Psychiatry, Psychology, and Society: Multilevel Conversations at the Margins
An open conversation about contemporary issues in mental health
Introduction to the conversation.
The impetus for the below “Substack conversation post” between myself and
first originated when I found myself very much engaged and challenged by the content and insights from Awais’s excellent Substack Psychiatry at the Margins. Recognizing our common interests, along with the fact that we are both members of the HiTOP consortium, I saw an opportunity for dialogue that might be of value to both of our readerships given that: (1) I recognized we draw from different subsets of readership orientations to issues in mental health, psychology, and psychiatry; and (2) we both had notable points of disagreement both on conceptual orientations to mental health issues, but also on the specific issues discussed below, that we were willing to discuss and debate in good faith in a longer-form medium. As I said when I initially reached out to Awais via e-mail after engaging with him on Substack:I think we have a lot of common interests despite what appear to be some different views, but I think talking about them together might be of value for both of our audiences. I have really enjoyed and been challenged by your commentary on Substack. I also know we are both in HiTOP. Stigma & shame come to mind as possible ideas to discuss (as does nosology from both an individual and social perspective). Let me know what you think. No pressure!
Below is the discussion that resulted from a back and forth over several weeks with Awais. This discussion is also timely as it coincides with his recent co-authored piece ‘Philosophy of psychiatry: theoretical advances and clinical implications’ in World Psychiatry. I hope readers and other public intellectuals who have written on the mental health issues discussed herein, such as
, , , , , , , , and among others, find value in the discussion and help continue the conversation by adding their own commentary and reactions. It is only by open dialogue that I think the mental health fields can survive intact the current crises that are facing them.—
Haltigan: How do you describe the field/discipline of “critical psychiatry”? What would you say is its conceptual/theoretical undergirding? How do you define “Mad studies?” Is there a thinker/intellectually associated with this particular strand of intellectual thought? I have read the Wikipedia page for Mad studies, but I would trust your comments much more so as to its accuracy, etc.
Aftab: “Critical psychiatry” and “mad studies” are both fuzzy enterprises with flexible boundaries, and they can be difficult to pin down.
There is a general and broad sense in which critical psychiatry is about critiques of mainstream psychiatry and its tendencies towards biological reductionism, diagnostic reification, medicalization, influence of pharmaceutical industry, neglect of iatrogenic harm, neglect of lived experience, etc. This is the sense I adopted for my Psychiatric Times series “Conversations in Critical Psychiatry” (with a book adaptation forthcoming from Oxford University Press). I took an inclusive approach towards psychiatric critique and didn’t really concern myself with characterizing “critical psychiatry” as a unique strand of it. Over the years, however, I have come to appreciate the merits of conceptualizing “critical psychiatry” in a more narrow and specific way, as one strand of psychiatric critique among many others. There are peculiar dynamics around who identifies as a “critical psychiatrist,” and who distances themselves from this label. In the US, for example, Allen Frances is a prominent critic of diagnostic inflation and over-medicalization, but he wouldn’t identify as a “critical psychiatrist.” In a strict sense, “critical psychiatry” refers to the views expressed and promoted by representatives of the Critical Psychiatry Network (CPN), an international network of psychiatrists primarily based in the UK, with Joanna Moncrieff, Sami Timimi, Duncan Double, and Patrick Bracken being some prominent names. There is a group of UK psychologists and psychotherapists, involved with the Division of Clinical Psychology of the British Psychological Society, who are opposed to psychiatric diagnoses, fiercely criticize psychiatric treatments, and prefer various formulation-based alternatives, and because of their ideological convergence with the CPN, they are often included under the umbrella of “critical psychiatry” as well (especially on social media). In my opinion, what is distinctive about “critical psychiatry” in this specific sense is a general commitment to a cluster of philosophical and scientific positions about the nature and treatment of psychopathology: an understanding of “illness” in biological terms such that mental illnesses are excluded from the category, comparativist critiques of psychiatry that view general medicine to be categorically distinct from psychiatry, a commitment to essentialism in classification (such that psychiatric classifications fail to meet the standard), a rejection of the medical model as inapplicable to psychiatric problems, a rejection of the existence of brain mechanisms of psychopathology, and “drug-centered” psychopharmacology. I find all of these positions to be untenable. I think there are productive strands of philosophical psychiatric critique that do not take this route, and instead they emphasize conceptual and explanatory pluralism, embodied cognition, and a recognition of the value-laden nature of medical concepts; these are the approaches that I lean towards, and in the forthcoming OUP volume I describe them using the term “critical and integrative pluralism.”
Mad studies… the Wikipedia page seems fairly accurate to me, to be honest. I have had fairly limited direct involvement with Mad studies, but I approach the discipline with an open-minded curiosity and a recognition of its potential. For an introduction to Mad studies, I recommend Hel Spandler’s Mixed Bag entry on the topic. The way I see it, Mad studies is an academic undertaking that uses the “lived experience” of madness as a starting point for scholarly inquiry and activism rather than the traditional medical perspective on mental illness or the traditional psychological perspective on psychopathology. It has roots in the psychiatric survivor and service user movement, so existing scholarship is dominated by voices who’ve had negative experience of medical and psychiatric care, and who have found non-medical approaches (such as the Hearing Voices Movement) to be more valuable than traditional medical approaches. I think Mad studies scholarship has its own problems and blind spots, and there is much to criticize. What I admire about Mad studies is that Mad individuals are trying to understand and explain their experiences in a manner that is not constrained by or dominated by the medical way of thinking about these things. Historically, psychiatric patients have not been included as active participants in the process of producing psychiatric knowledge. Their voices and perspectives have been filtered through the medical framework. There are philosophers of science, such as Helen Longino, who argue that a scientific process is more objective if it engages a diverse array of points of view with different normative background assumptions. The science of psychopathology has been distorted by the values and perspectives of the sane, so to speak. So I see the development of Mad studies as a step in the right direction, because it sets up the possibility of a productive dialogue between mad scholarship and mainstream psychiatry, it forces us to re-examine our background assumptions, and I think our scientific understanding of psychopathology and clinical treatment will ultimately be enriched by that.
