The Paradox of Alternative Spaces: Q&A with Sascha Altman DuBrul
“at the intersection of the public mental health system & the Mad Underground”
Sascha Altman DuBrul, MSW is a writer, mental health coach, and longtime advocate for transformative approaches to mental health. In 2002, DuBrul wrote “Bipolar World,” an article published in the San Francisco Bay Guardian, relating his personal experiences being diagnosed with bipolar disorder. Shortly afterwards, at 27, he co-founded The Icarus Project, a peer-led support network and media project aimed at reshaping the language and culture around what gets called mental health and illness. After many years in grassroots radical mental health spaces, Sascha earned his Master’s from the Silberman School of Social Work and went on to work in the public mental health system in New York City, focusing on first-episode psychosis and peer workforce development. He served as the lead peer trainer at the Center for Practice Innovations at the New York State Psychiatric Institute from 2016-2019.
Sascha is the co-author (with Jacks McNamara) of Navigating the Space Between Brilliance and Madness (2004) and the author of Maps to the Other Side: The Adventures of a Bipolar Cartographer (2013). He currently works in private practice while serving as a trainer with the Institute for the Development of Human Arts (IDHA). He lives in Los Angeles with his partner and their twins.
Awais Aftab, MD is a psychiatrist in Cleveland, OH, and clinical assistant professor of psychiatry at Case Western Reserve University. He is interested in conceptual and philosophical issues in psychiatry and writes online at Psychiatry at the Margins. His first book, Conversations in Critical Psychiatry (OUP, 2024), is an edited collection of interviews.
Aftab: Sascha, you’ve had a fascinating career with so many transformations and rebirths as an activist, writer, and mental health professional… punk rock musician, co-founder of the Icarus Project, peer specialist trainer for first-episode psychosis programs through New York State Psychiatric Institute, and a mental health counselor and consultant. Your interests have been, in your own words, “at the intersection of the public mental health system and the Mad Underground.” How do you make sense of your own life, and where do you think it’s headed?
DuBrul: I think of my life as a long experiment in navigating different worlds—bridging movements, institutions, and the spaces in between. I’ve spent decades trying to make sense of madness, power, and the systems we build around them. If I step back, I see my life as a series of cycles—building something, watching it grow, then hitting the limits of what’s possible and finding a new way forward. Icarus was one of those cycles. Becoming a trainer was another. Becoming a therapist was yet another. Right now, I’m in a phase of integrating everything—documenting, archiving, and building something sustainable. I’m thinking about what it means to support the next generation of mad thinkers and organizers while also taking care of myself and my family.
I often reflect on the three years I found myself deep inside the psychiatric system—working at NYSPI—after having spent so much time locked up in psych wards myself, fighting to build alternatives. It was surreal to be sitting in all those clinical meetings, watching the machinery of institutional psychiatry in action, seeing how diagnoses got shaped and treatment decisions were made. What struck me most wasn’t just the rigidity of the disease model, but how deeply embedded it was in the very structure of research and funding. Even the most well-intentioned people—researchers who genuinely wanted to improve care—struggled to see beyond the biomedical lens because that was the only framework they had ever been trained in. There were moments where I thought, “Could a different paradigm even exist inside an institution like this? Or does it have to be built outside, in the cracks, in the underground spaces where new ideas can take root?”
Where am I headed these days? I’m still working that out. But I know I want to keep creating spaces where people can see themselves reflected in ways they never have before. Spaces where madness isn’t just pathologized or romanticized but understood as a deep part of being human—one that holds the power to disrupt, reveal, and transform culture itself.
And right now, it’s more important than ever. Things are shifting fast—politically, socially, environmentally. The institutions that once seemed immovable are fraying, and new possibilities are emerging in the cracks. This isn’t a time to double down on old ways of thinking. It’s a time to get close to your people, to build relationships of trust and solidarity, to imagine beyond the limits of what we’ve been told is possible. Because the world we thought we knew is already changing—whether we’re ready for it or not.
