Bridging Critical and Conceptual Psychiatry: An Interview with Awais Aftab

Awais Aftab is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University.

He is a member of the executive council of the Association for the Advancement of Philosophy and Psychiatry. He has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry.

He leads the interview series Conversations in Critical Psychiatry for Psychiatric Times, which explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo. He is also a member of the Psychiatric Times Advisory Board.

In this interview, he explores his journey into both philosophy and psychiatry and how he understands the relationship between these two disciplines. Aftab goes on to discuss how he began the critical psychiatry interview series and what he has learned from this experience and the pushback he has received. He then elaborates on how studying the philosophical issues in psychiatry, through a “conceptual competence” curriculum, could transform the doctor-patient relationship and improve mental health care.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: Can you tell us about your background and what led you to a career in medicine and psychiatry?

Awais Aftab: I think a lot of people might not know that I’m from Pakistan, and that’s where I was born and grew up and went to medical school. Before I went into medical school, I was really interested in philosophy, and I was seriously considering whether I could pursue that on a professional basis. But philosophy as an academic discipline, especially as a way of making money, was pretty much nonexistent in Pakistan.

I do have physicians in my family. My older sister is a physician herself, so there was all this passive exposure that I was getting through family members who are physicians in Pakistan. It seemed like a natural choice for me to go into medicine as well.

I was interested in philosophy and psychology before medical school, and it became pretty clear to me early on that the only medical specialty that attracted me was psychiatry. It was not an easy decision, though, because there is a lot of stigma in Pakistan surrounding mental health, and this stigma also applies to people in the mental health profession.

There was a general perception at that time that good doctors don’t go into psychiatry and, if you’re intelligent, then you’re going to be drawn to specialties like surgery. I had to explain to family and to teachers that I’m passionate about this field and about changing this field.

 

Karter: You spoke about the stigma in Pakistan around utilizing psychiatric services and also the stigma toward professionals in the field. What was psychiatry training like in Pakistan? How do cultural differences impact training and practice in the field? Did any differences jump out to you when you began practicing in the US?

Aftab: There are tremendous differences in how medicine, in general, is practiced and in Pakistan versus the US, and those differences are present in psychiatry as well. Most of the medical training loosely follows the British model.

I think psychiatry in Pakistan struggles with being under-resourced, and the ratio of psychiatrists to patients is very low. The availability of medications, especially newer drugs, was a big problem. In general, there were a lot of challenges within the system.

When I started my psychiatric training in the US, one thing that was different was the legal apparatus that exists here with regards to mental health care. There is a system of rules that exist that set boundaries and also establish some accountability.

In Pakistan, there are very few legal regulations that apply to mental health care. It can create a sense of chaos when you’re treating someone who is experiencing symptoms of psychosis or mania, and the family is concerned. This can lead to deception on the part of the families, which sometimes can cross ethical boundaries.

It is pretty common there that family members would obtain psychiatric medications and mix it into the food of a person without that person knowing. That’s not ethically defensible, but I think you can see it as a consequence of a society that has failed to develop other ways of addressing these situations.

In the US, to obtain the majority of psychiatric prescriptions, you have to go to a doctor, and they have to prescribe the medication to you. In Pakistan, things are changing now, but when I was there, essentially, you could go to any pharmacy and get any medications you wanted. The psychiatrists were not the gatekeepers of psychiatric drugs, and anyone could go to any pharmacy and get a benzodiazepine or an antidepressant. So even though the number of psychiatrists was limited, the use of psychiatric medication was still widespread.

Another interesting difference between psychiatry in Pakistan and the US that I noticed was in terms of patient presentations. When it comes to depression and anxiety, a lot of people in Pakistan presented with what would be considered a neurasthenia presentation, where they’re focusing much more on somatic symptoms, such as headache, physical fatigue, weakness, or digestion issues.

There was this emphasis, privileging body problems, and physical problems over mental health problems. So people tended to present when they were depressed or anxious in that classic neurasthenia manner.

We used to see a lot of conversion disorder cases—far more than I’ve seen in the US. I think this is partially due to the fact that conversion disorder is seen much more often in women who are highly oppressed in many ways within the larger social system. I think that the higher rates of conversion disorder were sort of a barometer of social oppression.

