Awais Aftab Rising

My profile of the integrative critical psychiatrist.

I have a profile of Psychiatry at the Margins Substacker Awais Aftab over at Psychotherapy Networker. I spoke to Aftab on the podcast a few months ago, but in case my fascination with his work wasn’t sufficiently clear from that conversation, now you can read 3,500 more words about it.

From the piece:

What [Aftab] does is bypass the binary that structures, or imprisons, so much of the conversation and conflict about mental health and illness in America. I sometimes visualize this conversation as a kind of tableau in which two figures are standing on either side of a chasm, glaring across at each other with deep suspicion. The rest of us are huddled down below in the chasm. We’re vastly more numerous but far less organized and far less clear on what we think, and so we defer, uneasily, to the figures above.

One figure is the Scientist, the very model of a modern biological psychiatrist. He’s in his 50s, has an MD-PhD from Harvard, is chair of a department at a major research university, and is the principal investigator on a big, multi-site study of treatment for first episode psychosis. He’s aware in an ambient way that people have suffered, in the past, from the profession’s excessive faith in its own expertise, and that his field has yet to establish a really firm biological understanding of the kinds of distress it treats and studies. This doesn’t, however, inspire in him much skepticism. Instead, his core motivating belief is that by doing the science and treatment better this time around, we can improve people’s lives in small ways in the short term and move inexorably toward truly transformative conceptualizations and treatments for mental illness in the long term.

Opposite him is the Survivor. She’s in her 50s as well. When she was a teenager, she began acting out in ways that so alarmed her parents they brought her to a psychiatrist, who diagnosed her with bipolar disorder I, prescribed her some meds, and conveyed to her and her parents that the best she could probably hope for, long term, was a simple, highly medicated, highly managed life. A half-life, basically, but one that was tolerable. For the next few decades, like so many people with severe mental distress, she rode a roller coaster of dysfunction that involved occasional institutionalizations, periods of relative stability, long stretches of living with her parents, various revisions and additions to her diagnoses, and increasingly complex cocktails of medications. At some point, after reading the right book or finding the right online forum, she decided to get off most or all of her medications, joined a community of fellow survivors with similar stories, and reoriented her identity around a root-to-branch critique of psychiatry, the mental health system, and the medicalization of human distress and neurodiversity.

Both the Scientist and the Survivor are good, caring people. They’re both driven to help others, and they rely on their hard-won insight into the nature of the human psyche and human suffering to aid them in doing so. But they’re each, unfortunately, trapped within a too-rigid framework for understanding the world in which they, and we, live.

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.

Read the rest over at Psychotherapy Networker (it’s free to read, but you have to give them your email address).

I’m terrible at predictions, so take this with a huge grain of salt, but 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. Or to put it another way: I don’t think we’ll be using the DSM in remotely the same way in 20 years, if we’re using it at all. It feels like a very rickety structure to me, one that even its defenders are defending in suspiciously qualified and nuanced ways. And when I say we won’t be using it, I don’t mean that in a narrow sense, in which some other diagnostic manual will replace the DSM. I mean that the whole way of conceptualizing mental distress and illness that is most powerfully reified by the DSM, as these discrete, semi-scientific disorders that we “have,” will be (or at least should be) radically displaced.

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.

Someone like Aftab, then, is especially valuable because he’s bringing these critiques that are well understood within the profession into the public space. New Yorker writer Rachel Aviv, who I interview for the article, and who was recently interviewed by Aftab on his Substack, is also great in this way. Her book Strangers to Ourselves: Unsettled Minds and the Stories That Make Us is super smart on this subject.

One of the reasons I pushed Freddie deBoer so much on his beef with Aftab, when I interviewed him on the podcast (now unpaywalled), is that I see him as another writer who is trying to navigate all these complicated scientific, political, and social tensions in a pragmatic and thoughtful way that is oriented, above all, toward helping people. It pains me that he goes so hard at Aftab, and it also seems unnecessary. The book he’s working, and the one that Aftab is working on, should be complementary efforts to reorient the public conversation around mental health and illness.

Anyway, read the piece, and let me know what I got wrong in the comments.