Aftab: I enjoyed your 2014 article, “The Icarus Project: A Counter Narrative for Psychic Diversity,” in the Journal of Medical Humanities, which I read recently for the first time on its republication in the Mad Studies Reader (Routledge, 2024). I encourage folks to read the piece to learn more about the Icarus Project. In retrospect, what do you think the Icarus Project accomplished? What have you learned regarding the challenges involved in creating and sustaining spaces for people struggling with mental health issues outside the healthcare system? Why are such spaces necessary to begin with?
DuBrul: Icarus was about creating a different kind of language and community around madness—one that wasn’t about medical diagnoses but about personal meaning, politics, and possibility. At its best, it was a refuge for people who didn’t fit neatly into clinical categories or activist frameworks. We helped thousands of people rethink their experiences and find solidarity. And we left a lasting impact on how mental health is talked about in radical spaces.
But sustaining a movement like that is hard. There were contradictions we never fully resolved: How do you build a community that embraces fluidity and identity while maintaining enough structure to survive? How do you hold space for pain and crisis without burning out or becoming another system of control? And how do you sustain an organization when people’s needs and priorities shift?
The Icarus Project became a case study in the paradox of alternative spaces: We were trying to build something outside the system, but we still depended on it—through funding, through the institutions we worked with, through the very language we were trying to rewrite. I think we did something important, but the fact that Icarus doesn’t exist in the same way today speaks to the challenge of keeping these kinds of spaces alive.
DuBrul: The Icarus Project became a case study in the paradox of alternative spaces: We were trying to build something outside the system, but we still depended on it.
And yet, we still need them. Because the mainstream system isn’t enough. It fails so many people. There has to be room for different ways of understanding madness—spaces where people can come together outside of clinical settings, outside of coercion, and create meaning on their own terms.
At the same time, I’ve had to reckon with how leftist identity politics fractured us instead of making us stronger. We started with a vision of shared struggle—of finding common ground in our experiences of madness, oppression, and survival—but somewhere along the way, the focus shifted. We got caught in the trap of competing identities, measuring harm, and constantly reassessing who had the most legitimacy to speak. It eroded trust, turning what should have been spaces of solidarity into spaces of fear. I wouldn’t do it that way again. The work of liberation isn’t about perfecting categories or policing each other—it’s about building relationships strong enough to hold our contradictions and still move forward together.
Aftab: What frustrates you the most about the current state of mental health activism and advocacy?
DuBrul: There’s a lot that frustrates me. On one side, you have a medical model that still dominates the conversation, where everything gets reduced to brain chemistry and treatment compliance. On the other, you have activist spaces where people talk about mental health in purely social and political terms, often in ways that feel disconnected from the actual experience of living through madness.
I also see a lot of performative politics—people using the right buzzwords but not actually building structures of care. And I see a lack of real conversation across different perspectives. The psychiatric survivor movement, the neurodiversity movement, the peer support world, the clinical world—they’re often talking past each other instead of finding ways to collaborate.
And then there’s the question of power. We’re still living in a world where poor and marginalized people get locked up for being mad while wealthy, eccentric entrepreneurs turn their delusions into billion-dollar companies. That hasn’t changed.
Aftab: What do you wish mental health professionals really appreciated about individuals with mental health problems who are alienated by mainstream approaches?
DuBrul: That madness isn’t just a problem to be solved—it’s a profound human experience. That the stories people tell themselves actually matter more than anything we know about genetics and brain chemistry. That paranoia, delusions, altered states—these things have deep meaning.
I wish more clinicians understood that madness often makes perfect sense in the context of someone’s life. If you’ve been traumatized, if you’ve been oppressed, if you’ve lived in a world that gaslights you, then of course your mind is going to develop ways to survive that might not fit neatly into a diagnostic manual.
And I wish they knew how much power they hold—not just in the treatments they prescribe but in how they listen, how they frame a person’s experience, how they validate or dismiss what someone is going through. That power can be healing, or it can be deeply harmful.
The best clinicians I know are the ones who figure out how to use their own lived experiences to connect with the people they work with. The ones who understand that we aren’t just applying techniques—we’re engaging in relationships. That healing isn’t something we do to people, but something we do with them.
