thank you Steven! Appreciate your kind words! I’m a full time clinician. These days I work in an intensive outpatient and partial hospitalization program. Have somehow been managing to find time, but it’s not easy 😊
I think it’s great when psychiatrists can provide psychotherapy too. I had decent psychotherapy training during residency and consider myself psychodynamically informed. I don’t do psychotherapy myself, but I work with psychotherapists and encourage patients all the time. It’s ok for people to specialize in different modalities. Neurologists don’t do physiotherapy, for instance. The important thing is recognizing when patients stand to benefit from psychotherapy and recommending it to them. Access is a huge issue.
So I don’t wanna be too repetitive about that aspect. But I haven’t written specifically about homelessness and mental illness, and that may be something I need to say more about. Im generally skeptical that involuntary commitment and treatment is a meaningful or desirable solution to this problem.
Hi Dr Awais, I'm sorry for haunting your comments section, I am awed by the efforts you are making to educate both patients and health care providers about all matters mental health. I belong to both of these demographics and am hopelessly lost trying to figure out why trauma and dissociation is such an avoided topic in psychiatry, unlike in therapy. My own doctor is one of the only ones that sees patients with my history and presentation. It feels like being relegated to a closet. I've been collecting research and resources to help bring trauma and its consequences out of the darkness its shrouded in. I would love to have a discussion about this from a neuropsychiatric perspective, considering trauma is not only a common denominator in psychiatric illness, but it reaches into the realm of physical ailments, inflammation, and chronic disease. Thank you!
The psychiatrists I know are generally quite aware of issues related to trauma and dissociation, and there is a lot of awareness in the general public as well thanks to books like Body Keeps The Score. I suppose there may be a generational divide in how much psychiatrists take trauma seriously, and there may also be psychiatrists who tend to ignore the role of trauma in situations other than PTSD. And then there’s the fact that medications go only so far in the management of trauma-related disorders and many psychiatrists have little to offer beyond meds.
Thank you for the response! I didn't mean to imply most psychiatrists are unaware of trauma. I think a better question or rather request would be for your opinion on how far the medications do go for a person suffering from PTSD, and similar disorders like BPD and DID. Particularly how you feel about PTSD as a biological entity rather than merely a "mental" one, considering changes can be detected on imaging. I agree that there is a massive shift around the education about trauma. I feel like I've been on both sides of it and can see things changing in real time. It is important to me also because living in Canada, my psychiatrist is free of cost to see, but I have had to spend exorbitant sums on therapy over a great many years when I'm of the "lite" opinion that a hospitalization and dedicated psychoeducation could have saved me a great deal of time and money, but being a medical professional I couldn't ask for the care I felt I needed to protect my career. I have many fellow practitioners in this conundrum, even in the US. It may be my bias, but I felt let down by the medical system I had so much faith in, getting dragged through counterproductive therapies and being medicated for everything under the sun rather than some one poke at a trauma history that was completely under wraps. I'm from Pakistan if that helps communicate the load of trauma in the general populace there.
God, I wrote a whole response that I accidentally deleted! Long story short, the differential diagnosis of PTSD was withheld from my knowledge and in place of that priority was given to BPD, such that when I complained about ongoing abuse, I was disbelieved, and my family were even told that I was in the wrong in seeking help at all, further weakening me and allowing more abuse to take place. Things eventually got bad enough that I did attempt to do myself serious harm with intent to do myself in. Then I got hospitalized but I was so averse to the thought of “treatment” that the interventions were counter productive. Dare I say, they gave me new trauma!
There was a great push towards insisting I “had it in me all along” to heal or just get over things. I was told I need too much validation by a therapist who believed borderlines require incessant validation as a character flaw rather than amnesia. A big problem was that there was hardly any time to tell a 33 year long story, made more difficult with the disorganized thinking and speech from discussing the overwhelming events of my life. It was as though I had to fight for the label where I believe that if I had been voluntarily hospitalized when I was most ill and fully cooperative the misdiagnoses and mistreatments wouldn’t have survived constant observation. The suspicions wasted years of my life, made me reluctant to get treatment at all, requiring me to provide evidences of my ill health in the form of videos, tons of time wasted on phase 1 of the treatment, workbooks that I could have taught better myself.
