Thank you Awais for putting into words what I have been struggling with since I started practicing- ‘what can I do for the person who is in front of me right now’ is a very different to ‘what would I do for this person in a world where there are no structural, resource, or individual constraints.’ Treatment planning with someone who has stable housing, good social supports, good health, good insight and good judgement is very different to treatment planning with someone who does not have those things, yet many of our policies and guidelines assume the former. Case in point: ‘suicidal patients do better in their own home with the support of their loved ones than being in hospital’ is only true if they have a home and supportive family who are capable and willing to care for them. Gold standard care presumes gold standard funding, and gold standard environments.
Thank you again Awais for a clinically grounded piece and as always nuanced and wise! As a clinical psychologist in Sweden the dilemma of moralizing, overdiagnosing or prioritizing a ”subclinical” over someone with more severe problems is an everyday occurrence in our government sponsored health care system. I also think you make the situation so vivid in which you have somebody suffering right in front of you even if they may not be the correct level of care for the psychiatric out- patient clinic where I work. Being honest, validating of their experience and inserting some education about the complexity of mental health issues that Bob Krueger, Colin DeYoung, and you narrate so elegantly, I agree is probably the most respectful and helpful response. Thank you!
This insightful essay is, on the surface, a reflective piece about the knotty challenges of psychiatric practice. Drop a little deeper, though, and for me it becomes a disturbing critique of our modern civilization. What kind of world do we live in where this is the kind of impossible job carried by those who have the most to give? Thank you Awais, for what you do, and for writing about it.
We gotta keep two things in mind at the same time: first, HERE AND NOW the only thing to do might be individual help to the struggling person. But LONG TERM, we shouldn't have a shitty job market and shitty society where SO many people can't keep up and seek psychiatric help as a result.
Clearing my throat, getting up on the soapbox:
Long term, we need political change, we need to rebuild the welfare state (or build one in the first place, in a US context ...), We need to go back to a situation where job security and union membership was the norm - what people WORK WITH can change, but THIS can still be the norm - instead of uncertain gig jobs where everyone constantly compete against each other.
None of what I say would magically make all psychiatric problems go away, but it solves some problems and MITIGATES others. Every single issue described in the DSM gets WORSE if you live under constant stress, job stress and economic stress - or relationship stress, because you can't afford to leave.
Thanks for this! Super helpful to think with. For me it also raises broader questions about agency - what is it, how much do we have, how do we get it, how can we “exercise” it and how much and in what circumstances? And how much this is or is not related to biology, culture, environment, etc. For me, I also wonder if the distinction between clinical and non-clinical or “mental illness” and “mismatch between environment and person’s capacity/disposition” is less often a meaningful distinction than we might think. I think so many of my own patients would have the capacity to more skillfully manage their issues if they had adequate health care, good nutrition, sufficient sleep, stable housing, and fewer instances of abuse in childhood, for instance. Like would they still “have” GAD if they could work reasonable hours and afford childcare and have more time walking in the woods? Would they still “have” ADHD if they didn’t have to answer 40 emails a day and ten phone calls and log into 20 different accounts and sit at a desk for 45 hours a week? I know this is an eternal chicken/egg debate/question with no absolute answer but increasingly I lean in the direction that a significant portion of the suffering I see in my practice is a broader mismatch issue not only for individuals and their own specific environment, but also more generally for humans and the world(s) and systems we have collectively created for ourselves.
This is not to diminish the reality of mental illness or the intrinsic etiology that contributes to them, but just to highlight how nearly impossible it often seems to disentangle this from the general mismatch between the circumstances under which humans are most likely to flourish and circumstances to which most humans are subject.
I continue to love this “What do we owe the...” series. The moral and clinical nuance in these essays is rare and deeply needed. This piece, especially, captures a tension that many of us feel daily: the oscillation between wanting to alleviate suffering in the person in front of us and wanting to avoid colluding with conditions that are harming them.
However, I find myself wondering about a complementary question (that I would love to see a piece from you on): What do we owe the people who are NOT in our offices?
Because the it is impossible to forget my empathy for the patient sitting across from me. Her pain is immediate, embodied, persuasive. If I withhold a diagnosis, a medication referral, an accommodation, I worry I am being "moralistic or disapproving" as you put it. And I worry I am failing to validate her suffering. And yet I also worry that if I empathize only with the pain -- and not with the parts of her that are functioning exactly as designed -- I may dampen important feedback loops in her, in her environment, in the people she interacts with, and in society at large.