Haltigan: Why would one consider that the “science of psychopathology has been distorted by the values and perspectives of the sane, so to speak” was necessarily problematic in any way? Psychopathology is, by definition, the study of abnormality or the non-normative. Indeed, Sroufe & Rutter (1984) originally situated the field of developmental psychopathology within the context of pathology and disordered behavior and defined the field thusly: “the study of the origins and course of individual patterns of behavioral maladaptation…(emphasis on ‘mal’ added). A quote from Winnicott comes to mind:
“This ugly word—maladjustment—means that at some early date the environment failed to adjust appropriately to the child, and the child is therefore compelled either to take the cover-work and so lose personal identity, or also to push round in society forcing someone else to act cover, so that chance may come for a new start with personal integration.”
-D.W. Winnicott
Accordingly, should not the science of psychopathology be informed by the sane, as they are the statistically normative, the positively adapted or ‘well-adjusted.’ Otherwise, there is no ground truth about what is and what isn’t psychopathology and psychological disorder from normative functioning; what is and what isn’t insanity from sanity.
Aftab: Well, I think this way of thinking is reflective of a deep historical prejudice. To argue for some sort of categorical exclusion of individuals with mental illness from the process of knowledge production would entail making untenable arguments, such as taking the view that people with mental illness are incapable on reflecting on their experiences, that they cannot use their experiences to generate scientific hypotheses, that they are incapable of recognizing and developing appropriate goals of care, etc. The characterization of psychopathology depends, in many respects, on phenomenology, the first-person experience, so there is already a fundamental restriction built into the science of psychopathology where scientific work relies on information derived from first-person experience. Good clinicians and psychopathologists, of course, take that first-person experience seriously, but it is still filtered through preconceived ideas and existing clinical methods. On the other hand, those with lived experience of psychopathology—if they are in a position to be active participants in the process of knowledge production—can offer additional insights that rely on personal introspection and dialogue within mad communities, utilizing different background assumptions. In one sense, this is not controversial at all. World Psychiatry has published reviews on the lived experience of depression and psychosis that are co-written by “experts by experience” and academics and that already illustrate the value of such an undertaking. There is also work on phenomenology of psychosis—for example, by Nev Jones, a researcher with lived experience—highlighting considerations generally neglected in mainstream accounts of psychosis. Marsha Linehan’s development of DBT was directly influenced by her own experience of psychopathology and her experience of psychiatric care. I think individuals with mental illness especially have a lot to contribute to health services research because they have direct experience of navigating the system as a user.
Scientific communities benefit from a diversity of backgrounds, and individuals who have lived with and struggled with mental health problems are in a position to consider things and ask questions that may be neglected by others. Antidepressant withdrawal as a clinical phenomenon was historically neglected because clinicians have had a bias to interpret symptoms in the context of dose reduction/discontinuation as relapse, forcing many patients to form online communities and figure out ways to help themselves. On the clinical research side, there are issues of what gets studied and what outcomes get prioritized in clinical trials. Clinical trials of antipsychotics, for example, tend to focus on relapse prevention as the primary outcome (which is what clinicians and families see as most valuable), but patients are often more interested in quality of life, or their social and occupational functioning, and we have limited research studying that. Would our trial designs be improved if more people designing them had personal experience of mental illness? I personally think so.
I want to qualify here that I am not devaluing scientific expertise and training. It matters a great deal. We rightly expect people to have certain skills, a certain appreciation of the scientific method, a certain sensibility towards scholarship, etc. in order to be members of the scientific community. Similarly, not everyone with a personal experience of mental illness has the necessary skills to critically assess evidence, conduct research, or serve in an advisory role. But some do, and we should invest in creating a pipeline of such individuals to be a part of the scientific community.
Haltigan: In my view, “inclination”, rather than “prejudice” is a more accurate/fair word to describe this aspect of the history of psychopathology and psychiatry; prejudice implies conscious malice, which I don’t think was the overwhelming theme of early efforts in knowledge production around psychopathology; observed behavior was crucial (e.g., Cleckley as described below). Was some prejudice baked in? No doubt, but overall, I think it was a natural inclination to rely on observation of disturbance rather than on the narratives or lived experiences of troubled or help-seeking individuals. I am not arguing here that lived experience cannot be informative, but it should be formalized—to the extent possible—around common patterns and universal laws of cause-effect with robust predictive validity for specific mental health outcomes. Otherwise, the risk is that science simply becomes story-telling. Personal idiographic narratives that, while compelling on their own terms—eliciting affect, sympathy, concern—are limitless and are intractable when it comes to mental health social policy that should be both efficient and practically implementable at scale. In short, one cannot predicate mental health social policy on extremely low prevalence conditions, or, in more plain language, N = 1 case study mental health conditions.
Aftab: The idea is indeed to go beyond “story telling” and “personal idiographic narratives” to some sort of generalizable understanding and knowledge. “Mad studies” tries to do with “madness” what disability studies does with disability. It is a scholarly examination of the meaning and nature of “madness” (a messier concept than disability, no doubt), so it’s aiming for a conceptual and theoretical examination of the experience and identity of madness that can go beyond the experience of any one individual. Mad studies is important for psychiatry in my opinion because scholars in this tradition are working with assumptions that are very different from the assumptions that are usually implicit in psychology and psychiatry, so engaging with that forces a critical re-examination of the assumptions that guide mainstream psychiatric science and clinical practice. However, to the extent that Mad studies aims to generate new knowledge with regards to the causes and mechanisms of psychiatric suffering and care of individuals with such conditions, or to the extent that Mad studies makes claims that are empirical or that contradict empirical findings from psychiatry, it has to demonstrate the sort of empirical orientation and rigor that we expect from any scientific discipline. Whether that will happen or not, I don’t know, but I am willing to engage with the field with an open mind. As I noted earlier, Mad studies is currently dominated by a mindset that is generally hostile to medicine, and that has to do with the roots of the field in the psychiatric survivors movement. It will be important for Mad studies to critically grapple with its own biases as it progresses, otherwise there is a risk that it will get stuck in a state of dogmatism.