And the ones who truly get that this work is about reciprocity. It’s not just about guiding others; it’s about being willing to be changed in the process. The people who come to us for help aren’t just patients or clients—they’re teachers. They’re holding pieces of wisdom about survival, about transformation, about what it means to be human in a world that so often demands we cut off the parts of ourselves that don’t fit. The best clinicians listen, not just for what needs to be fixed, but for what needs to be understood.
Aftab: In what sense do you consider mental health conditions such as depression and schizophrenia to be “gifts”? Do you ever encounter individuals and families whose suffering and disability is so severe that calling it a gift rings hollow?
DuBrul: Madness can be a gift in the sense that it opens doors—into creativity, into spirituality, into ways of seeing the world that others might miss. Some of the most visionary thinkers, artists, and revolutionaries have been people who walked the edge of madness.
But suffering is real. There’s nothing romantic about being unable to function, about being lost in terrifying delusions, about feeling so much pain you want to die. When people say “madness is a gift,” I think they’re often speaking from a place of survival—of having found meaning in something that could have destroyed them. But not everyone makes it to that place. And I think we need to honor the full range of experiences, without trying to fit everything into a single narrative.
DuBrul: There’s nothing romantic about being unable to function, about being lost in terrifying delusions, about feeling so much pain you want to die. When people say “madness is a gift,” I think they’re often speaking from a place of survival—of having found meaning in something that could have destroyed them.
I’ve been using the language of Dangerous Gifts for many years because it captures this complexity. It acknowledges that madness can be powerful, but it can also be perilous. A gift is something that can be cultivated, but it can also be overwhelming, even destructive, if we don’t have the right conditions to hold it. Too often, the mental health system focuses only on eliminating symptoms, seeing madness as something to suppress. And on the other side, some radical spaces glorify it without acknowledging the real suffering it brings. Neither approach feels honest to me. Dangerous Gifts is about making space for the contradictions, about recognizing that madness is neither just a curse nor just a blessing, but something that demands care, skill, and community to navigate.
Aftab: You’ve been open about your use of medications such as lithium. What’s your perspective on how psychopharmacology can help mad individuals live better lives?
DuBrul: I see meds as tools. They’re never the whole answer, but they can be useful. Lithium has helped me, but I take it on my own terms. The problem is that in our current system, meds are often forced on people, or they’re presented as the only solution. There’s no room for real conversation about their risks, about alternatives, about how to use them in a way that feels empowering instead of coercive.
After working with The Icarus Project for years and crossing paths with so many people, it became so obvious that everyone reacts differently to psych drugs. For some, they’re lifesaving; for others, they’re numbing, disorienting, even harmful. There’s no one-size-fits-all approach, yet the system treats medication as if there is. I’ve known people who found real stability through psych meds, and I’ve known people whose lives were shattered by them. What’s missing is choice—real, informed choice. The space to experiment, to taper safely if needed, to actually be in charge of your own mind and body.
For me, lithium has been a steadying force, but I also know that when I’m edging toward psychosis, when my thoughts start running too fast and reality starts slipping, I take Seroquel to sleep. It’s not a long-term solution, but it’s a tool I know works for me. And I’m incredibly grateful for it. And I think about that in contrast to cannabis, which has also played a role in my life—the way antipsychotics and cannabis or psychedelics seem to work at opposite ends of the spectrum. One opens doors, the other closes them. Psychedelics can expand perception, break down barriers between the self and the world, create profound states of meaning. Antipsychotics, on the other hand, can pull the mind back from that edge, dull the overwhelming intensity, put up the boundaries again. Both have the potential to be lifesaving.
There’s a balance to be struck—between insight and stability, between exploration and grounding. The problem is that the mental health system tends to privilege control over curiosity. It fears the doors that open but rarely questions the ones that close. When I worked at NYSPI, I was the only person on my entire training team who (admitted to) smoking cannabis. This stood out to me, especially given how many young people in our FEP programs were habitual marijuana users. It revealed a disconnect—between clinicians and the people they served, between institutional norms and lived reality.