Before I started my psychiatric training in the US, I had spent almost one year of psychiatric training in Doha, Qatar, where things are very different from the US and Pakistan in the way their society is organized. There is almost what you could call a ‘slave class.’ You have these laborers that come from various South Asian countries, like Nepal, Bangladesh, India. They come to Qatar seeking work, and then they get trapped there for various reasons, and they’re working in really horrible conditions.

While I was working there, we saw extremely high rates of what is called a ‘brief and reactive psychosis’ that refers to episodes of brief psychosis that seem to arise in situations of really high stress. That was a very common presentation among those laborers in Qatar. In contrast, it’s relatively rare to see a ‘brief reactive psychosis’ when the society’s not as oppressive for as many people.

 

Karter: It sounds like your experiences were really rich for thinking about these philosophical questions that come up in psychiatry and psychology about the role of culture in the experience of mental distress, and about ethical issues around coercion and deception in psychiatry. How did your philosophical training continue to develop during your medical training?  You produced a blog on the “History of Modern Philosophy” while you were in medical school. How did you see its relevance to medicine and psychiatry?

Aftab: My real love was always philosophy. Even though I was in medical school, I still was devoting a lot of time to my personal reading of philosophy. At that time, I was doing a lot of reading in the history of philosophy, especially the history of modern philosophy from Descartes onward.

As I was doing that reading, I was keeping notes, but once I had accumulated a relatively large volume of notes, I realized that with some more effort, I could give them a little bit more form and shape as a sort of book in a blog form. It ended up being this blog on the history of modern philosophy from an amateur perspective. I think that personal study gave me a solid foundation for further philosophical inquiries that I was interested in later on.

Initially, I didn’t see it as being that relevant to medicine. There was a bit of a disconnect in my mind. As I progressed, I began to appreciate how philosophical thinking can inform medicine. There are all of these hidden conceptual dynamics present in the way people make sense of distress, talk about disease categories, and approach them. I began to see this hidden philosophical structure beneath the practice of medicine, and this became much more apparent to me when it came to psychiatry.

Psychiatry is one area where things are relatively more subjective, and there’s a much stronger influence of values. It’s easier to see the influence of some of those philosophical assumptions on how things are practiced. But I don’t think that the nature of the underlying philosophical assumptions is that different in the rest of medicine.

Another big influence in this area happened during my final year of medical school when I became familiar with the work of the famous existential psychotherapist Irvin Yalom. At that time I was, I was personally really interested in the existentialist philosophers. I was exploring the views of Nietzche, Heidegger, Sartre, Camus, and when I discovered Yalom and started reading him, that made a huge impression on me as a medical student.

I love the way Yalom integrates existential thinking into his practice of psychotherapy and psychiatry and the way he makes sense of people’s distress and their anxieties. It gave me a much richer appreciation of what psychiatric practice could be like if done in the right fashion.

Later on, before starting my residency, I also read “The Divided Self” by R.D. Laing, who many people would recognize as being one of the so-called antipsychiatry philosophers. It’s a fascinating book because Laing is trying to understand psychosis from the perspective of existentialism. He’s trying to make sense of delusions, the disorganization, and the paranoia from an existential perspective, and he’s desperately trying to see meaning in those experiences. I don’t think I was fully convinced by what I read, but the sheer force and beauty of that intellectual effort left a deep mark on me.

 

Karter: You mentioned that you started reading works that applied philosophy to clinical practice in different ways. Yalom applies existentialism to psychotherapy, and Laing’s work takes existentialism and phenomenology and applies it to the lived experience of psychosis. How did this lead you to explore more of the critical psychiatry literature, and how did that shape your thinking?

Aftab: When it comes to the relationship between the field of philosophy of psychiatry versus what we now loosely call critical psychiatry, there is a big overlap, but they are also relatively distinct and somewhat insulated from each other. For much of my psychiatric training, I was reading literature in philosophy of psychiatry, and I was familiar with the intellectual work of the classic antipsychiatrists, such as Thomas Szasz and Michel Foucault.