Haltigan: In your essay unpacking the term ‘antipsychiatry’ you mention at the end: “Nor should it be construed as a dismissal of the need to engage with patients, service users, survivors, and individuals with psychiatric disabilities, as well as movements such as Mad pride and neurodiversity.” The neurodiversity movement is one movement I find to be ideologically-bounded and often at odds with evolutionary psychiatry. How do you view the neurodiversity movement? What is it about in your view? Here are some things I have noted previously, see here, here, and here.
Aftab: Adam Hunt and Tanya Procyshyn do a good job in identifying areas of convergence and divergence between evolutionary psychiatry and neurodiversity. My own understanding of neurodiversity is enmeshed with my familiarity with the work of Robert Chapman, who is also a good friend. I think neurodiversity offers a powerful challenge to traditional notions of dysfunction and pathology in psychiatry. The fundamental ideas in neurodiversity are: there is a diversity of neurocognitive profiles, the world is organized in such a manner as to create difficulties for people with certain neurocognitive styles, disability in many cases can be relieved by appropriate accommodations, and certain neurocognitive styles that have conventionally been thought to be states of deficit often come with unique strengths. The problem lies, I think, in determining the appropriate scope of this framework, since it is also clear that some neurocognitive differences can be validly thought of as dysfunctions or disorders. Neurodiversity movement does not have a single spokesperson. There are disagreements within the movement. Different theorists focus on different thing. Some focus on aspects of social justice and human rights, others on notions of dysfunction and how to understand dysfunction in not only evolutionary but also ecological terms. And it remains the case that there are many autistics who do prefer to think of autism as a disorder, and caregivers of severely disabled autistic individuals often find it hard to relate to ideas of celebrating neurocognitive diversity. These are important issues to be tackled and theorized further, but I am convinced that the neurodiversity framework is valuable and deserves a seat at the table.
Haltigan: Thank you for this candid and detailed reply. I enjoyed reading your linked interview with Chapman where he outright notes it is a “social justice movement.” My chief concern here is with ‘philosophers of science’ who often introduce and advocate for these sorts of activist-based scholarship strands of work relative to empirical quantitative researchers who set out to study psychological disorder, specifically (the) neurodevelopmental disorder(s). The two seem at odds when a movement at the outset is an ideological political project, not a scientific one. This is the same issue with ‘gender ideology’ and its associated signature elements including the normalized use of pronouns, including ‘they/them’ which are at cross-purposes with our empirical understanding of the binary nature of sex. How do you, as a psychiatrist, resolve this tension? Have you conducted empirical, quantitative work on a psychiatric question that has to—in some manner—empirically formalize the endless idiographic array of human functioning that the activist scholarship directly implies? Formally, such idiographic dispersion is dispersion or ‘scatter’ from a mean value. In my view, while of potential value to inform empirical questions, they are not answers to empirical questions as the population level, of which our best, most efficient and unbiased statistical estimate is typically the mean. Similarly, as with my remarks below pertinent to gender identity and personality psychopathology, it seems to me that a strong case could be made that much of what individuals believe to be their ‘neurodiverse identity’ may instead be a form of personality psychopathology that reflects, in no small degree, an elevated level of pathological narcissism. How do you react to this claim?
Aftab: The social aspects are not as distinct from the scientific ones as you might think. The problem fundamentally is that disorder characterization is not simply an empirical matter. When do differences in developmental trajectory become disordered? Some cases are quite clear because there is broad consensus, but other cases are not, and “empirical quantitative researchers” cannot ignore the disagreement involved. We can study “autism” an empirical phenomenon—its epidemiology, causal mechanisms, evolutionary history, etc.—just as we can study homosexuality as an empirical phenomenon, but that doesn’t by itself determine what our clinical attitude towards this condition should be.
You mention “pronouns” and the binary nature of sex, and I fail to see why our language and identity should be constrained by any particular biological understanding of sexual differences. “They/them” pronouns are not a claim about the nature of sexual differences as they arise in evolution. Their use is fundamentally about how we relate to ourselves and others in a certain social context, and what we want to communicate to others and what we want others to acknowledge about us. “They/them” pronouns are not intended to be empirical representations of one’s physiology that can be falsified by scientific research. To think so is to misunderstand the nature of pronouns and gender identity. I do think it is a problem if any movement aimed at social justice rests on a rejection of established science, but I don’t think that’s what’s going on here. It only seems that way because we are treating notions of “psychopathology” and “gender” as if they were empirical facts when they are at least partly socially constructed. (I also want to note that there are scientific—and not simply social justice—aspects to neurodiversity, e.g. in the form of an ecological conception of “dysfunction” offered by Robert Chapman.)
Haltigan: OK, but from the standpoint of public health and the practical limitations of structuring social policy around a seemingly ever-increasing confetti of diverse identities, it becomes clearly problematic and unmanageable when any identity or non-normal perception of the world is used to invoke mental health accommodations. This recent piece from Freddie DeBoer illustrates this issue and specifically highlights the problem of invoking disabilities or ‘neurodiverse identities’ with exceptionally low prevalence rates as a means for mental health advocacy and special accommodation. This is especially problematic for the neurodiversity agenda as there is essentially limitless possibility for anyone to claim a particular ‘lived experience’ as neurodiverse and deserving of special accommodation. Here is an example, from recent campus protests, where, although not explicitly linked to the neurodiversity agenda, illustrates the sorts of problems this agenda lends itself to. More generally, in my view, the neurodiversity agenda and associated ideological movements like disability activism lend themselves to this sort of behavior and has been enabled by a strand of personality psychology driven by an idiographic, person-centered paradigm that foregrounds 'subjective experience'. This is fine for 'clinical insight' but destructive at the level of social policy. Limitless my truths are not tractable for humane social policy.