In essence I was victim blamed and my life was in danger at home. I was aghast because I thought the stories of victims being blamed were outlying data but the way I was approached as a dangerous and wild animal was extremely dehumanizing and dare I say has crippled me further if not for life, especially financially. The explanations I was given by the BPD specialist therapist lacked any sort of depth aside from repeatedly asserting that I was borderline. As if that explanation would satisfy me or anyone. I’m certainly in very good hands now, and I had no sooner touched them and gotten a chance to tell my story that I actually started to see improvements.
I was reading the wrong books, like “I hate you, don’t leave me” and yet others like “understanding the borderline mother” which insisted that all male children of borderlines turn out to be sociopaths. I hope to be one of those that does tell a story of salvation. A DID specialist existed in the province I’m living in, just the one such, but was held out of reach of me despite my eventual insistences to see some one more trauma competent. I feel like I was left hanging for longer than was necessary, giving access to further abuse at home. The hilarious thing is, the abuse has stopped since I have started making these efforts, here, just as I did at home, from just educating my family. It’s a bittersweet but happier ending than I thought it would be! Sorry this is not shorter.
Unfortunately a lot of people are let down by the system like that. In my experience, medications help with mood, anxiety, irritability, impulsivity, & sleep issues, but things like dissociation, traumatic memories, avoidance, negative self-image, shame, etc require good psychotherapy, and access to trauma-focused psychotherapy can be quite difficult. Can you say more about how hospitalization and psychoeducation would’ve helped you?
I’m happy to support your conversation with everyone. I find it incredibly thought-provoking and insightful. Honestly, as patient, it helps me understand myself better and be a better advocate for treatment. Thank you for your time and thoughtfulness.
1. This is indeed a suspicious amount of overlap and many autoimmune conditions remain undiagnosed for years cause they are treated as psychosomatic. Yet it does seem that there are conditions such as conversion disorder that are not explainable as autoimmune disorders.
2. Nobody really knows since the neurological mechanisms of functional illness remain unknown. Neuroticism as a trait may be involved but unclear how.
There’s one thing I was wondering about: How do psychiatrists deal with and distinguish between potential manipulation and expected symptoms in patients with personality disorders? (Narcissistic, borderline etc.)
All teen girls were labeled as “bpd” and manipulative back when I was a patient 20 years ago…. Asking for a towel to shower could be seen as manipulative. Pretty much any pushback or anything that inconvenienced staff was manipulation
People with personality disorders can be manipulative with romantic partners, family members, friends, etc. Often patients will tell themselves that have engaged in manipulative behavior in the past & they want to change that pattern. Or their family might say so, if the clinician talks to them. Manipulative behavior in clinical settings is usually aimed at achieving something. Maybe they want medical leave, or controlled substances, or psychiatric admission, etc. In psychotherapy contexts, the manipulative behavior can be re-enacted with the therapist. The dynamics in the inpatient setting are different, as pointed out by Midge. Expressions of distress, help-seeking, or an insistence on one’s preferences or autonomy can be easily mistaken as “manipulative” by the staff and used against the person. The antidotes are empathy, compassion, and an open-minded consideration of all possibilities.
And just to add on, another antidote is clear communication among members of the treatment team. One of the most important reasons for team rounding on inpatient psych that is underemphasized (I think) is for the team to identify and manage their countertransference and to be able to provide a unified front to the patient to minimize risk of miscommunication or splitting. Same principle applies in outpatient too though, eg good communication between psychiatrist and therapist during split treatment.