Despite having this familiarity with the classic antipsychiatry thinking, the philosophy of psychiatry literature that I was engaging with wasn’t explicitly dealing with critical psychiatry issues. The critical psychiatry movement has very strong roots in the UK, particularly in the Critical Psychiatry Network. Until recently, there was not as much of a critical psychiatry influence in the US and the American journals and academic literature that American trainees are exposed to.

Even though there were articles related to critical psychiatry that were showing up in British journals and international journals, I wasn’t getting a lot of exposure to that in my training in the US. I think a lot of these critical psychiatry debates were happening in a much more prominent fashion online, especially on Twitter and on some of the blogs.

The result is that my exposure to what we would call critical psychiatry happened pretty late, near the end of my psychiatric draining. It was only shortly before the edited book on critical psychiatry by Sandra Steingard came out.

About a year before that, I did end up reading “Anatomy of an Epidemic” by Robert Whitaker. Reading “Anatomy of an Epidemic” and engaging with those ideas was quite an experience for me. Most of the people that I had spoken to or who I had mentioned that book to before had been pretty superficial and dismissive about it, calling it extreme or antipsychiatry. When I decided to read the book, I was expecting that it would be something I could quickly go through and thought it wouldn’t be something I had to spend a lot of time and energy on.

Reading “Anatomy of an Epidemic” ended up being a really jarring experience because I quickly realized that a lot of the arguments and a lot of the data presented in the book were not easily dismissed. And the nature of what was being discussed—the possibility that psychotropic medications can worsen outcomes, at least in a subset of patients—was one that was particularly unsettling to me.

I think back to my relatively naive days, and I wasn’t exposed to this larger body of work. Whereas now, two years later, after reading the book, I’m still thinking about trying to address those issues.

I think that book left a pretty deep impression on me. It wasn’t just because I accepted all of the arguments in the book, or was immediately convinced that everything that was being said was correct. I could see that a lot of the arguments, at the very least, are deserving of serious engagement.

As I started talking to other psychiatrists in the community, I realized that a lot of other people had actually read the book too. A lot of them were struggling to make sense of these issues in the same way that I was.

This was a relative surprise to me because most of the people who read this book, within the psychiatric community, have a tendency not to talk about these issues. But when you speak to them on a personal level, where they might feel free to talk more openly, I think a lot of them would say that this book unsettled them, that it is not something that they can immediately dismiss, and that this is something that they are actively trying to make sense of.

That book launched me into a whole new, different area of inquiry. Then later on, when I started becoming more active on Twitter, that’s when I started getting more exposure to the critical psychiatry folks and in the UK and started reading their work.

 

Karter: You’ve produced a series of interviews titled, “Conversations in Critical Psychiatry” for Psychiatric Times with several of the leading voices in critical psychiatry. Can you tell us how this series came about and what’s been your biggest takeaway from these interviews?

Aftab: When I started this interview series, I didn’t quite understand critical psychiatry in the same way as someone from the UK or someone who was active on Twitter might. I had a more neutral idea about the term “critical psychiatry” as being representative of the very diverse ways in which critical thinking and criticisms can be directed at psychiatry.

I was actively reading this critical literature that seemed very serious and worth engaging with, and then I felt a weird disconnect because almost nobody in mainstream psychiatry was talking directly about these issues. There was a tendency to either ignore them, be indifferent to them, or talk about them in informal settings.

That was a little frustrating for me because I thought that these critical perspectives had something valuable to offer psychiatry and that psychiatry would, in fact, benefit by engaging with them. I wanted to start an avenue for meaningful engagement with these critical ideas, where I could highlight some of the issues that I think are important to our field.

I think I was lucky that I had a good working relationship with Psychiatric Times editorial team at that time. When I pitched the idea to them, initially, there was some hesitation, pretty understandably, because no one had done anything like this in mainstream psychiatry, and no one knew what exact shape this would take and how it would be received. But they decided to take a chance on me, and I’m really glad that they did. Overall, the series has done pretty well.

Going back to the reasons why: one reason was that I wanted to highlight the critical perspectives that I think we as a field needed to hear. Even though I may not personally agree with all of the views expressed in the series, I still think it’s very important that we hear these things and engage with these ideas.

