The Unsettled Work of Psychiatry in 2025
The ethical demand to honor complexity and pluralism
Something I appreciated in both the profile and the companion blog post was Dan’s take on where the psychiatric profession sits in relation to the wider society and how that perspective frames the work I’m doing. I want to use this post to highlight that.
Dan imagines “the binary that structures, or imprisons, so much of the conversation and conflict about mental health and illness” as a distrustful conversation between two figures standing on either side of a chasm. On one side is the Scientist, a polished academic psychiatrist researcher who believes that incremental improvements in science and medical care will eventually result in sweeping breakthroughs, and the best thing to do is to continue on this path. On the other side is the Survivor, say, a person whose early psychiatric diagnosis led to decades of hospitalizations, shifting labels, and cocktails of medications before she broke away, connected with fellow humans with similar stories, and embraced a sweeping critique of psychiatry and the medical system. Both aim to reduce suffering, yet each operates inside a rigid worldview that leaves them, and us, poorly equipped to properly understand and tackle the problems we confront.
“One way to conceptualize Aftab’s project, in this schema, is that he’s trying to listen closely to what these two figures have to say, assimilating what’s valuable in their perspective, while adding more voices to the conversation, each with their own valuable but incomplete perspective…
It’s a chorus of voices and overlapping ways of understanding and approaching the mind and its discontents, not a single paradigm or silver bullet. “Psychiatry has had a tendency to rely on single answers based on different kinds of faddish paradigms,” says Aftab. “Pretty early in my career, I realized that that’s not going to take us anywhere meaningful. So we have to do two things. One, we give up the search for simple answers and embrace complexity in a meaningful way. Secondly, we embrace a very strong form of humility…”
It’s not, on the surface, a radical way of looking at a topic that everyone concedes is immensely complex. What’s radical in it, perhaps, is the revision that truly, madly, deeply adopting it would demand to psychiatrists’ sense of themselves and their way of being with patients.” (my emphasis)
I love this last sentence! I don’t know if I could’ve put it any better myself.
This is not in the profile Dan wrote, but in addition to the Scientist-Survivor dynamic, there is another opposition of roles I’ve been mindful of, and one I’ve been trying to resist and transcend. I’ve previously described it as the dialectic between the Repenter and the Represser (borrowing terms from the philosopher Liam Kofi Bright) in Psychiatric Psychodrama:
“The Repenter type in psychiatry responds to the history of the profession with an overwhelming sense of guilt and alleviates this guilt by engaging in vocal and performative criticisms of contemporary psychiatric practices, and constant exhortations that the profession has lost its soul. All the while, the Repenter will either work outside the public system, such as private practice, catering to those who can afford such services, thereby contributing to existing inequities in care for the most vulnerable members of the society, or will work within the public system such that their day-to-day practices are highly constrained by systemic forces and by and large indistinguishable from those of their colleagues, both situations further aggravating their guilt and the need for performative action. The Represser rejects any admission of guilt and sees it as a sign of irrational self-hatred. They will emphasize the progress that has been made in the field, the growth in scientific knowledge, and the availability of interventions and evidence of efficacy and safety from randomized controlled trials. They will highlight the horrors patients had to endure prior to the arrival of modern psychopharmacology, and reassure themselves that although things could be better, we are not doing so bad after all. Patients and service users — at least the ones who are sufficiently engaged in this politics — are largely devoid of power and representation, but opportunities arise for them to align themselves with either the Repressers or the Repenters, and use their lived experiences to support the narratives of the two groups.”
Dan touches on the parallel I’ve previously drawn between the psychiatric profession and the police. Both encounter people at fragile moments, both wield unusual authority over others, both carry long records of mistakes and harm, and both remain woven into how society functions. That mix of power and necessity invites relentless public scrutiny.
“This often feels unfair to their practitioners, and no doubt much of it is unfair. The key point for Aftab, though, is that in a global sense it’s utterly fair that psychiatrists (and police too, surely) receive this level of skepticism. It’s simply the job, with all its privileges and burdens. Psychiatrists are paid well, accorded high social status, legally vested with the power to prescribe psychoactive drugs, and charged with managing profound decisions about not just what kinds of lives many of us will lead but the very terms by which we will understand them. How could it be otherwise?
To be a psychiatrist in America in 2025, then, isn’t a bad thing to be, but it’s complicated. And the ethical demand is to honor that complexity, within pragmatic reason, to the best of your ability.
What this looks or sounds like is highly context dependent. It will look different in a cozy office with a worried-well patient than in a hospital ER confronting someone with severe psychosis, and different yet again in the pages of an academic journal of philosophy of science. To read Aftab over time, however, is to get an increasingly strong sense of the feel of it.”
There is additional useful context in Dan’s companion post on his Substack:
“… my sense is that we’re approaching a tipping point when it comes to the professional (and ultimately public) understanding of our diagnostic categories for mental illness… This larger transformation isn’t explicitly what my profile of Aftab is about, but I think it’s the subtext. It’s why giving so much attention to him felt worthwhile to me, because we’re in this weird intellectual space where so many of the smartest and most thoughtful mental health practitioners absolutely know that the old paradigm is exhausted, and are pragmatically going about their clinical lives with this exhaustion in mind, but the public discourse is still mostly conducted in the old language and concepts.”
A weird intellectual space it indeed is!
It means a great deal to me that thoughtful, eloquent people like Daniel Oppenheimer have spent this much time with my work and have found value in it. I plan to keep going. As I’ve said previously, Psychiatry at the Margins is a one-person-plus-friends operation. Many of the ideas readers gravitate toward are borrowed from, or developed in collaboration with, folks who are more knowledgeable, sharp, and wise than I am. I hope what I’m doing also helps guide people toward engaging with that larger body of thought.
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