Its the truth 😭 the main goal there was coercion and control. Basically the expectation was that we were going to take medication (debatable whether or not it was indicated) and do what we were told and say that we were not suicidal anymore. Any deviation from that script or any kind of pushback or questions about medication was seen as noncompliance. Therefore noncompliance was seen as “manipulation” most of us were foster kids dumped there by group homes. It truly was a horrifying experience. Definitely opened my mind to how “care” was given. It was really messed up.
Hi Awais,
It's interesting to see from the comments below that your sub-stack is frequented by clinicians and patients alike. It just occurred to me to share it with some of my patients.
There are few forums - are there any others?- that are heterogenous this way, and where a clinician can "come out" as also a patient.
As a psychiatrist who was also pretty depressed, for whom meds and other treatments caused serious problems I also think, like David M, about whether the cure isn't often worse than the disease, and I also try to think about partnering with patients. I think I've actually argued with AA about the validity of diagnosis! I almost never insist that people take medication.
But I was trained in the medical model. It seems like we drs don't feel we have anything to offer unless we are prescribing. We want to feel needed and in control, having worked so hard and acquired so much "knowledge." It's interesting to think about how to re-educate psychiatrists to work in tandem rather than in a top-down model. It runs contrary to medical training.
I definitely feel that there's a way in which I know more as a patient than as a dr, though.
My experience, like David's. has been that, in general, non-MD therapists are more able to see patients as equals; there is less of a polarized dynamic. Of course, MDs also worry about their licenses, litigation, etc. But a real partnership between patient and dr seems unlikely to end badly, in my view.Thanks, as always, for some good reads!
Thanks for these comments, Susan! Yeah, I can’t say that there are a lot of avenues for such clinician-patient encounters. Publications such as Psychiatric Times have become more open to it over time.
There was recently a post on psychology today that hospitalizing for suicidal ideation can cause iatrogenic harm…. My question is why does MH hospitals have to be so degrading? And why should a physicians potential liability trump a patients refusal to be hospitalized? 😢
Thank you for all you do
There are a lot of reasons for why inpatient experience is often so negative. A big reason is that the hospitals/units have been optimized over time for minimizing risk (trying to prevent patient access to things that could be used for self-harm or violence & prevent opportunities for harm), with patient comfort/dignity/autonomy being secondary considerations at best. A second reason is not enough funding or reimbursement for things like decent food or arranging more activities for patients. A third reason is inadequate staffing such that there aren’t enough nurses/aides and people are burnt out. There are many other factors as well but these are some off the top of my head.
I'm curious what the balance of your work is, inpatient/outpatient, teaching, research, etc?
edit: I missed you already answered that below
I’m full time clinical with an adjunct academic appointment. I worked inpatient at a state psychiatric hospital for several years, mostly with forensic patients, and got to see the dynamics of long-term inpatient care first hand. These days I work in an intensive outpatient and partial hospitalization program and round on inpatient unit on some weekends. I do lectures with med students and residents as part of their didactics, clinically supervise trainees sometimes, and I offer a reading/discussion elective to residents interested in conceptual and critical issues in psychiatry. No formal research these days. Academic writing in between clinical work and in my personal time 😊 What about you?
You've got your hands full, but are also clearly more disciplined with your time than I am. I did private outpatient group practice for a couple years out of residency and started a psychoanalytic training program but stopped, both because they didn't adapt well to virtual during COVID and for various theoretical and institutional-culture reasons. Then I went full inpatient (with some PHP and consults once in a blue moon) in the community and kept a small side practice which is in hibernation for the time being. I do some teaching with APNs and family medicine residents but no psych residents or med students unfortunately. I did lots of teaching in med school and residency and that is one area of academic medicine I really miss. But I'm still a psychotherapy supervisor for PGY2s at my residency, which keeps me plugged into those worlds.