For example, let's say I diagnosis a student with ADHD when criteria are not fully met and suggest a trial of stimulants, mostly because a chaotic classroom environment is overwhelming her. How then does the environment get feedback about its limits? When we diagnose "demand–capacity mismatches" as ADHD , teachers may conclude they are excellent at "detecting ADHD" (and go on to refer 5 more children for evaluation next year), rather than wondering if they need stronger universal design in their classrooms. Workplaces and universities may get "better" at providing accommodations to those well-resourced enough to advocate for them, without ever learning that they create environments that exert unsustainable pressures on many of their employees. If high-achieving, medicated parents normalize chronic overextension and crushing perfectionism as “genetic ADHD”, what gets transmitted to their children might be a standard of grueling endurance, stamped with medical legitimacy. When a partner wants to say, “What this environment is asking of you is not sustainable for us,” what happens when they now confront their partner's response of, “No, my psychiatrist assured me this is biological”? A couple that might have re-examined shared goals instead doubles down on them, now medically reinforced.
Over time, each of these decisions also subtly reshapes our shared sense of what is typical, what a meaningful life should look like, and what kinds of suffering are signals to reconsider our path versus symptoms to be medicated away. Young people, especially, absorb these messages, learning to scrutinize every friction point as a potential disorder rather than a clue about fit, limits, or values. Much in the same way that a young woman immersed in beauty culture might begin to experience ordinary appetite or dissatisfaction with cosmetic perfection as evidence that something in her needs medical correction.
There are research and training consequences as well. As diagnostic categories broaden to capture more and more normal but painful problem-in-living scenarios, we risk losing signal. We're already having more difficulty tracking environmental contributors (e.g., it's hard to study how air pollution affects neurodevelopment when "neurodevelopmental disorders" are being diagnosed at high rates in children who are not particularly different from their undiagnosed peers). Our medication and therapeutic effects are also diluting. With finite resources and broadening categories, we're also having more difficulty tracking, conducting essential research, and intervening with severe forms of disorder. And our junior colleagues are struggling to have any understanding of what certain diagnoses "look like" or even mean conceptually, as the categories become so elastic that they could fit anyone.
More existentially, I worry about what cultural anthropology we are co-creating. If friction is routinely medicalized, if signals of mismatch are framed primarily as symptoms, if defeat requires clinical remediation, what happens to meaning, agency, and the creative destruction through which new systems are born? Many of our most important social innovations were built by people who discovered -- painfully -- that a cherished path was not for them and who then went on to build another.
None of this negates the obligation to treat suffering. But it complicates it. Clinical decisions reverberate outward. Resources are finite. Our practices often fill with high-functioning, high-SES strivers who resemble us more than the severely ill do. Who advocates for those outside our waiting rooms when we expand the boundaries of what counts as disorder?
I would be deeply interested in an essay exploring this other side of the moral ledger. Not as an argument for indifference or austerity, but as an honest reckoning with the ecosystem-level consequences of how we deploy empathy, diagnosis, and medical authority. Because while the person in front of us commands our compassion, the people not in the room are affected by our decisions too.
Thank you for this excellent comment, and apologies for my delayed reply! I definitely share your concerns and they are quite legitimate. Something I need to develop further in future posts. One thing I'll say is that I also agree that sweeping demand-capacity mismatches that don't meet diagnostic thresholds under formal diagnoses is not the right answer, or is at best a temporary solution. It leads to all sorts of downstream problems that you highlight, and it is also deceptive. This is why I emphasize the need for the better clinical language. The problem right now is that our options are fairly limited: either stretch a diagnostic category in a way that misrepresents the situation (/changes its clinical meaning) or do nothing and dismiss the problem as not being a clinical problem. And the first step out of this, I suspect, is developing a clinical language that can accurately talk about the problem at hand without clinically dismissing it or misrepresenting it. More later!
Appreciate this synthesis of something many of us struggle with as those who are asked to help when someone come to us with their suffering right now. Weighing short and long term benefits and discerning current capacity and what it would take to increase capacity, and being honest, transparent, and collaborative in that process. As a psychologist working to help my clients grow their capacity to adapt, to make structural changes when possible, and to find and adopt more effective interpretations (meaning making), I agree that CBT and DbT can be useful tools. However they can also be inadequate tools for certain types of meaning making challenges. There are better therapies and sometimes avenues unrelated to therapy that are far more impactful. (Like reading good literature, for example).
