The Szaszian Heart of MAHA Psychiatry

Moderate-sounding entry points to an unpopular agenda

Daniel Bergner is an attentive and prudent writer who has covered mental healthcare with more care and seriousness than most. His latest piece in the New York Times Magazine, “The Strange Alliance Trying to Remake American Psychiatry,” generously describes this substack as “cautiously thoughtful,” and it is precisely as someone he treats as a fair interlocutor that I want to take issue with the narrative he constructs in the rest of his article. If even a writer like Bergner has these blind spots, that is itself worth examining. It reveals how readily thoughtful commentators can fall into a binary that obscures what is most distinctive, and most contestable, about the Moncrieff-Whitaker-Delano brand of psychiatric critique.

The article builds on a familiar opposition. On one side, “around 1980, mainstream psychiatry adopted a medical model” and ever since, “troubles of the mind have been viewed mostly as physiological diseases of the brain, with treatments focused largely on pharmaceuticals.” On the other side, a movement of reformers and dissidents calling for something… different. Bergner does not say what that something different is, exactly. He gestures at “foundational change” and how some critics want “a true conceptual revamping.” But the alternative remains a kind of negative space in the piece.

I am not defending the particular version of psychiatry Bergner describes. The disease-based, reductive, chemical imbalances-corrected-by-pharmaceuticals account of mental health problems is one I have spent years criticizing. Bergner isn’t wrong about the limitations of that picture. The problem is that in his piece he treats this picture as if it constituted the medical foundation of psychiatry and treats the critics he profiles as if they were the natural and unique alternatives to it.

You know what else was published in 1980, by the way? George Engel’s “The clinical application of the biopsychosocial model” in the American Journal of Psychiatry. The “medical model” that Bergner places as having taken over psychiatry in 1980 was already, in 1980, being articulated in a form quite different from the one he describes.

As I have written before, there is a long-standing public confusion in which the medical model is identified with the idea that all psychiatric conditions are discrete biological disease entities of the brain. This caricature isn’t true even of much of general medicine, which routinely deals with multifactorial syndromes, problems shaped by environment and trauma, conditions defined by symptom clusters without identifiable biomarkers, and it certainly isn’t true of psychiatry. What we call the “medical model,” properly understood IMO, is an aspiration to extend the conceptual and practical tools of general medicine to mental health problems: classification and diagnosis, attention to natural history, multi-level causal explanation, and the use of a wide treatment armamentarium that includes, but is by no means exhausted by, pharmacotherapy. It is also a model that, in theory, comfortably exists in a broader pluralism of clinical and non-clinical approaches.

The binary of disease-based reductive psychiatry on one side and “critical psychiatry” on the other nudges us to assume there is nothing in between. In fact, the space between is large and well populated. Various strands of explanatory and methodological pluralism and theoretical developments like embodied cognition, enactivism, complex dynamic systems, phenomenological psychopathology, psychodynamic psychiatry, social determinants of health, etc… these are not minor footnotes. They are scientifically grounded, neuroscientifically and psychologically informed, philosophically aware, humanistically oriented, and deeply skeptical of reductionism.

The critics of psychiatry depend on this binary being invisible. If the only choices on offer are 1980s neuro-reductionism on one side and a self-righteously critical, anti-medical posture on the other, then anyone disenchanted with the first is shepherded toward the second. Once you see the binary, you see that the rhetorical machinery of critical psychiatry runs on it.

Bergner places Thomas Szasz at “the far edge of the movement.” I don’t believe that’s correct. Maybe that’s true in terms of how Szasz exists in our contemporary imagination as some ridiculous antipsychiatry arch-villain, but it’s definitely not true in terms of Szasz’s actual ideas. The Szaszian core, the view that mental illnesses are not illnesses at all, that the medical characterization of psychic suffering is a category error, that what we call “mental disorder” is really a moralized description of problems in living, is not at the periphery of contemporary critical psychiatry. It is at its heart of it. Joanna Moncrieff has openly defended Szaszian conceptions of mental illness. Laura Delano’s own conceptual framing of her psychological difficulties sits squarely in this tradition. The Szaszian commitments are load-bearing. Robert Chapman has traced the persistence of Szaszian assumptions across the broader critical literature.

I’d expect someone like Bergner to ask Delano on the record: what, exactly, do you disagree with in the Szaszian conception of mental illness? I’ve read her book. I can’t say I can articulate that there is a disagreement on the core ideas.

Bergner writes of Delano that her diagnoses “might have been better understood as a reaction to life’s trials.” I find this telling.

What does it mean to characterize something as a reaction to life’s trials in a manner that threatens the psychiatric conceptualization of mental disorders? Does psychiatry have no vocabulary to talk about reactions? Do “reactions” of all variety lie outside the proper concerns of medicine? Reactions can very well be excessive, prolonged, disabling, dangerous… what then makes the concept of “reaction” stand in contradiction to the concept of “disorder”? Reactions can be sticky and can be responsive to a wide range of interventions, including medications. Reactions can be and are shaped by biology and personality.

The dichotomy of “reaction” versus “disorder” is a false one. Some reactions are disorders, and some disorders are reactions. Once you recognize that minds are embodied, embedded, and enacted, these binaries dissolve quickly. Psychiatric conditions have simultaneous neurophysiological, experiential, existential, and sociocultural dimensions. We know this!

The seductiveness of the binary is precisely the Szaszian tradition at work: it requires illnesses to be discrete biological essences and, absent evidence of such an essence, declares the application of illness concepts a category mistake.

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I want to note, with some bemusement, Bergner’s parenthetical aside: “Aftab, who is hardly a radical critic of his field…” I do not object to the description. By the standards of Mad in America, I am hardly radical. I also don’t care about being radical. I care about getting it right. If I thought the radical critics were getting it right, concerns about radicalism would not stop me. But I don’t think they are.