I love reading your work! A few questions – would love to hear your take, and any recommendations you have for articles/books/podcasts/interviews/films etc. on these subjects that you think might be useful:
1) What do you make of Thomas Szasz’s idea that mental illnesses are not "illnesses/diseases" but issues of insufficient/misaligned incentives? I understand that profound neurological changes take place in addiction, depression, and other conditions, but I find Szasz’s take to be optimistic in that it A) suggests (much like IFS) that you are not ‘broken’ or wrong for enacting a maladaptive coping mechanism – it is a functional response to the horrors of contemporary life, B) charts a potential path out of a cycle of victimization/helplessness in that it meaningfully differentiates between diseases without a cure (cancer) and mental conditions that may respond to therapeutic intervention and C) in so doing emphasizes the human capacity for change.
2) Do you feel like we have arrived at a moment where affective labor has become too medicalized, in the sense that therapeutic relationships are becoming valorized over simply having a robust friend group?
3) Do you feel like, given the a-political nature of therapy, it has the potential to be truly transformative? In other words, to what extent are our "bad feels" the result of internal cognition/ideation and to what extent are they the result of structures of inequity/capital/social life that make people feel bad?
Thanks Chase!
1) Szasz made a lot of problematic claims, about how "illnesses" should be defined, the nature of medical authority, and the nature of mental health problems. There is certainly value in characterizing mental health problems as "functional responses" but it only applies to a subset of mental health problems, and Szasz is neither unique nor distinctive in that regard. Psychoanalysis and psychodynamic thinking, for example, look for hidden and non-obvious forms of functioning underlying the apparently obvious. Some discussion of it in these posts:
https://www.psychiatrymargins.com/p/four-ways-of-going-right
https://www.psychiatrymargins.com/p/the-impact-of-framing-depression
2) In a manner of speaking, yes. A lot of people experience loneliness and social isolation, and some of them end up trying to use psychotherapy as a way of having a meaningful human connection. (But it's usually not as simple as that, because prolonged loneliness and social isolation often generate or exacerbate other mental health problems, which do warrant clinical treatment.)
3) I don't think it has the potential to be socially transformative. Psychotherapeutic and psychiatric treatments are not going to change whatever sociopolitical dysfunctions exist in our society, and it is unreasonable to expect them to do that. As I wrote in a prior post (https://www.psychiatrymargins.com/p/people-are-stumbling-from-one-misguided )
"I agree that most medical and psychiatric interventions are focused on the individual, but that is not because the “medical model” fails to understand context, but because the manner in which we as a society organize and reimburse healthcare makes it impossible for clinicians to do anything about the context of a person’s life other than acknowledge its relevance. The clinic often treats individual effects of sociopolitical dysfunction, but the clinic is powerless to treat the sociopolitical dysfunction itself. If we want political change, we have to undertake the difficult, messy work of politics. No model applied in the clinic will do that for you."
I really appreciate this thorough and thoughtful response – thank you!
Regarding 1, if you haven't already read Scott Alexander's refutations of claims by economist Bryan Caplan that mental illnesses are voluntary preferences, you may find them relevant to the question of the extent to which incentives apply: https://www.astralcodexten.com/p/sure-whatever-lets-try-another-contra?utm_source=publication-search
Fabulous – thank you for sharing!
For any relevant professional still reading this thread:
1. Is it just me, or is there a suspicious amount of overlap between the epidemiology and symptoms of syndromes frequently claimed to be psychosomatic (e.g., fibromyalgia, chronic fatigue, functional this, dysautonomic that...) and known autoimmune disease?
2. What neurological differences between males and females could account for disparate rates of psychosomatic illness, the way immune system differences account for disparate rates of autoimmune disease? (If you point to disparate rates of depression and anxiety between sexes, you merely rephrase the question: What neurological features of depression and anxiety cause somatic symptoms not caused by other mental illnesses?)
Hi Awais,
I'm a medical student doing an ED term on the very team that screwed me over so disastrously as a patient... Prof misdiagnosed manic psychosis as borderline in crisis and his treatment plan was don't admit, as a result the police took me to ED 5x in 6 days saying she's psychotic, the ED psychiatrist literally wrote in my notes she doesn't have a psychiatric illness, police think she's psychotic, they need to be told she's not, her issues are purely behavioural... A month in a locked ward and three forensic psych reports later all agreeing florid manic psychosis for the time period the ED psychiatrists were adamant there was nothing wrong with me... Oh yeah, and that I didn't have a personality disorder...