I have suggested it previously, but, if others find Big 5 or equivalent trait models sort of ambiguous with regards to "adaptation to context", that is growth and self-actualization, I suggest Dabrowski's theory of positive disintegration useful. Unlike most in psy-land, he embraces neuroticism as a driver of positive change. https://en.wikipedia.org/wiki/Positive_disintegration
The only question is, when does one pull the plug, if you will, in regards to relying on turmoil to pursue goals? When is suffering no longer justified?
I called it quits on my 2nd episode of psychosis in my last grad school. Not worth the third, imo. Now, all i care for is stability with cyclical jolts of plasticity (chaos) to keep life interesting and on my toes.
Hard to do when psychometrics tailors towards averages rather than individuals.
I also value this chance to think and reflect on what we're all doing.
It's pretty tough to acknowledge our limitations while still being helpful to the person in front of us.
Framing some clinical and non-clinical problems as mismatches can be face-saving for the (I'm just going to say 'patient' here) patient. I have concerns about, in an instance of mismatch, which side has to make the adjustment; it may be that only one side is capable of any movement.
This calls to mind the large issue of how/when/if we "help" the patient by medically calling for some accommodations on the part of a school or business; how many of us have been asked to endorse an ADHD student's getting "50% more time" to complete exams? And do we ever rescind that once the symptoms are well-controlled? My guess, not much. One can extend that kind of discussion to disability, a "break" from work, even jury duty excuses. I get that I'm referring to more clearly clinical matters, but the boundary between mismatch and accommodation for symptoms is not ironclad.
Some people, after we've heard the history, have a pattern of finding themselves in what they've seen as mismatches, not of their making. We do have to point that out when we see it. It cannot be that a series of bad experiences with supervisors, coworkers, friends, spouses should be written off by the patient as mismatches. We owe the overburdened the truth, presented humbly and with compassion, as we understand it.
I am a longtime fan of Jay Haley, who I remember asking hospitalized psychotic patients things like "how did you arrange to be hospitalized?" I have used a less-snarky form of that question with good results often. We can usually control little of the patient's outside world, but we can help them deal with it more effectively. Most people do have power they're either not aware of, or are using it to shoot themselves in the foot.
Thank you Awais for putting into words what I have been struggling with since I started practicing- ‘what can I do for the person who is in front of me right now’ is a very different to ‘what would I do for this person in a world where there are no structural, resource, or individual constraints.’ Treatment planning with someone who has stable housing, good social supports, good health, good insight and good judgement is very different to treatment planning with someone who does not have those things, yet many of our policies and guidelines assume the former. Case in point: ‘suicidal patients do better in their own home with the support of their loved ones than being in hospital’ is only true if they have a home and supportive family who are capable and willing to care for them. Gold standard care presumes gold standard funding, and gold standard environments.
Thank you again Awais for a clinically grounded piece and as always nuanced and wise! As a clinical psychologist in Sweden the dilemma of moralizing, overdiagnosing or prioritizing a ”subclinical” over someone with more severe problems is an everyday occurrence in our government sponsored health care system. I also think you make the situation so vivid in which you have somebody suffering right in front of you even if they may not be the correct level of care for the psychiatric out- patient clinic where I work. Being honest, validating of their experience and inserting some education about the complexity of mental health issues that Bob Krueger, Colin DeYoung, and you narrate so elegantly, I agree is probably the most respectful and helpful response. Thank you!
This insightful essay is, on the surface, a reflective piece about the knotty challenges of psychiatric practice. Drop a little deeper, though, and for me it becomes a disturbing critique of our modern civilization. What kind of world do we live in where this is the kind of impossible job carried by those who have the most to give? Thank you Awais, for what you do, and for writing about it.
Great piece as always.
We gotta keep two things in mind at the same time: first, HERE AND NOW the only thing to do might be individual help to the struggling person. But LONG TERM, we shouldn't have a shitty job market and shitty society where SO many people can't keep up and seek psychiatric help as a result.
Clearing my throat, getting up on the soapbox:
Long term, we need political change, we need to rebuild the welfare state (or build one in the first place, in a US context ...), We need to go back to a situation where job security and union membership was the norm - what people WORK WITH can change, but THIS can still be the norm - instead of uncertain gig jobs where everyone constantly compete against each other.
None of what I say would magically make all psychiatric problems go away, but it solves some problems and MITIGATES others. Every single issue described in the DSM gets WORSE if you live under constant stress, job stress and economic stress - or relationship stress, because you can't afford to leave.