Secondly, I was still in the process of learning more and making sense of this body of work. I thought this series would present an excellent opportunity for me to learn more about these critical ideas and perspectives.

Very importantly, I wanted these engagements to happen in a relatively non-threatening, productive manner. I think there’s this tendency toward an unhelpful dynamic that develops where criticisms tend to be aggressively presented, and then the other side reacts in a state of being totally defensive.

That doesn’t help lead to meaningful engagement. It is fine if you want to refute something or if you want to dismiss something, but it’s not conducive to learning. It was really important to me that these interviews happen in a non-confrontational manner so that the readers would think about these issues without being threatened.

 

Karter: So you ended up in the middle of two worlds that you felt weren’t always speaking to each other in a very productive way. I’m curious about two things: First, what has the response been on both sides—How has the mainstream psychiatric community responded to hearing these critical voices and how has the critical psychiatry movement responded? Second, what have you learned by existing in that intersection? What have you noticed about the dialogue between critical psychology and the field at large?

Aftab: I have to say, and I was a little taken aback by this as well, that overall, the reception has been very positive. I was surprised by how well these interviews were received, at least by the people who were reading them, and even by even by psychiatrists that you would think of as being thoroughly mainstream, and as operating within with the current mindset.

A lot of them found the interviews to be thought-provoking. I think a lot of people may simply have ignored these interviews, at least in the beginning. I think, initially, a large chunk of readers probably didn’t really care for these interviews that much, and then a smaller chunk found these interviews to be worthwhile and positive.

Then there was a smaller group that responded to it in a little bit more critical manner, saying, “I don’t really think focusing on critical ideas is such a good thing. That’s not what we need. That’s not what the field needs right now.”

So there was a small amount of backlash, but it was fairly small within the psychiatric community. I have to say that the criticisms have not been to the extent that I might have feared when I started the series. I have to emphasize that overall the reaction from the psychiatric community has been very positive.

To some extent, that may be due to the way these ideas and arguments were presented. For example, the very first interview was with Allen Frances. I think that said something about the intention of the series because Allen is someone who was essentially part of the psychiatric establishment until, during the DSM-5 debates, he started writing much more about the philosophy of psychiatry. He started writing about the limitations of DSM and the harmful effects that it has had on society at large.

Because Allen has that background, being one of the architects of modern DSM, no one can come out and say, “Oh, Allen, he’s just antipsychiatry.” That’s just not an argument that anyone can make in good faith. I think starting off with someone like Allen was symbolic because it showed the series was aiming to be rooted within the psychiatric tradition, but also honest in genuinely exploring these criticisms.

Another example: when Anne Harrington’s book came out last year, a lot of the initial reaction to that book, within psychiatric circles, tended to be relatively negative because people hadn’t read the book itself, but were mostly relying on the various book reviews.

When I decided to interview Anne Harrington, I was anticipating that there would probably be more backlash for that interview. But when the interview came out, Anne Harrington presented her work in a very balanced, scholarly, thoughtful manner, without any sort of inflammatory comments. And, similarly, the interview was very well received, even though the same people who liked the interview might have reacted negatively to the general perception of the book.

I think that gave me a very valuable lesson about the importance of context—that it’s not just about the content of the argument, but the context of the argument also matters, and the perceived intentions of those arguments also matter. I think that if we want psychiatry to engage with these critical views, we have to present them in a context where the mainstream psychiatric community will be able to engage with them.

There have been some interviews that have generated more controversy. I can think of two interviews in particular. The interview with Joanna Moncrieff generated a lot of discussion on both sides. Some people felt strongly that what Moncrieff was saying was wrong or expressed that they did not like the overarching trajectory of her comments. But, at the same time, Moncrieff has a large fan following, and I think there were a lot of people who liked that interview.

The interview with Giovanni Fava was more controversial because we touched upon some of the more sensitive issues surrounding psychopharmacology, especially these concerns related to the possibility of worsening long-term outcomes in a subset of patients, issues over withdrawal, and some of the other critical problems in psychopharmacology. I did notice that the Fava interview generated more critical comments and some more backlash, at least online and on Twitter.