No-one on the current team was there then except for my treating psychiatrist who I've managed to avoid, but it's strange seeing how it would have played out, and our current prof isn't great, I'll just say my psych doesn't have very complementary things to say about him... And watching him make personality disorders diagnoses of patients when in crisis, which was the mistake made about me... Being pimped about ideas of reference and thinking I've got this one, it's when people on the TV talk directly to you, and being told no, it's when they talk about you, not to you... And thinking damn I'll have to pay out my treating psych for not telling me my ideas of reference were atypical.... It's so frustrating not being able to have intelligent conversations with the doctors because they assume I'm much more ignorant than I am! Clinically I'm a novice, but from my treating psychiatrist... I know more about bipolar than some psychiatrists... I've got a solid theoretical basis... And I even educated prof on valproate restrictions in the UK which he was unaware of. Anyway, any thoughts on humane psychiatry electives for our 4th year program? That don't cost an arm and a leg and a prosthesis??? Being a single parent of a child with a disability and all...
A bpd patient criticised her care providers and got pathologised for her pains, I kept my mouth firmly shut but I thought she made some cogent points and that they were profoundly pathologising and invalidating of her (she didn't like her doctors and to be honest, if I was a patient, I wouldn't have either!) (and made other legitimate criticisms that were ignored) - but if I had peeped that I had agreed with her this would have been seen as splitting, not as a genuine problem with the way we perceive people with bpd. She did have problematic behaviours, but that's not a reason to discredit everything someone says. Grrr.
That’s the danger of the BPD framing… it provides grounds for automatic delegitimization of any reasonable protest
It is terrible that you had this experience Heather, I’m so sorry. A crisis situation isn’t the right context for a new diagnosis of a personality disorder, and even if someone has a personality disorder, the crisis deserves an appropriate response.
I’d suggest looking into options for electives in medical humanities, narrative medicine, or medical ethics. You could also look into a psychodynamic psychiatry elective at Austin Riggs if traveling was an option. An elective at a first episode psychosis program might be good too.
What do you make of the claim that mental health discourse has the unintended effect of inducing sociogenic mental illness (commented on by Scott Alexander in a few posts, e.g., https://www.astralcodexten.com/p/book-review-crazy-like-us, https://www.astralcodexten.com/p/book-review-the-geography-of-madness)? It's certainly not a great leap from "mental illnesses can be socially mediated and ontologically dependent on social constructs" to "mental illness can be sociogenic," but the latter is difficult to prove.
Also, if it were correct and if it was found that there is an unavoidable trade-off between reducing under-diagnosis/under-treatment and avoiding sociogenic mental illness, would you be a cold, calculating utilitarian focused on minimizing QALYs lost to mental illness policy, or would you prioritize one goal over the other?
These are challenging questions that I am still wrapping my head around. I’m inclined to think that there is a degree of plasticity in psychological distress and impairment such that whether they take the form of an illness or not does depend partly on sociocultural conceptualization. Our scientific understanding of this is very rudimentary at the moment. I suspect there is an optimal balance between recognizing suffering and creating mass illness, and my guess is that it requires epistemic pluralism and it requires talking about mental health problems without reification of categories. I hope to write more about this. Great question, thank you.
Hi Awais, thanks for the AMA and I have appreciated your nuanced and thoughtful takes! You seem to have a diverse readership, which is great. But almost as great is the generative cross-dialogue between this blog and other clinicians, philosophers, psychiatrists, service users and advocates on adjacent newsletters and platforms. So it feels like a node of sorts helping to connect people closer to the center with people "at the margins" of psychiatry.