With respect to pronoun usage specifically, my view is that language pertinent to mental health issues should be clear and informative to the utmost extent. Especially regarding gender identity, the conflation between sex and gender has a deep historical background which points to an ideological severing between the terms, such that gender was originally intended as a more polite form of referring to one’s biological sex and later was distorted by feminist scholars. To the extent that the use of pronouns, which are routinely equated with the essence of one’s biological sex by trans activists and ideologues, they communicate inaccurate information to the population and can lead to medication and ordering errors in addition to incorrect data analysis in the context of health and medical records, reversing patient safety initiatives.
Gender and trans activists believe that pronouns reflect a person's gender identity, which is being construed as a person's "brain sex," which is an innate and immutable property of individual brains. So, it is incorrect to say that they/them pronouns "are not a claim about the nature of sexual difference" in this context. It’s also unclear what they mean by pronouns being a way they communicate to others about how they relate to ourselves and others in a certain social context. For example, do you believe all people who use “she/her” pronouns are claiming to conform to feminine stereotypes? Or that everyone who uses “he/him” pronouns are communicating that they align with masculinity? Or are they rather simply communicating that they are females and males, respectively, and thus may be simply expressing their ‘gender nonconformity’? The latter is certainly true, but we already had ways to describe ourselves in terms of how we relate to social roles, such as “masculine” and “feminine.” We all understand what it means to say someone is a “masculine woman” or a “feminine man.”
But the nonbinary identity and corresponding “they/them” are ideological terms that views men and women and he/him and she/her pronouns as communicating something about a social role a person identifies with instead of simply a statement about their sexual biology. Are they just indicating gender nonconformity? More plainly, what distinguishes gender identity from gender nonconformity?
In my view, gender ideology which is the underlying driver of pronoun usage is dangerous especially for vulnerable female adolescents as the surge in Rapid Onset Gender Disorder (ROGD) would suggest. That is because the elastic use of pronouns, not anchored to the biological essence of the type of gametes one is able to produce, leads vulnerable adolescents astray during a developmentally sensitive time when misgivings about one’s feelings and selfhood are both common as well as rapidly fluctuating.
Aftab: This is a loaded debate and I am not going to pretend that I can change your views on this (or vice versa), nor would an attempt at refutation be the best use of our discussion. So I'll try to clarify aspects of what I believe, keeping in mind the issues you’ve raised above, without pretending that I’ve successfully refuted you. I am skeptical that there is an “essence” to biological sex or that biological sex is immutable. It is true that at the time of birth we possess certain physiological characteristics that generally correspond to certain trajectories of sexual development. It is also the case that these trajectories demonstrate sexual dimorphism. Crucially, there is considerable variation within and considerable overlap between the sexual categories, and there are also various intersex phenomena. Given advances in medicine, humans are also in a position to intervene on this trajectory of sexual development. We can modify our biological characteristics, and in the context of such malleability, physiology at the time of birth doesn’t have some special, immutable status. Over the course of human history, dimorphic social roles developed around our sexually dimorphic developmental trajectories, but social roles are subject to even greater variability and malleability. A psychological sense of oneself being a man, woman, or neither, exists at this interaction of physiology and society. I am sure there is some biological underpinning, so to speak, to a persistent psychological experience of identifying as a man/woman/non-binary, but I don’t think the idea of “brain sex” does justice to the complexity of what is involved, especially if the notion of brain sex invokes essences and immutability. It is in this context that we have to tackle the issue of a person’s subjective identity not being aligned with the particular physiological characteristics that they were born with or that they currently possess. It is up to us to determine what our attitudes towards gender incongruence should be, and I think our attitude should be one of inclusivity and acceptance. Pronouns are linguistic and social tools, not representations of sexual physiology. While previously we could only modify social roles (and there is a long history of people living their lives as members of the opposite sex), now we also have the means to modify sexual physiology. Gender identity is also different from notions of masculinity and femininity. There are many masculine women or feminine men who continue to think of their identities as women or men respectively and have no desire to transition.
Haltigan: Where do you draw a line between invoking “heterogeneity” in mental illness (which is always present) vs. recognizing common elements of mental illness that, while more crude and not necessarily person (read: patient)-specific, provide necessary (categorical) heuristics that allow practically efficient patient management for the largest segment of a suffering population?
Aftab: I think clinical work requires some form of categorical schema. Even dimensional systems such as HiTOP accept the need for practical categories. The problem we face is that there is no obviously correct way to recognize the “common elements” of mental illness across different contexts. I think DSM and ICD are useful starting points, they have a long history and a lot of effort has gone into their development, but even with respect to clinical assessment, they are clearly suboptimal. I’ve discussed some of these problems previously—see for example this post and this Q&A with Dost Ongur. I suspect heterogeneity will continue to be a problem until we develop satisfactory explanatory accounts for different disorders. For example, if it turns out that predictive code account of psychosis is correct, the problem of the heterogeneity of psychotic symptoms and the heterogeneity of causal factors would become tractable thanks to this explanatory backbone, in the same way as the heterogeneity of “congestive heart failure” doesn’t really trouble us because the physiological understanding of the cardiovascular system offers a unifying explanation.
Haltigan: I would concur that clinical work requires some form of categorical schema. I would also agree the DSM and ICD are both useful starting points, but also should be viewed as ‘our best estimate of correctness as to the common elements of mental illness across different contexts’ until we have an alternative system this is not only empirically accurate, but also practically tractable. I think HiTOP is a good effort to this end (of course I am a member of the consortium like yourself!), but it is intentionally atheoretical; there is still a ways to go, and guarding against solely relying on only dimensional approaches (i.e., factor models) to model building is important. That is, modeling that incorporates both dimensions and categories (i.e., factor mixture models) should be also leveraged to understand the symptom structure of mental illness. HiTOP currently recognizes the need for categories on the back end; that is, finding practically useful cut-offs of dimensional symptom models, but should also explore more fully the suitability of factor mixture models to explaining common elements of mental illness symptomatology. With all of this said, have you encountered the fast–slow–defense (FSD) model of psychopathology as an alternative framework for recognizing the common elements of mental illness across different contexts? Any thoughts?