The implicit logic seems to be: even Aftab, who is no radical, sees these problems. This is meant to lend credibility to the critique. Fair enough. But who are the radical critics? Delano? Whitaker? Davis? Are we supposed to cheer for the radicals? And why are the radicals bending over backwards to present moderate versions of themselves to the American public?

We are in this weird moment where some woke critics of psychiatry will say things like “Abolish psychiatry!” and when pressed on what they mean by “abolish,” it’ll turn out that they mean something like, “judicious use of medications and comprehensive biopsychosocial services and sociopolitical action aimed at social determinants of health.” Very radical! (E.g. see Emmett Rensin’s review of Empire of Madness.)

But when it comes to the current iteration of the MAHA movement, we are dealing with the inverse phenomenon. There is a deliberate moderation of positions. Over-pathologization, over-medicalization, iatrogenic harm, etc, all the right buzzwords, and when pressed on the specifics of their psychiatric worldview, it emerges that they mean something quite Szaszian.

To Whitaker’s credit, in his comments to Bergner, he’s not playing the moderation game: “I don’t think serious reform is enough.” Language like “overmedicalization” is, for him, “limited in outlook,” “implied call for reduction rather than a true conceptual revamping,” “entrenching instead of displacing psychiatry’s medical model.”

It also tells us what the public face of the movement is doing. “Overmedicalization” and “overprescribing” are popular and sympathetic causes — who could really be against them? — and they function as the moderate-sounding entry points to an underlying program that, if stated plainly, would lose most of its public support.

If someone doesn’t even believe in the reality of mental illness, I don’t quite think they can be seen as having valid concerns about “overdiagnosis,” when, by the logic of their own framework, every diagnosis is overdiagnosis.

As I’ve written previously, the Whitaker-Moncrieff version of critical psychiatry, at its core, is a philosophically and scientifically exhausted movement. Despite a lot of effort, it has not persuaded the clinical and scientific communities of the positive account it offers of the nature of psychopathology and its treatment. Having lost the argument inside medicine, the movement has pivoted to the public square, leaning on the popular and sympathetic vocabulary of overdiagnosis and overmedicalization, and finding political traction with a government whose anti-expertise sensibilities make it unusually receptive to its agenda. Where the political and cultural influence of this pivot will peak, I do not know and I am afraid, but philosophically and scientifically, it is already stagnant and degenerating fast.

The one domain in which critical psychiatry has, in my view, gained genuine clinical ground is around antidepressant discontinuation and the practice of hyperbolic tapering. And there, the cause has advanced with momentum because the patient experience of withdrawal and successful use of hyperbolic tapering filled a medical gap where guidance was genuinely lacking; it is still notable that we neither have high-quality scientific evidence for expansive conceptions of protracted withdrawal nor for the specific efficacy of hyperbolic tapering regimens.

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A useful diagnostic question for understanding MAHA’s relationship to medicine is: what is the source of MAHA’s ideas about medical reform? These ideas are a dangerous mix of respectable science, fringe science, and pseudoscience… as we have seen in situations like vaccines, psychedelics, autism etiology, and nutrition. MAHA psychiatry is no different in this regard, but proponents are noticeably more cautious in how they present things to the public.

To the extent the MAHA proposals on psychiatry have merit and broad appeal, they generally articulate existing ideals of good psychiatric practice. More awareness of medication risks. Less reflexive prescribing in primary care. Fewer antipsychotics off-label for non-psychotic indications in children. More non-pharmacologic options. More humility about long-term maintenance. Psychiatric mainstream has been moving (too slowly and too defensively, perhaps, but moving) toward each of these positions for years. The MAHA position there is a louder version of existing medical wisdom the field has under-prioritized. Fine.

But what makes MAHA psychiatry MAHA and gives it its distinctive character are precisely the ideas that go beyond existing ideals of good psychiatric practice, that are on theoretically shaky ground, and where the scientific community hasn’t been persuaded because the evidence isn’t there yet to persuade enough physicians.

Furthermore, whatever MAHA psychiatry says, the Trump administration’s broader agenda has been to weaken the public health and social safety net infrastructure that any humane response to mental illness depends on.

This is why I hesitate to endorse even the sensible-sounding parts of MAHA agenda. Bergner’s piece is structured around the optimistic framing of the alliance. What if this works? You can kinda tell that he is hopeful against odds that it will work. But he gives less attention to the structure of the alliance.

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Anything MAHA touches today will be studied by scholars in coming decades as the health rhetoric of twenty-first-century American fascism.

Strange alliances are sometimes necessary in politics, but nothing about the MAHA-critical psychiatry convergence is a strange coincidence. It is the natural unfolding of the logic of disability-skepticism, bodily purity, self-reliance, and medical distrust.

Bergner is right that something is shifting. Vibes. Just like the MAGA cultural vibe shift of early 2025, I believe the prognosis of this vibeshift is guarded. Not because of pharma ads on TVs or because of the psychiatric establishment holding on to its scientific authority, but because curbing medical authority will not, on its own, produce better collective mental health. It is the wrong instrument for the goal, like expecting tariffs to stimulate economic growth.

A quarter of the way into the twenty-first century, we are only beginning to scratch the surface of the deep wells of human mental suffering. Psychiatry, clinical psychology, and social work are reaching, and over-reaching, as they search for solutions. They are also, for all their faults, engaged in the project of understanding and remedying psychological suffering through scientific evidence, clinical humanism, and public accountability. For now, they are the only game in town.

Man Ray, Max Ernst, 1934.

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See also:

Unshrunk and MAHA: A Diagnosis-Critical Case Study

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