I would be interested in your thoughts on the upcoming series of blog posts from Mad In The UK critically examining the neurodiversity concept and the related movement (1st one here: https://www.madintheuk.com/2024/07/part-1-neurodiversity-what-exactly-does-it-mean/
I know there has been some disagreement and infighting recently, which makes it harder to know what to take entirely at face value. But it looks to be a useful overview of the big issues and concerns.
More generally, I would love to see posts devoted to OCD or related issues, as this is a remarkably heterogenous condition that often gets shoved into a box, and in my experience leaves many sufferers falling through the cracks. The "gold standard" of exposure therapy is not as gold as many would have you believe (though obviously very helpful for some), and psychodynamic approaches simply dismissed. Psychedelic research aside, the field can feel narrow and insular, with little awareness of critical or conceptual issues. But I think it lends itself to philosophical questions and really deserves more qualitative accounts (Dana Fennell's recent book is a rare exception). It was great to see the Rose Cartwright article come up here.
Thanks for the kind words, Chris!
I read that first post on Mad in the UK, and I was rather annoyed by it. I find it increasingly difficult to take MITUK seriously. I have rather pro-neurodiversity, but I have some reservations about aspects of neurodiversity myself, and it might be good to discuss this in more detail.
OCD, good suggestion! Thank you.
I think you're doing really thoughtful, sensitive work here, Awais . I'm especially intrigued by the discursive interchange on "psychiatry's ignorance" you joined alongside Ikkos, Poole, and Huxley. It has stoked my curiosity about Whooley's book. I'll admit, I find myself largely in agreement with many of his critiques, though as a clinician, I think back to residency and my days in psych emerg, and I immediately want to wag my finger and say, "yes, but." On the ground, it's just so much more complicated, and as you do such fine work exploring, the layers of subtlety surrounding psychiatric--and adjacent--theory and practice are endless. Ultimately, I think clinical humility, as you write, takes us a long way toward doing good and doing well. And a little more engagement with the humanities and social sciences, certainly.
Thank you Ben!
Depression can be quite resistant to treatment with existing options and I recall you making the point of just how much progress is still needed in the treatment of mental illness in general. It boggles the mind then that newer paradigms like TMS aren’t be deployed with much greater urgency…
https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-024-05928-4
I have been hoping to write about TMS for some time now. It’s a great option but still rather difficult to access for a lot of patients.
I am hoping the SNT protocol will help with speed, efficacy and uptake
https://www.nature.com/articles/s41386-023-01599-z
As a (much more amateur) psychiatrist-philosopher myself, I'm in awe of your capacity to think so deeply, and to take the time to write so thoughtfully. Do you have a clinical practice too? How do you find the time?
I wonder if you've thought about (or have already written about) the psychiatric generalist. I mean psychiatrists, myself included, who offer both medication and psychodynamic psychotherapy. (I see medication and CBT more of a piece, and thus a less interesting question, both being focused primarily on manifest symptoms.)
"If all you have is a hammer, everything looks like a nail." Thus your comment here that "many psychiatrists have little to offer beyond meds," and the common criticism that psychiatrists overmedicate. Perhaps any controversy over a "bigger toolbox" relates to the mixed feelings in our field about eclecticism, and how this term seems, to me, conflated with dilettantism. But I'd love to read your thoughts on this.
Thank you Steven! Appreciate your kind words! I’m a full time clinician. These days I work in an intensive outpatient and partial hospitalization program. Have somehow been managing to find time, but it’s not easy 😊
I think it’s great when psychiatrists can provide psychotherapy too. I had decent psychotherapy training during residency and consider myself psychodynamically informed. I don’t do psychotherapy myself, but I work with psychotherapists and encourage patients all the time. It’s ok for people to specialize in different modalities. Neurologists don’t do physiotherapy, for instance. The important thing is recognizing when patients stand to benefit from psychotherapy and recommending it to them. Access is a huge issue.
Engage with ACX/de Boer question of mentally ill homeless people?