Aftab: I am not as familiar with the details of the FSD model as I should be, but it seems to me to be a promising evolutionary framework. Thinking of psychiatric conditions as fast spectrum (F-type), slow spectrum (S-type), and defense activation (D-type) disorders appears valuable. I am uncertain about the validity of extending the fast-slow species continuum to psychopathology itself, but it could be a useful model for explaining patterns of comorbidity and epidemiological and developmental features. I’d love to see if the predictions of the model can be made somewhat precise and if we can identify predictions that would otherwise be unlikely or unanticipated (a la Meehl’s risky tests), and if such predictions can be empirically tested. I do agree that the model has “considerable potential and heuristic value” and I’d love to see more empirical work inspired by it.
Haltigan: Do you view mental illness stigma as always a negative influence, regardless of disorder and regardless of the larger societies need to resist normalizing what is, in fact, statistical deviancy? Substance (ab)use comes to my mind most readily here, followed by schizophrenia (the urban homeless, mentally ill population).
Aftab: I suppose it depends on how you understand the term “stigma.” Generally, it’s taken to imply social disapproval, a mark of shame, a negative social attitude, negative stereotypes, etc., such that it leads someone with that condition to feel demeaned, judged, disgraced, or humiliated. We have many examples of medical conditions that were historically stigmatized but are now less so. Take epilepsy. In many parts of the world, people keep their epilepsy diagnosis a secret because otherwise their marriage prospects would be jeopardized. There used to be a stigma around cancer and HIV. There was stigma around social things, such as divorce. In this sense, stigma is a genuine obstacle when it comes to mental illnesses. It prevents people from being open about their problems, it prevents them from seeking help, and it leads to an entrenched sense of shame. Stigma also contributes to poor outcomes, for example, the social ostracism experienced by many with psychotic disorders.
Obviously, to say that something shouldn’t be stigmatized isn’t the same as saying that something is desirable. Epilepsy shouldn’t be stigmatized but we all want there to be less epilepsy. We just don’t want there to be a situation where people who develop epilepsy have to live their lives with a mark of shame.
Addiction is a serious disorder, and it devastates lives. It is also a clinical disorder in which decision-making and judgment are altered in unhealthy ways. The problem of addiction intersects with sociopolitical issues (e.g. access to or distribution of various substances), and raises problems for the legal system. There are complex policy issues involved. There are good reasons to regulate access to substances and to be stringent about legal consequences for reckless behaviors such as driving under the influence. But I think most clinicians and researchers would agree that attitudes of social blame and social disapproval have been unsuccessful as treatment strategies.
For schizophrenia, I don’t think we as a society have ever come close to “normalizing” it. Schizophrenia remains one of the most stigmatized conditions in contemporary healthcare. And our societal attitude vacillates between coercive control and social abandonment. I do not think schizophrenia is a state of health or well-being. Even as I recognize the phenomenological complexity of psychosis and the fact that some people experience some psychotic states as a source of insight, chronic and recurrent psychosis is so disabling that its status as an illness is difficult to dispute. What people with schizophrenia need is not more social disapproval… they need more social connection; they need society to care about them and provide them with resources to live meaningful lives.
Haltigan: “As treatment strategies.” OK, but what about public officials? My underlying counterpoise here is that ‘clinicians and researchers’ might lack perspective from those in the ‘working class’ or general population who have to live amidst the consequences of dubious treatment strategies like ‘harm reduction’ which arguably worsen the condition, are ineffective at scale, contribute to social anomie, and detract from quality of civic life. What is your reaction to such views as those of Sally Satel and Vanyukov on the issue of stigmatization in psychiatry and mental health?
Moreover, do you feel that the ‘destigmatization’ agenda has overcorrected with such things as renaming ‘abnormal psychology’ courses to ‘problems in living’? With valorizing unhealthy weights as ‘body positivity’ because of the ‘stigma’ that terms like ‘overweight’ and ‘obese’ carry with them? This strikes me as overcorrection, unproductive, and more akin to virtue signaling than anything else.
Aftab: It seems to me that what is driving this debate is the view that the fundamental goal of “destigmatization” (to take the example of addiction) is to reject any notion of responsibility and to reject all forms of social disapproval of addiction-related behaviors. I am not sure who, if anyone, has presented an account of destigmatization in these terms, but that’s not how I understand it. Substance use is a multifaceted phenomenon. We use all kinds of substances for all kinds of reasons. We encourage the consumption of some substances (e.g., caffeine, medically prescribed substances) and there are others we tolerate within limits (e.g., alcohol, cannabis). I think it makes sense to socially disapprove of certain behaviors that can be associated with problematic substance use—I don’t think anyone is rushing to normalize alcohol-related domestic violence or advocating to get rid of driving under the influence laws —but we need to temper our social attitudes of disapproval with a) an appreciation of the reasons why people use drugs and what makes drug use problematic, and b) making it easier for people to acknowledge that they have a problem and to get help for it.
I am not quite aware that harm reduction approaches have been shown to be ineffective as public health policies and that they have contributed to worsening social conditions. My understanding is that on some metrics, e.g. things like overdose deaths, harm reduction works quite well. But my familiarity with literature on this is rather limited.
Weight is another complicated issue. I think people are mistaken when they try to deny the link between adiposity and poor health, especially when it comes to severe adiposity. I do think obesity is a public health crisis and we need both medical and social interventions to address it. But social attitudes are often quite focused on disapproving representations and acceptance of overweight individuals (who are not otherwise medically obese), e.g. in fashion magazines or movies. Many “overweight” (by BMI) individuals are in excellent health or at least in no worse health than most of us. And even for the medically obese, while there are negative health consequences, I don’t think recognition of the health consequences of adiposity warrants the kind of social shame and disapproval that we see around weight. So, while I don’t think we should valorize being obese, or deny the negative health consequences, I don’t think our social attitude should be one of public criticism and condemnation.
I haven’t heard of “abnormal psychology” courses being renamed as “problems in living” but if that is happening, it’s not something I support. I think “problems in living” is a highly inadequate replacement, and if we do want to use terms other than “abnormal psychology,” psychopathology or clinical psychology are better alternatives.