Talking about how these conversations happen on Twitter, I’m seeing a similar polarization between people defending mainstream psychiatry and people criticizing mainstream psychiatry. You see this exchange, this back and forth, between relatively extreme positions. People get emotionally engaged in these debates, and sometimes these debates turn pretty ugly.

I think a philosophical perspective can offer you a little bit more nuance, and a little bit of stability in the debate.  Having a little bit of that philosophical sensibility can help you be grounded in the polarized debates that we are currently seeing on social media.

 

Karter: Does the success of the interview series and the way it has been received indicate that things are beginning to change in psychiatry?

Aftab: I would like to think so. My generation of psychiatrists (who is just entering the psychiatric workforce) is much more mindful of the ways in which the profession has been unable to deliver on the promises of the last three decades.

Around the time I started my residency, NIMH’s Research Domain Criteria (RDoC) was all the rage, and Thomas Insel had famously described the DSM as lacking validity and had said that patients with mental disorders deserve better. Allen Frances, on the other hand, while no fan of RDoC, was on a crusade against DSM-5 of his own and campaigning against widespread medicalization.

So my generation of psychiatrists trained in the shadow of these debates. Very few of us see our current diagnostic system with rose-tinted glasses; we are acutely aware of the limitations. At the same time, the literature on the long-term efficacy of psychiatric medications has accumulated, and studies such as STAR*D don’t paint a very pretty picture.

There is increasing awareness of bias in research, particularly misconduct by pharmaceutical companies, so I see a lot of caution among my colleagues with regards to research studies funded by pharma. My generation is also much more mindful of social justice issues and takes them very seriously. So I think there is a strong sentiment in my colleagues to question received wisdom and to look for alternative answers, and my series reflects that to some extent.

 

Karter: You’ve proposed this idea of conceptual competence as a framework for improving mental health training in psychiatry, and the goal is to bring some philosophy training to psychiatrists and other mental health professionals. I’m wondering what you think philosophy training would add. How would conceptual competence help trainees in the field to be part of these conversations between critical perspectives and mainstream views? What do you think some of the major theoretical issues are that trainees should be exposed to? How would this training change everyday practice?

Aftab: I’ve been very engaged in efforts to promote the philosophy of psychiatry among psychiatric trainees. While I was chief resident in my psychiatry residency program, I developed this preliminary curriculum for teaching philosophy of psychiatry to psychiatry trainees, which I implemented at my program for two consecutive years, and it was received very well by the residents. We ended up publishing a report on that in Academic Psychiatry.

Recently, Scott Waterman and I got together, and we wrote this piece arguing for this notion of conceptual competence in psychiatry. We are definitely not the first ones to talk about this idea of conceptual competence. You, yourself, have written about conceptual competence when it comes to psychiatric diagnosis.

But when it comes to mainstream psychiatry, we were probably one of the more prominent voices talking about this. Our basic notion is that it’s pretty well established now how all these implicit conceptual assumptions are guiding psychiatric research and practice. Including assumptions, for example, related to what mental disorders mean and what constitutes the border between “normal” and “disordered.”

If it is recognized that all these conceptual assumptions are influencing a psychiatric perspective, then why don’t we talk about these assumptions and examine them and engage with them more explicitly and rigorously?

The main idea is that we train psychiatrists to recognize the conceptual ideas that are influencing their approach and the conceptual ideas that are dictating and guiding their practice. I think it is precisely our neglect of these conceptual ideas that lead to some of the more widespread problems, such as the reification of psychiatric constructs.

When we think that these DSM constructs represent some sort of discrete diseases, and we attribute more reality to these constructs than is warranted, it raises issues of widespread medicalization.

How do we draw the boundary between what should fall within the domain of medicine and what should not? Right now, the process of medicalization is operating through its own logic, and we’re seeing this steady expansion in the proportion of the population that falls under these various psychiatric constructs.

My main goal in promoting conceptual competence is that trainees start asking these questions and that they become more explicit about these hidden philosophical ideas. Once that happens, then we can begin to ask more meaningful questions about what to do next and how to change things?

If you have more awareness, if you have more understanding, then then I think we can engage with these philosophical issues in a more productive manner, and we can start making the changes in our practice that need to happen.