Thanks for this! Super helpful to think with. For me it also raises broader questions about agency - what is it, how much do we have, how do we get it, how can we “exercise” it and how much and in what circumstances? And how much this is or is not related to biology, culture, environment, etc. For me, I also wonder if the distinction between clinical and non-clinical or “mental illness” and “mismatch between environment and person’s capacity/disposition” is less often a meaningful distinction than we might think. I think so many of my own patients would have the capacity to more skillfully manage their issues if they had adequate health care, good nutrition, sufficient sleep, stable housing, and fewer instances of abuse in childhood, for instance. Like would they still “have” GAD if they could work reasonable hours and afford childcare and have more time walking in the woods? Would they still “have” ADHD if they didn’t have to answer 40 emails a day and ten phone calls and log into 20 different accounts and sit at a desk for 45 hours a week? I know this is an eternal chicken/egg debate/question with no absolute answer but increasingly I lean in the direction that a significant portion of the suffering I see in my practice is a broader mismatch issue not only for individuals and their own specific environment, but also more generally for humans and the world(s) and systems we have collectively created for ourselves.
This is not to diminish the reality of mental illness or the intrinsic etiology that contributes to them, but just to highlight how nearly impossible it often seems to disentangle this from the general mismatch between the circumstances under which humans are most likely to flourish and circumstances to which most humans are subject.
I continue to love this “What do we owe the...” series. The moral and clinical nuance in these essays is rare and deeply needed. This piece, especially, captures a tension that many of us feel daily: the oscillation between wanting to alleviate suffering in the person in front of us and wanting to avoid colluding with conditions that are harming them.
However, I find myself wondering about a complementary question (that I would love to see a piece from you on): What do we owe the people who are NOT in our offices?
Because the it is impossible to forget my empathy for the patient sitting across from me. Her pain is immediate, embodied, persuasive. If I withhold a diagnosis, a medication referral, an accommodation, I worry I am being "moralistic or disapproving" as you put it. And I worry I am failing to validate her suffering. And yet I also worry that if I empathize only with the pain -- and not with the parts of her that are functioning exactly as designed -- I may dampen important feedback loops in her, in her environment, in the people she interacts with, and in society at large.
For example, let's say I diagnosis a student with ADHD when criteria are not fully met and suggest a trial of stimulants, mostly because a chaotic classroom environment is overwhelming her. How then does the environment get feedback about its limits? When we diagnose "demand–capacity mismatches" as ADHD , teachers may conclude they are excellent at "detecting ADHD" (and go on to refer 5 more children for evaluation next year), rather than wondering if they need stronger universal design in their classrooms. Workplaces and universities may get "better" at providing accommodations to those well-resourced enough to advocate for them, without ever learning that they create environments that exert unsustainable pressures on many of their employees. If high-achieving, medicated parents normalize chronic overextension and crushing perfectionism as “genetic ADHD”, what gets transmitted to their children might be a standard of grueling endurance, stamped with medical legitimacy. When a partner wants to say, “What this environment is asking of you is not sustainable for us,” what happens when they now confront their partner's response of, “No, my psychiatrist assured me this is biological”? A couple that might have re-examined shared goals instead doubles down on them, now medically reinforced.
Over time, each of these decisions also subtly reshapes our shared sense of what is typical, what a meaningful life should look like, and what kinds of suffering are signals to reconsider our path versus symptoms to be medicated away. Young people, especially, absorb these messages, learning to scrutinize every friction point as a potential disorder rather than a clue about fit, limits, or values. Much in the same way that a young woman immersed in beauty culture might begin to experience ordinary appetite or dissatisfaction with cosmetic perfection as evidence that something in her needs medical correction.
There are research and training consequences as well. As diagnostic categories broaden to capture more and more normal but painful problem-in-living scenarios, we risk losing signal. We're already having more difficulty tracking environmental contributors (e.g., it's hard to study how air pollution affects neurodevelopment when "neurodevelopmental disorders" are being diagnosed at high rates in children who are not particularly different from their undiagnosed peers). Our medication and therapeutic effects are also diluting. With finite resources and broadening categories, we're also having more difficulty tracking, conducting essential research, and intervening with severe forms of disorder. And our junior colleagues are struggling to have any understanding of what certain diagnoses "look like" or even mean conceptually, as the categories become so elastic that they could fit anyone.