Haltigan: I think we have certainly probed an issue that warrants further discourse. I will be interested to hear what readers may have to say about these companion issues of stigmatization and destigmatization. My sense, from reading works like those from Michael Shellenberger (San Fransicko) and the paper from Vanyukov noted above is that there is good reason to believe that both ‘destigmatization’ and ‘harm reduction’ approaches have been problematic at the population level. Here is a recent piece in The Atlantic of all places making exactly this case. I certainly cannot say I have surveyed the data myself either, thus precluding definitive statements that harm reduction approaches do not work, but my inclinations are similar to those noted below where harm reduction approaches only benefit a small minority of individuals and when applied at scale are iatrogenic at the level of society. Here is another recent example that illustrates the problems with harm reduction programs that do not set limits on the target problematic behavior; unsurprisingly, this example comes from San Francisco as well. Do you have any specific reactions to the Vanyukov piece, the Atlantic Piece, or this example?
Aftab: “All movements go too far…” as Bertrand Russell said, and it is quite possible that harm reduction has been taken too far in some places, such as San Francisco. Living in a rather conservative region of the US myself (Ohio), I find it difficult to relate to the idea that our social attitudes have become too permissive of substance use when I work as a clinician in contexts where this is clearly not the case. I do agree with Vanyukov on the point that “destigmatization” cannot be taken to mean that any social disapproval is unjustified or harmful. I personally think social disapproval of certain aspects of addiction is quite justified given the destructive effects on individual and social well-being, but considerable refinement is needed in our moral attitudes given the dimensionality and heterogeneity of substance use and substance use problems. It is also the case that harm reduction is entirely inadequate as a strategy in isolation. I do think there is a legitimate role for harm reduction strategies—especially when it comes to preventing overdose deaths and infections (such as HIV)—but such strategies need to be complemented with strategies aimed at preventing substance use problems, ensuring access to adequate treatment, and dealing with violations of the law and the rights of others. These are complicated issues and the balance can be hard to get right.
Haltigan: In your 2-part series reviewing Adler-Bolton and Vierkant's “Health Communism” you seem to move between what seems to me a stance that favors some sort of health communism/Marxism yet also recognizes how such a utopian state of healthcare that 'overthrows capitalism' is at odds with human nature (and more generally, evolutionary psychiatry). You note: "I am drawn to the idea of “a radical abundance of care” and “all care for all people” but it also strikes me as quite utopian.” So also, you seem to recognize a ‘bureacratic’ apparatus that is distinct from a clinical apparatus: “The clinical and the bureaucratic are often enmeshed and intertwined in our world, but they are not the same.” Given this, where do you see the value of their work? As simply aspirational? If so, does it make sense to aspire to something so radical as to be disconnected from human nature? It would seem this would be a perpetually disheartening stance for true believers, unless cultural revolution was the end goal (i.e., overthrowing capitalism etc.).
Aftab: There is value in moral clarity, and there is value in identifying and theorizing problems, even if we are limited in our ability to do much about them. I think Adler-Bolton and Vierkant identify something disturbing about the influence of capitalism on healthcare. Their discussion of extractive abandonment and eugenic debt burden was eye-opening for me, and as I mentioned in my review, once I became familiar with this dynamic, its presence in the clinical systems of care around me became much more obvious. Being aware of how these dynamics play out is a step towards some sort of solution. I am not a political activist or even a political theorist. I hesitate to endorse goals like “overthrow capitalism” because I don’t know what other economic system will work better. At the same time, I don’t think it’s hopeless or futile to try to address the exploitative aspects of capitalism. Capitalism today is already different from what it was a century ago. The Nordic model of combining market economy and social welfare is an example of how capitalism can be constrained. There is room for optimism about accomplishing meaningful sociopolitical change that moves us closer to the ideal.
Haltigan: I think your view here is laudable, and I find myself in strong agreement. In fact, Christopher Lasch, in “The Minimal Self: Psychic Survival in Trouble Times” draws attention to similar issues in the context of industrialism, modernism, consumerism, modern technology and the degradation of local institutions of self-government, culture, and tradition.
Haltigan: In your review of Bloom's Psych: The Story of the Human Mind, you note, “What makes psychopathology more moral and political than general medical conditions isn’t dimensionality per se. It’s the tension between changing the individual vs. changing society to relieve distress or disability, and it’s the potential source of error around, ‘Are we calling this condition abnormal because we are socially prejudiced and have reified social oppression into individual disadvantage?’ Medicine isn’t exempt from these considerations, but they are of particular relevance to the science and treatment of psychopathology’.” (My emphasis added here.)
In your view, at present, do you believe that the DSM or more generally the state of the field of psychopathology are guilty of being socially prejudiced? If so, what particular examples might you cite to support this view? Or do you believe that is researchers dependent in the case of the field of psychopathology?
Aftab: It's inevitable for the practice of medicine and psychology to be colored by social prejudice to some degree, and I think our notions of psychopathology are particularly vulnerable. This isn’t to say that most of what we call psychopathology is simply a reflection of social prejudice. I don’t think that is the case. But because this vulnerability exists, we have the responsibility to guard against it. Homosexuality is the clearest historical example. Paraphilias, asexuality, transgender identity, autism are conditions where social evaluative judgments become quite relevant. And I think social attitudes matter a great deal for some cases of “voice hearers,” certain personality styles (e.g. schizoid or schizotypal), grief, cases of substance use, temperamental styles (e.g. hyperthymic), etc. And I think the best way to do that is to have an open discussion about why something is a problem, for whom it is a problem, and to have a democratic dialogue between the stakeholders about the value-judgments and practical needs involved. The empirical aspects of diagnosis have to be settled via scientific inquiry. Attributions of “pathology” and “disorder” are not simple empirical matters though. Facts about causal mechanisms don’t determine, for example, whether we see the condition as problematic or undesirable, the contexts in which the condition comes to clinical attention, and decisions regarding whether we should try to change the person or the environment around them, whether our attitude needs to be one of acceptance, accommodation, or cure, and whether we should pay for the care involved through money devoted to healthcare needs. There is no naturalistic boundary between psychopathological and normative psychological functioning. We are drawing lines on a continuum without natural discontinuities and we have to be mindful of the goals our thresholds and distinctions are intended to achieve and the value disagreements around these goals.