DuBrul: For me, lithium has been a steadying force… There’s a balance to be struck—between insight and stability, between exploration and grounding. The problem is that the mental health system tends to privilege control over curiosity.
We need a framework that embraces complexity, one that recognizes medication, like any powerful tool, can be wielded skillfully or destructively. Its impact depends on the person, the context, and—most importantly—the level of agency they have over their own treatment.
Aftab: What kind of social transformation is necessary for the lives of mad people to be meaningful, valued, and free?
DuBrul: First, we need to recognize that the way we currently think about mental health is inseparable from capitalism, racism, and systems of control. The dominant framework medicalizes distress while ignoring the conditions that create suffering—poverty, isolation, oppression, the deep disconnection at the heart of modern life. Real transformation would mean rethinking everything, from how we support people in crisis to how we structure our communities.
It starts with access to care that isn’t coercive, dehumanizing, or just about managing symptoms. People need spaces where they can explore the meaning of their experiences, not just suppress them. That means funding peer-led alternatives, crisis respite centers, and community-based support instead of just expanding police and forced treatment.
It also means breaking the link between economic survival and mental health. So many people are crushed by financial insecurity, living in survival mode. Universal basic income, housing as a human right, access to meaningful work—these aren’t separate from mental health, they are mental health interventions.
And finally, it means shifting the cultural narrative. Madness isn’t just an illness; it’s part of the human experience. Some of the most brilliant thinkers, artists, and revolutionaries have walked the edge of madness. We need a world where those experiences are valued, where difference isn’t pathologized, where people don’t have to be “cured” to be accepted.
Transformation isn’t just about better treatment—it’s about reshaping the entire world we live in.
Aftab: There is a phrase that I am rather fond of: “all the élan of revolution with none of the drudge of responsible administration” (used by James Carney in a review of 4E Cognition). Valuing madness as a human experience, as a dangerous gift, challenging capitalism, racism, and systems of control, etc.... I see the appeal of it all, but how can we reconcile this utopian aspiration for radical change with the mundane and unsexy tasks of caring for people in the here and now? You’ve actually been in the trenches yourself, so you know what I'm talking about. What can we do to not lose sight of the drudge of responsible administration amidst our talk of revolution?
DuBrul: I appreciate this question so much because it hits at the heart of a tension I live with every day.
When I was working at the New York State Psychiatric Institute (NYSPI), I came to a painful realization: the system was never really designed to help people like me. It was built to manage us, contain us, and separate us from the rest of society—not to understand, support, or walk with us through our suffering. That doesn’t mean there aren’t good people inside doing their best—it just means there’s only so much you can do when you’re operating within a framework that’s fundamentally flawed.
So yes, I’m drawn to the visionary language of radical change—of reclaiming madness as a form of wisdom, of challenging capitalism, white supremacy, and medical authority. But I’ve also been in the trenches, holding space for people in deep psychosis, grief, and despair. I know what it means to sit with someone who’s suicidal and not leave. I know the slow, patient work of showing up week after week and helping someone piece their life back together. And it’s that reality—the drudge, as you put it—that I want to center alongside the dream.
That’s where T-MAPs comes in. Transformative Mutual Aid Practices is a tool I’ve been developing for over a decade. It started as a grassroots project in radical mental health spaces—born outside the system—and it helps people create personalized documents that map out their support systems, wellness strategies, crisis plans, and most importantly, their own truths. It’s a way of saying: “This is who I am. This is what I need. This is how I want to be supported.”
T-MAPs has been used in peer support spaces, in activist communities, and even in clinical settings like first episode psychosis programs. But at its core, it’s about reclaiming authorship of our lives and building collective care from the ground up. It’s not a treatment model—it’s a relational, systemic, and deeply human approach to navigating mental health in a broken world.
To me, this is where Internal Family Systems has also been a game changer. The idea of being Self-led—not driven by fear, reactivity, or old trauma patterns—has helped me not get swallowed by the system, or by the grief of how far we still have to go. It helps me stay grounded in the present, even while I’m working for a radically different future.