More existentially, I worry about what cultural anthropology we are co-creating. If friction is routinely medicalized, if signals of mismatch are framed primarily as symptoms, if defeat requires clinical remediation, what happens to meaning, agency, and the creative destruction through which new systems are born? Many of our most important social innovations were built by people who discovered -- painfully -- that a cherished path was not for them and who then went on to build another.
None of this negates the obligation to treat suffering. But it complicates it. Clinical decisions reverberate outward. Resources are finite. Our practices often fill with high-functioning, high-SES strivers who resemble us more than the severely ill do. Who advocates for those outside our waiting rooms when we expand the boundaries of what counts as disorder?
I would be deeply interested in an essay exploring this other side of the moral ledger. Not as an argument for indifference or austerity, but as an honest reckoning with the ecosystem-level consequences of how we deploy empathy, diagnosis, and medical authority. Because while the person in front of us commands our compassion, the people not in the room are affected by our decisions too.
Thank you for this excellent comment, and apologies for my delayed reply! I definitely share your concerns and they are quite legitimate. Something I need to develop further in future posts. One thing I'll say is that I also agree that sweeping demand-capacity mismatches that don't meet diagnostic thresholds under formal diagnoses is not the right answer, or is at best a temporary solution. It leads to all sorts of downstream problems that you highlight, and it is also deceptive. This is why I emphasize the need for the better clinical language. The problem right now is that our options are fairly limited: either stretch a diagnostic category in a way that misrepresents the situation (/changes its clinical meaning) or do nothing and dismiss the problem as not being a clinical problem. And the first step out of this, I suspect, is developing a clinical language that can accurately talk about the problem at hand without clinically dismissing it or misrepresenting it. More later!
Appreciate this synthesis of something many of us struggle with as those who are asked to help when someone come to us with their suffering right now. Weighing short and long term benefits and discerning current capacity and what it would take to increase capacity, and being honest, transparent, and collaborative in that process. As a psychologist working to help my clients grow their capacity to adapt, to make structural changes when possible, and to find and adopt more effective interpretations (meaning making), I agree that CBT and DbT can be useful tools. However they can also be inadequate tools for certain types of meaning making challenges. There are better therapies and sometimes avenues unrelated to therapy that are far more impactful. (Like reading good literature, for example).
I have suggested it previously, but, if others find Big 5 or equivalent trait models sort of ambiguous with regards to "adaptation to context", that is growth and self-actualization, I suggest Dabrowski's theory of positive disintegration useful. Unlike most in psy-land, he embraces neuroticism as a driver of positive change. https://en.wikipedia.org/wiki/Positive_disintegration
The only question is, when does one pull the plug, if you will, in regards to relying on turmoil to pursue goals? When is suffering no longer justified?
I called it quits on my 2nd episode of psychosis in my last grad school. Not worth the third, imo. Now, all i care for is stability with cyclical jolts of plasticity (chaos) to keep life interesting and on my toes.
Hard to do when psychometrics tailors towards averages rather than individuals.
I also value this chance to think and reflect on what we're all doing.
It's pretty tough to acknowledge our limitations while still being helpful to the person in front of us.
Framing some clinical and non-clinical problems as mismatches can be face-saving for the (I'm just going to say 'patient' here) patient. I have concerns about, in an instance of mismatch, which side has to make the adjustment; it may be that only one side is capable of any movement.
This calls to mind the large issue of how/when/if we "help" the patient by medically calling for some accommodations on the part of a school or business; how many of us have been asked to endorse an ADHD student's getting "50% more time" to complete exams? And do we ever rescind that once the symptoms are well-controlled? My guess, not much. One can extend that kind of discussion to disability, a "break" from work, even jury duty excuses. I get that I'm referring to more clearly clinical matters, but the boundary between mismatch and accommodation for symptoms is not ironclad.
Some people, after we've heard the history, have a pattern of finding themselves in what they've seen as mismatches, not of their making. We do have to point that out when we see it. It cannot be that a series of bad experiences with supervisors, coworkers, friends, spouses should be written off by the patient as mismatches. We owe the overburdened the truth, presented humbly and with compassion, as we understand it.
I am a longtime fan of Jay Haley, who I remember asking hospitalized psychotic patients things like "how did you arrange to be hospitalized?" I have used a less-snarky form of that question with good results often. We can usually control little of the patient's outside world, but we can help them deal with it more effectively. Most people do have power they're either not aware of, or are using it to shoot themselves in the foot.
If you are idle, be not solitary, but if you must, then be not idle.