There has been a lot of discussion around involuntary treatment on this newsletter. Eg, the post I linked above and then these 2 interviews:
https://www.psychiatrymargins.com/p/reconsidering-involuntary-psychiatric
https://www.psychiatrymargins.com/p/cultivating-thoughtfulness-in-involuntary
So I don’t wanna be too repetitive about that aspect. But I haven’t written specifically about homelessness and mental illness, and that may be something I need to say more about. Im generally skeptical that involuntary commitment and treatment is a meaningful or desirable solution to this problem.
Hi Dr Awais, I'm sorry for haunting your comments section, I am awed by the efforts you are making to educate both patients and health care providers about all matters mental health. I belong to both of these demographics and am hopelessly lost trying to figure out why trauma and dissociation is such an avoided topic in psychiatry, unlike in therapy. My own doctor is one of the only ones that sees patients with my history and presentation. It feels like being relegated to a closet. I've been collecting research and resources to help bring trauma and its consequences out of the darkness its shrouded in. I would love to have a discussion about this from a neuropsychiatric perspective, considering trauma is not only a common denominator in psychiatric illness, but it reaches into the realm of physical ailments, inflammation, and chronic disease. Thank you!
The psychiatrists I know are generally quite aware of issues related to trauma and dissociation, and there is a lot of awareness in the general public as well thanks to books like Body Keeps The Score. I suppose there may be a generational divide in how much psychiatrists take trauma seriously, and there may also be psychiatrists who tend to ignore the role of trauma in situations other than PTSD. And then there’s the fact that medications go only so far in the management of trauma-related disorders and many psychiatrists have little to offer beyond meds.
Thank you for the response! I didn't mean to imply most psychiatrists are unaware of trauma. I think a better question or rather request would be for your opinion on how far the medications do go for a person suffering from PTSD, and similar disorders like BPD and DID. Particularly how you feel about PTSD as a biological entity rather than merely a "mental" one, considering changes can be detected on imaging. I agree that there is a massive shift around the education about trauma. I feel like I've been on both sides of it and can see things changing in real time. It is important to me also because living in Canada, my psychiatrist is free of cost to see, but I have had to spend exorbitant sums on therapy over a great many years when I'm of the "lite" opinion that a hospitalization and dedicated psychoeducation could have saved me a great deal of time and money, but being a medical professional I couldn't ask for the care I felt I needed to protect my career. I have many fellow practitioners in this conundrum, even in the US. It may be my bias, but I felt let down by the medical system I had so much faith in, getting dragged through counterproductive therapies and being medicated for everything under the sun rather than some one poke at a trauma history that was completely under wraps. I'm from Pakistan if that helps communicate the load of trauma in the general populace there.
God, I wrote a whole response that I accidentally deleted! Long story short, the differential diagnosis of PTSD was withheld from my knowledge and in place of that priority was given to BPD, such that when I complained about ongoing abuse, I was disbelieved, and my family were even told that I was in the wrong in seeking help at all, further weakening me and allowing more abuse to take place. Things eventually got bad enough that I did attempt to do myself serious harm with intent to do myself in. Then I got hospitalized but I was so averse to the thought of “treatment” that the interventions were counter productive. Dare I say, they gave me new trauma!
There was a great push towards insisting I “had it in me all along” to heal or just get over things. I was told I need too much validation by a therapist who believed borderlines require incessant validation as a character flaw rather than amnesia. A big problem was that there was hardly any time to tell a 33 year long story, made more difficult with the disorganized thinking and speech from discussing the overwhelming events of my life. It was as though I had to fight for the label where I believe that if I had been voluntarily hospitalized when I was most ill and fully cooperative the misdiagnoses and mistreatments wouldn’t have survived constant observation. The suspicions wasted years of my life, made me reluctant to get treatment at all, requiring me to provide evidences of my ill health in the form of videos, tons of time wasted on phase 1 of the treatment, workbooks that I could have taught better myself.