So how do we not lose sight of the “drudge” in the midst of visionary talk? I think we remember that tending to one another is revolutionary. That mutual aid, when it’s done with intention and depth, is infrastructure. And that our ability to sit with suffering, without turning away, is what will ultimately shape the kind of world we’re trying to build.
Aftab: What do you find appealing and valuable about Internal Family Systems (IFS)?
DuBrul: What I love about IFS is that it gives people a framework to understand their internal world with curiosity instead of shame. Instead of labeling thoughts and emotions as pathological, it assumes that every part of us is trying to help in some way, even if it’s causing pain. That’s a radical shift.
It resonates with me because I’ve always felt like my mind was a constellation of voices, each with its own perspective, its own needs. IFS doesn’t try to silence or eliminate those voices—it helps people build relationships with them. And that’s what makes healing possible.
It’s especially useful for people who’ve been through psychiatric systems because it moves away from the idea of a single, broken self that needs to be fixed. Instead of saying, “This is your disorder,” it says, “These are your parts. Let’s get to know them.” That can be profoundly liberating.
Also, IFS works well with altered states. If someone is having what psychiatry calls a “psychotic break,” instead of shutting it down, we can ask: What’s happening inside? What parts are speaking? What do they need? That’s a completely different approach than just medicating the experience away.
What’s frustrating is that while IFS is having its moment of popularity right now—getting recognized as a powerful tool for trauma and personal growth—it still isn’t taken seriously enough in the treatment of people struggling with what gets called serious mental illness (SMI). And this isn’t new. There’s a history of systemic family therapy (SFT) working with schizophrenia and SMI that’s been largely dismissed in mainstream psychiatry.
In the 1950s and 60s, people like Gregory Bateson, Salvador Minuchin, and the Milan school of family therapy were looking at psychosis not as an isolated brain disease, but as something emerging from complex relational dynamics. They recognized that extreme states often reflected profound disconnections—within families, within systems, within society. And they developed ways of working that didn’t just focus on the individual, but on the whole web of relationships they were part of.
But that work was overshadowed by the rise of the biomedical model. The dominant narrative became that psychosis was a purely biological disorder, best treated with medication and institutionalization. And in the process, we lost some powerful, humanizing approaches to working with people in distress.
That’s why IFS and systemic thinking are so important. Because they bring us back to the idea that extreme states aren’t just random malfunctions of the brain. They’re meaningful. They’re responses to something—trauma, isolation, oppression, unresolved conflicts. And they can be worked with relationally, not just chemically.
For me, IFS is about self-leadership, deep listening, and seeing madness as something that can be worked with—not as something to fear or suppress. And I want to see it taken seriously, not just as a trendy self-help tool, but as a legitimate framework for working with people who are struggling in the deepest, most profound ways.
Aftab: You’ve followed Psychiatry at the Margins for some time now. Hopefully you see me as a well-intentioned fellow explorer of these psychic landscapes. What advice do you have for me so that I don’t lose my way?
DuBrul: I appreciate that you’re asking this. It tells me you already know that the field you’re navigating is filled with contradictions, power struggles, and ethical landmines. My advice? Stay uncomfortable.
Whenever we start feeling too sure of ourselves, too confident that we have the answers—pause. Listen to the people the system has harmed the most. Be wary of getting pulled into respectability, of choosing intellectual legitimacy over radical honesty.
Take your own piece on antipsychotics and long-term outcomes—it’s a thoughtful attempt at carving out a middle ground, acknowledging both the failures of mainstream psychiatry’s maintenance model and the limitations of full antipsychiatry rejection. Your emphasis on personalization over polarization is important, but does the psychiatric system as it exists actually allow for that? Even if medication withdrawal studies are confounded by the natural history of illness, how do we separate that from iatrogenic harm? How do we move toward true informed consent in a system still structured around risk aversion, coercion, and forced treatment?
From an IFS lens, I wonder which “parts” of psychiatry are speaking in your work—the pragmatic clinician who wants to do right by their patients but is bound by systemic constraints? The reformer who sees the problems but doesn’t want to alienate the profession? The defender of scientific legitimacy, wary of arguments that seem too radical? It’s not an easy position to be in. But if you can keep holding space for complexity, for discomfort, for the voices psychiatry would rather ignore—you won’t lose.