Haltigan: I agree we do have to guard against social prejudice. But, at the same time, we also have to guard against straying from evolutionarily-minded and biologically grounded empirical realities relevant to mental illness. You include transgender identity above in regard to my social prejudice query. Do you believe that transgender identity is something real in the biological sense? It seems metaphysical and frankly almost gnostic to me. What is meant by a ‘trans child’ or ‘trans kid’ for you? (this question was recently posed here on Twitter/X). While the other examples you highlight have much more firm grounding biologically, transgender identity (like similar neurodivergent identities) seems to be a form of personality psychopathology more than anything (especially for adolescent females) to me. That is, there is no empirical, biologically grounded reality to a ‘transgender identity.’ One can also make a case as to homosexuality being a form of psychopathology from an evolutionary psychiatry standpoint. Cleckley also seemed to hold this view at least in part, although he was by all accounts compassionate in his concern for homosexual individuals and how they are treated by society and the psychiatry profession. How do you feel about evolutionary psychiatry informing these issues in ways that are not always socially palatable?
Does the meteoric rise of youth gender transition and the gender affirmation model of care (e.g., American Psychiatric Association’s gender-affirming psychiatric care textbook) alarm you at all? It seems to me that ideologically captured professional organizations are abdicating their mandate to “do no harm.” The increasing first-hand accounts of detransitioners are harrowing. Did you happen to read the recently released Cass Report? More generally, are you able to share where you stand on these issues, or is there pressure within ranks that you feel to remain quiet about your particular views, much like there is in the Academy?
Finally, to pose a more general thought for reaction: Is it possible that medical practitioners, including psychiatrists, have personality characteristics (e.g., more empathy), that while advantageous for treating individual patients, become liabilities when applied to matters of public (mental) health policy? I discussed this possibility in relation to the pandemic response by public health officials in this podcast (cue @ ~46min mark) with Drs. Accad & Koka, but I think it has relevance to the matters we have been discussing throughout our Q & A.
Aftab: I am not sure what “real in biological sense” means in the context of any psychological notion of identity, not just transgender identity. It’s not like we can point to an area of the brain or the activity of a brain network and say, “this is where gender identity is.” What we have are various aspects of physiology that reflect a particular trajectory of sexual development, and then we have a more complicated subjective sense of who we are in relation to our physiology and the gendered social norms. Social gender categories are not direct and inevitable expressions of one’s physiology. That was true even in the past, but it is especially true in an age when we have the means to modify our physiological characteristics. Why is it that some people’s psychological sense of who they are is at odds with their bodily and hormonal physiology? We don’t know, and neuroscience hasn’t advanced enough for us to offer an account of identity in neuroscientific terms. Transgender identity is a state of misalignment between a person’s internal, personal sense of their own gender and the identity we’d typically expect that person to have given the particulars of their neurophysiology on birth. Our clinical and social attitude towards this misalignment is up to us. Neurophysiology and evolutionary history do not determine what we ought to do. Judgments of “psychopathology” especially when applied to gender identity are anything but straightforward. This is why I understand disorder judgments in (partly) social constructionist terms. To the extent that judgments of pathology and psychopathology reflect our clinical and social attitudes towards a particular state of being, they are socially constructed, and to the extent that judgments of pathology and psychopathology reflect neurophysiological or evolutionary empirical facts, they do not determine our clinical and social attitudes (even though they are certainly relevant). This is, in one sense, an ethical question: How should we—as individuals and collectively as society—approach people with transgender identity? What can we do to alleviate their dysphoria and enhance their well-being? Affirming people’s gender and ensuring they can transition successfully is a far better strategy, in my opinion, than forcing people to live with their dysphoria. Similar logic applies to homosexuality, where the case for socially accommodating the sexual difference is far stronger than trying to change the sexual orientation. In contrast, we have good ethical and social reasons to not accommodate states such as pedophilia. Evolutionary biology provides us with hypotheses and facts related to our evolutionary history. It doesn’t tell us how things ought to be. Evolutionary design is not synonymous with health. Our notions of health, well-being, and psychological flourishing are not determined by facts about our evolutionary history (although they are informed by it). Whether homosexuality is in some sense a failure of some naturally selected mechanism or not—and I am not convinced that it is—it doesn’t determine what our clinical and social attitudes towards gay individuals should be. This is where I think some proponents of evolutionary psychiatry go wrong. They seem to think that facts about evolution have the power to settle issues which are fundamentally ethical and social in nature.
My personal opinion regarding transgender individuals holds no special merit. I am not a researcher or an expert on these issues nor I am an active participant in these debates. Personally, I am not alarmed by the figures about gender transition, and as a clinician and psychiatrist, I am in general agreement with the model of gender affirming care. I think we would be abdicating our Hippocratic mandate if our response to trans-suffering was to deny trans people gender-affirming healthcare. I think the suffering of those who detransition matters; we shouldn’t ignore it, we should discuss it openly and we should ensure that relevant facts are available to individuals and families who are deliberating on transition. But detransition is uncommon enough that it doesn’t justify, in my opinion, broad restrictions to gender-affirming healthcare.
Is it possible that empathy can become a public health liability? It’s possible. Good intentions do not always translate into good outcomes. There can be situations where individuals are mistaken about what will help them and the medical community is mistaken about what will help them, and we end up causing harm. All medical interventions cause some harm to some people. But I have not seen evidence—at least not persuasive evidence—that gender affirming care is by and large hurting more people than it is helping.
Haltigan: Do you distinguish between gender dysphoria and gender identity disorder? Relatedly, if you do not, do you believe ‘trans people’ truly exist independent of personality psychopathology? I raise this issue because it is germane to a fundamental point of issue: is the notion of a ‘trans person’ real? What about an animal person? Someone who believes they are born in the wrong (human) body, but are in fact an animal? Do you see a problem here?