In essence I was victim blamed and my life was in danger at home. I was aghast because I thought the stories of victims being blamed were outlying data but the way I was approached as a dangerous and wild animal was extremely dehumanizing and dare I say has crippled me further if not for life, especially financially. The explanations I was given by the BPD specialist therapist lacked any sort of depth aside from repeatedly asserting that I was borderline. As if that explanation would satisfy me or anyone. I’m certainly in very good hands now, and I had no sooner touched them and gotten a chance to tell my story that I actually started to see improvements.
I was reading the wrong books, like “I hate you, don’t leave me” and yet others like “understanding the borderline mother” which insisted that all male children of borderlines turn out to be sociopaths. I hope to be one of those that does tell a story of salvation. A DID specialist existed in the province I’m living in, just the one such, but was held out of reach of me despite my eventual insistences to see some one more trauma competent. I feel like I was left hanging for longer than was necessary, giving access to further abuse at home. The hilarious thing is, the abuse has stopped since I have started making these efforts, here, just as I did at home, from just educating my family. It’s a bittersweet but happier ending than I thought it would be! Sorry this is not shorter.
Unfortunately a lot of people are let down by the system like that. In my experience, medications help with mood, anxiety, irritability, impulsivity, & sleep issues, but things like dissociation, traumatic memories, avoidance, negative self-image, shame, etc require good psychotherapy, and access to trauma-focused psychotherapy can be quite difficult. Can you say more about how hospitalization and psychoeducation would’ve helped you?
I’m happy to support your conversation with everyone. I find it incredibly thought-provoking and insightful. Honestly, as patient, it helps me understand myself better and be a better advocate for treatment. Thank you for your time and thoughtfulness.
Thank you Cari!
1. This is indeed a suspicious amount of overlap and many autoimmune conditions remain undiagnosed for years cause they are treated as psychosomatic. Yet it does seem that there are conditions such as conversion disorder that are not explainable as autoimmune disorders.
2. Nobody really knows since the neurological mechanisms of functional illness remain unknown. Neuroticism as a trait may be involved but unclear how.
There’s one thing I was wondering about: How do psychiatrists deal with and distinguish between potential manipulation and expected symptoms in patients with personality disorders? (Narcissistic, borderline etc.)
What sort of manipulation do you have in mind? As in, what are they trying to manipulate the clinician into doing?
All teen girls were labeled as “bpd” and manipulative back when I was a patient 20 years ago…. Asking for a towel to shower could be seen as manipulative. Pretty much any pushback or anything that inconvenienced staff was manipulation
Beat me to the punch 💀
People with personality disorders can be manipulative with romantic partners, family members, friends, etc. Often patients will tell themselves that have engaged in manipulative behavior in the past & they want to change that pattern. Or their family might say so, if the clinician talks to them. Manipulative behavior in clinical settings is usually aimed at achieving something. Maybe they want medical leave, or controlled substances, or psychiatric admission, etc. In psychotherapy contexts, the manipulative behavior can be re-enacted with the therapist. The dynamics in the inpatient setting are different, as pointed out by Midge. Expressions of distress, help-seeking, or an insistence on one’s preferences or autonomy can be easily mistaken as “manipulative” by the staff and used against the person. The antidotes are empathy, compassion, and an open-minded consideration of all possibilities.
And just to add on, another antidote is clear communication among members of the treatment team. One of the most important reasons for team rounding on inpatient psych that is underemphasized (I think) is for the team to identify and manage their countertransference and to be able to provide a unified front to the patient to minimize risk of miscommunication or splitting. Same principle applies in outpatient too though, eg good communication between psychiatrist and therapist during split treatment.
Its the truth 😭 the main goal there was coercion and control. Basically the expectation was that we were going to take medication (debatable whether or not it was indicated) and do what we were told and say that we were not suicidal anymore. Any deviation from that script or any kind of pushback or questions about medication was seen as noncompliance. Therefore noncompliance was seen as “manipulation” most of us were foster kids dumped there by group homes. It truly was a horrifying experience. Definitely opened my mind to how “care” was given. It was really messed up.