 

Karter: There have been other movements in the field of psychiatry. The movement for multicultural competence and humility helps to train mental health professionals to think about the role of culture in experiences and expressions of distress. Structural competence is a movement to think about how institutional discrimination and systemic racism impact clients and patients. How do you see conceptual competence complimenting these other movements, and what does it add to those existing movements in the field?

Aftab: I think that the development of cultural competence and structural competence are some of the most promising developments that have happened in medicine and psychiatry at large over the last 10 to 15 years.

I think that these movements are forcing us to engage with issues of cultural diversity. These movements have challenged to consider the way culture affects medical presentations, including psychiatric presentations, and, very importantly, to get away from taking the Western perspective to be the default natural perspective. We can be more mindful, we can be more respectful, and we can be more understanding of the way culture interacts with medical and psychiatric problems.

Structural competence is doing an excellent job of highlighting how various social systems and forces of oppression—whether this is gender discrimination, racial discrimination, economic inequality, extreme poverty—influence medical conditions, prognosis, and access to treatment.

There is a pretty good body of literature to show that psychiatrists need to be more mindful of the ways social forces operate if we are to provide good care.

 

Karter: To take this a little bit further, if a psychiatric trainee or a psychiatrist were to make a study of a conceptual competence curriculum and utilize the framework, how do you imagine that would change daily practice? If you were a service-user showing up to a psychiatric visit, how might you experience that visit differently if this training were available?

Aftab: It’s difficult to say precisely how a conceptual competence would change psychiatric practice, primarily because the emphasis is first on recognizing what the hidden assumptions are and what the questions are that need answering.

The approach of conceptual competence doesn’t necessarily provide the answers themselves, because when it comes to philosophical questions—whether these are questions in philosophy medicine, philosophy of psychiatry, or philosophy of science—they rarely have clear cut and settled answers. It’s more of a process of dialogue where you have to engage with a question, think about it, and reflect on it.

One thing it does do, though, is it helps weed out some of the bad answers. There are some approaches to psychiatry that, if you are conceptually competent, you can see that they are mistaken. Take, for example, this reified view of the DSM as representing discrete disease entities. I think that someone who is conceptually competent is better able to understand the pragmatic nature of these constructs and the functions that these constructs serve.

I think conceptual competence can help psychiatrists become immune to some of the misguided tendencies that we see in current practice. By being more thoughtful, I hope that they would be able to engage with patients, and with the society at large, in a much more healthy fashion.

Right now, if you look at the public education that is being done with regards to psychiatry, the public is getting a very biomedical understanding of psychiatric disorders. There was all this talk of chemical imbalances, and there still is to some extent. There’s even talk of disorders being brain diseases.

The public is getting a certain version of how these things should be understood, but someone who has a better conceptual and philosophical understanding of these issues can easily see that these claims that are being made about brain diseases are somewhat simplistic and that they might not be helpful and that more conceptually healthy understandings of these categories are going to look very different.

If they have an openness and this conceptual understanding in their mind, I think that it will influence how they’re informing patients about a diagnosis, and how they’re educating and listening to their concerns. We might then be able to think more outside the box, and we might be able to listen in a more healthy and sincere manner to some of the longstanding concerns raised by the consumer, survivor, ex-patient community.

 

Karter: It sounds like conceptual competence may lead to a change in the relationship between service-users and providers as well, in that there might be more humility and maybe more openness; less an expert who is identifying something and more of a dialogue between parties.

Aftab: Exactly. I think the emphasis on humility is something that is very important. In fact, one of the elements of conceptual competence that is outlined in our paper is conceptual humility.

It is the idea that these are challenging questions, there are often competing answers, and reasonable people can disagree. The best approach we can take is to be open-minded and be humble about the possibility that what we are thinking may not turn out to be the case, and that we can wrong.

I think that a sense of humility can enable us to have a dialogue in a more open and sincere manner and to also listen to other perspectives, even if you may not agree with them immediately. At the very least, we can begin to engage with them, listen to them, and give them the respect and the attention they deserve.

I think we would see a very different sort of psychiatry if that happens.

 

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MIA Reports are supported, in part, by a grant from the Open Society Foundations