DuBrul: From an IFS lens, I wonder which “parts” of psychiatry are speaking in your work—the pragmatic clinician who wants to do right by their patients but is bound by systemic constraints? The reformer who sees the problems but doesn’t want to alienate the profession? The defender of scientific legitimacy, wary of arguments that seem too radical?
I’ve spent a lot of time thinking about shifting psychiatric paradigms—not just as an abstract intellectual exercise, but from the position of someone who has lived through the consequences of this system firsthand. The Icarus Project was about building a counter-narrative, a space where people could redefine madness for themselves outside the rigid structures of diagnosis and medicalization. And yet, even as we created alternatives, we had to reckon with the reality that psychiatry—especially the biopsychiatric model—was not just an ideology. It was an institution of power, deeply embedded in the state, in capitalism, in histories of coercion and control.
I listened to your recent interview on
’s Depth Work podcast, where she brought up Thomas Kuhn and the idea of paradigm shifts. You made a compelling point that biopsychiatry isn’t even scientific enough to qualify as a true paradigm. It lacks falsifiable hypotheses and rigorous debate, instead functioning as a patchwork of market-driven interests, political forces, and speculative neurobiology—an ideology disguised as science. And yet, it holds immense institutional power.The challenge is that we’re living in a time when everything is shifting—institutions are breaking down, trust in science is being weaponized by conspiracy movements, and the boundaries between underground and mainstream are eroding. Things we once thought were stable foundations are becoming contested terrain. And in that process, alliances will shift. Some of what we thought was “fringe” will become the future. Some of what we assumed was untouchable will collapse. And we have to be ready for that.
There’s a danger in this, too. Just because something is emerging from the margins doesn’t mean it’s inherently liberatory. Psychiatry at the margins doesn’t just mean innovative trauma-informed care or radical mutual aid—it also means the rise of quackery, grifters, and reactionary forces exploiting the collapse of institutional credibility. As someone who has been part of an underground movement for decades, I’ve seen firsthand how alternative spaces can be just as prone to authoritarianism and dogma as the institutions they critique.
DuBrul: Just because something is emerging from the margins doesn’t mean it’s inherently liberatory. Psychiatry at the margins doesn’t just mean innovative trauma-informed care or radical mutual aid—it also means the rise of quackery, grifters, and reactionary forces exploiting the collapse of institutional credibility.
So my advice to you, and to anyone navigating these shifts, is this: Hold onto your commitment to liberation, but don’t let yourself get lost in ideological purity. Stay open, but skeptical. Be willing to critique the dominant system, but also the alternatives. Don’t assume that because something is new, it’s necessarily better. And above all, remember that whatever happens next, we’re going to have to fight to keep a vision of mental health that is truly about justice, dignity, and collective care.
As for me, I’ll be out here fighting for that vision—no matter how the landscape changes, even as things get more fascist, even if we have to go back underground. Because the need for a liberatory approach to madness isn’t going away. If anything, it’s just becoming more urgent.
Aftab: Thank you!
This post is part of a series featuring interviews and discussions intended to foster a re-examination of philosophical and scientific debates in the psy-sciences. See prior interviews here.
Psychiatry at the Margins is a reader-supported publication. Subscribe here.
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Great discussion guys. Thank you for taking the time to talk this out. I think it would be game changing for psychiatrists, especially those with lived experience to be supported and encouraged to train in this field, and to oversee the alternative spaces. The insight that comes from experience, especially in matters that are elusive and volatile such as the brain and mind is so critical to the quality of care that is provided. I have more to say but will celebrate EID first, then I’ll restack with a note! Eid Mubarak to both of you!
This is wonderful! Thank you for articulating this so well: "The best clinicians are the ones who use their own lived experience," the importance or reciprocity, learning goes both ways, and of staying "uncomfortable" with dogma, what we are taught or absorb in training. Sorry to gush but I am now a fan. Thank you!