It is quite interesting to me that your view is that abdication of GAC (gender affirming care) would be abdicating the Hippocratic mandate when many (including myself) hold precisely the opposite view—that is, the widespread application of GAC, including the prescription of dangerous puberty suppressing hormones and other irreversible procedures, would be a violation of the Hippocratic mandate. GAC in practice is a complex multifactorial equation of risk versus benefits that demands a high level of certainty due to the high certainty of impacting the human right to sexual and reproductive hygiene and because children cannot consent to their own care. Jennifer Block’s 2023 investigative piece in the BMJ highlights not only that gender dysphoria is rising in young people, but so is medical and professional disagreement on how to address gender dysphoria. A key takeaway from the piece is that extant guidelines concerning the treatment of gender dysphoria (e.g., American Academy of Pediatrics [AAP]) are not evidence-based. This same takeaway was reiterated in Benjamin Ryan’s 2024 piece in the New York Sun summarizing the findings of the Cass Report which found that extant pediatric gender medicine is based on ‘remarkably weak evidence.’
How do you resolve this tension when more and more healthcare professionals, organizations, and other public intellectuals are now speaking out about the harmful consequences and problems with GAC, which essentially amounts to a promissory note for anything desired by the individual in practice? For example, see the organization Do No Harm and the work of Leor Sapir at Manhattan Institute who has written extensively on this issue. Of course, I imagine you are aware of Abigail Shrier’s “Irreversible Damage” which was one of the first major works to bring widespread attention to this issue. As GAC is something that is directly applicable to children and adolescents, reflecting a vulnerable developmental age range, do you not feel that extreme caution is warranted?
Aftab: You see transgender identity as arising from some combination of personality psychopathology, social contagion, and developmental vulnerability, such that vulnerable individuals are buying into a story they belong to the opposite gender, and this leads them down the path of gender transition and medical interventions that eventually hurt them rather than help them. And if that were the case, our response should indeed be one of alarm and concern, with steps taken to protect the youth. But based on my own clinical experience (in a general psychiatric setting rather than one specializing in gender affirming care), my interactions with trans individuals, and my familiarity with the literature, I don’t have reason to believe that this personality psychopathology plus social contagion story is applicable to vast majority of trans individuals. I wouldn’t say it applies to no one; the fact that some people do de-transition and express regret over medical treatment lends some support to it. But as far as I know, vast majority of people whose gender dysphoria is persistent and severe enough that they seek out puberty blockers, hormonal treatment, or surgical treatment have stable trans-identities. It is not a “phase” that they grow out of. People often focus on developmentally vulnerable adolescents, but then they extend the same attitudes even towards adults who have had stable trans identities for years and decades.
Much of the medical debate (e.g. Cass report) revolves around the quality and strength of the research evidence in support of medical interventions such as puberty blockers in youth. Saying that available evidence is uncertain or low quality by some standards (Cass Report: “not enough is known about the longer-term impacts of puberty blockers for children and young people with gender incongruence”), standards which are themselves subject to debate, is different from the conclusion that we should treat trans-identity as a pathology or that gender-affirming care by and large hurts people. The totality of evidence, which includes clinical trials as well as the testimonies of trans individuals, suggests that trans individuals indeed benefit from gender affirming care.
I get the point about developmental vulnerability and I think all individuals should have access to a comprehensive clinical assessment, adequate opportunity to reflect on the options available to them, and be informed of all the risks of hormonal treatment and surgical interventions, including data about detransition and uncertainties around evidence. No one should be rushed or forced into medical treatment. I think it is cruel to force children to undergo the physical changes of puberty that are unwanted and that cause them intense emotional distress. Puberty blockers and hormonal treatments have risks, but so does puberty for transgender and gender non-conforming youth. How to choose between these risks is a deeply personal decision and I agree with the American Psychiatric Association position statement that “For gender diverse youth and their families, decisions to which gender-affirming medical, surgical, social, and/or legal procedures to pursue are best managed via an informed consent approach.” I do agree that extreme caution is warranted. Puberty blockers and hormonal treatment aren’t things that anyone should take lightly. We should make all efforts to ensure that individuals will not later come to regret this, but eventually we have to confront the fact that trans-identity and gender non-conformity are neither transient fads nor a result of emotional immaturity and psychological confusion. And the most ethical and least harmful response in my view (which is also the position taken by the American Psychiatric Association) is to support access to affirming and supportive treatment for trans and gender diverse youth and their families, including puberty suppression and medical transition support, even as we debate the strengths and weaknesses of the research evidence and even as we take detransitioners seriously.
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This is a very interesting conversation and I salute both voices for the initiative of creating a civilised dissenting dialogue.
I am not an expert on mental health (i.e. I am not officially trained as a mental health worker). I have a background as a social scientist and experience as a therapist.
What makes this conversation interesting to me is how it combines multiple scales and multidimensions when discussing the theme of mental health. It unpacks some of its core themes, showing their grain and depth but above all reveals the holographic nature of mental health - the crisis and convolutions around its multiple natures, biological, social, political, philosophical - all reflecting the larger civilisation development crisis.
The tension between different positions in this dialogue seem to represent the wanting to keep/establish boundaries and the recognition that the intersection between biology, social, economic and political systems is inevitable. This tension is to some degree necessary in this historical moment when are all reshuffling things…
In my view, for interesting progress to happen 2 things need to fall into place: 1) the recognition that science as a system of knowledge production and sense making is inherently a cultural phenomena. I find it surprising that at this point we can still conceive of “empirical facts” - of whatever nature - as exempt from a human subject embedded in context. So of course the practice of medicine and psychology is profoundly socially conditioned and cannot but be so. The exemptionalism that still lingers in medical science is epistemologically naive and sterile, both in theory and in praxis. 2) assuming the multidimensional aspect of mental health (biological, cultural, etc) more than putting our efforts in establish clear boundaries (or even worse, colonising territories from any side) we should do well in applying full creativity in establishing correlations between phenomena, assuming the full complexity of what mental health means. In so doing exploring the deep ground of these articulations: capitalism; trauma; fear; power; human evolution, etc.
Again, my thanks to both authors.
Really wonderful prose.