As a double-board-certified child, adolescent, and adult psychiatrist with nearly twenty years of experience treating “mental illness” worldwide, I have attended more mental health conferences than I can count. Nowhere is the tension higher than when the conversation turns to “schizophrenia” and “psychotic disorders.” Putting people with lived experience, family members of those labeled unwell, and clinicians in the same room for the sake of meaningful dialogue can sour fast. The purported goal of determining how best to support and assess a person can quickly shift to how to manage and control them. Someone inevitably insists there is no other way than meds and, if needed, forced “care.”
Four Conversations at Once
Amidst the cacophony, I sometimes have nothing to say, sensing that jumping in might only make things worse. The stakes always seem high for everyone in the room, the emotional charge palpable.
We might hear from people subjected to psychiatric coercion from childhood onward because of the voices they lived with, forced to submit to a construction of mental illness requiring involuntary hospitalizations and medications, and to culturally unsound formulations that pathologized them rather than looking for their meaning and value.
We might hear from family members traumatized by our mental health system: parents who have watched their children thrown to the ground, physically restrained, and forcibly injected, and who are desperate to spare other families that same violence. Forcing people to endure “treatment” for their own good can seem to be what families have internalized from years of pain.
I often feel white supremacy culture at work in these rooms, in the sense Tema Okun describes: the insistence on only one right way, a constant sense of urgency, defensiveness, paternalism, fear of open conflict, and power hoarding. The rapid turn from supporting people to controlling them is white supremacy culture in action. Over the years, I have seen this most pronounced among family members, who in these spaces are often white and well-resourced. I say that not to blame individual parents, but because white supremacy culture shapes whose fear gets treated as reasonable and whose fear gets treated as dangerous. The coercive approaches defended in these rooms land hardest on Black, Brown, Indigenous, and poor people, who are already overdiagnosed and overpoliced.
Some people describe standard interventions as trauma: forced medications and hospitalizations they are still recovering from.
Others describe treatment as something they needed but couldn’t admit at first and eventually accepted.
For some parents, it’s the thing you had no choice but to do to your kid and then had no choice but to make peace with. Having made peace with doing it to your own child, you become certain it’s what other people need done to them too.
And for people like me, it’s the thing you do to other people. Either you believe unilaterally in the standards your profession holds you to, or, like me, you’ve seen the cracks become holes.
We aren’t having one conversation. We’re having several at once, and only one of them is backed by law and force. When a system offers families a single option and calls it treatment, defending that option can feel like the only way to keep your child alive, and the only way to live with what you’ve done.
I understand that certainty because I used to share it. I was trained to eradicate psychosis.
The Fishbowl
My first encounters with treating a schizophrenia diagnosis as a medical provider came during a rotation on an inpatient unit focused solely on psychotic disorders.
I was struck by how firm and unyielding the rules were. Heavy locked doors required cards and keys to enter and exit. Staff sat in what everyone called the fishbowl, a glass-enclosed station where you could watch everyone while they watched you watching them. Patients could reach us only by walking up to a door that opened partway. Sometimes people knocked, asking to speak with a provider. Often they were ignored.
We spent more time talking about people than to them. Not infrequently, I heard jokes made about patients. The message was clear: These people were very unwell, potentially dangerous, and very different from us. And we knew what was best for them.
One patient was a college student in their early twenties, far from home, with no family nearby. According to the medical team, they carried a bipolar diagnosis and were manic with psychosis. They had been moved from one unit to another, and somewhere in the shuffle their prized Walkman was lost.
I had an old iPod, so I offered to download their favorite songs so they could listen to them. I knew from my own experience in a locked unit in my early twenties that music could be calming and healing, a way to soften the blow of the trauma embedded in an involuntary hospitalization. I asked the supervising resident for permission, knowing I was still learning. But I was certain that this kind of supportive, healing approach was in this person’s best interest.
The request was met with punishment. My attempt at shared humanity was read as a major professional infraction, one that called into question my fitness for the profession. I was called into the office of the attending psychiatrist. They came across to me as a distant bully who seemed to enjoy antagonizing patients during the team rounds we held each morning. They told me I had no business being a psychiatrist. I was yelled at for “acting like a social worker,” because I had called the young person’s family regularly to learn more about their life and give them updates.
I was even told my clothing was provocative and inappropriate. I wore bright colors, and the people swimming on the other side of the bowl liked them and complimented me. My bright pinks and oranges were a nod to my heritage and culture, mimicking the saris I grew up seeing my mom wear, an attempt to disrupt the sterility of the unit by bringing color into the room. That alone was treated as a problem.
The meeting was awful. It was clear I had been talked about by every member of the team, and that the scathing feedback had been relayed to the rotation director, who didn’t go so far as to analyze my physical appearance but made it clear a conversation had happened. I had already taken a leave of absence after being “certified crazy” myself. I was on probation, being watched by the school, and I knew psychiatrists talked. I was terrified I wouldn’t get into a residency program.
The psychiatry residents on that unit were mean and derisive. They made fun of how I behaved and of the questions I asked. The attending had come after me, and I felt intimidated and even fetishized, as my attempts to connect with the people on the other side of the fishbowl were subtly sexualized as provocative. Even one of my closest friends, a former medical school classmate a few years ahead of me, who had seen me through my own breakdown, pulled me aside. He agreed the attending had targeted me, but said I needed to straighten up like a soldier and get a good grade. The evaluation from my psychiatry rotation played a pivotal role in determining my future in the field—mainly whether or not I had one.
My one saving grace during that experience was a supervisor, a lovely psychiatrist who took me under their wing. They appreciated the rare and unusual things I learned about the “patients,” because I knew their stories so well. They told me the nurses said I excelled and shined because of those relationships.
Looking back, I can see that the referendum on psychotic people being issued on that unit also felt like a referendum on me, a former patient who had been hospitalized for her own breakdown. Who had profound compassion for the people on the other side of the fishbowl because she could see herself in them. Which for psychiatry colleagues was precisely the problem.
Frequent Fliers
After graduating from medical school, I spent my first two years of adult psychiatry residency largely on inpatient units, which is the norm for psychiatrists at this stage of training. Fresh out of medical school, residents nationwide often learn by practicing on the poor, at county and public facilities funded by Medicaid. It was where I internalized the mandate to eradicate psychosis.
In those units, you learn what “frequent flier” means: the individuals who cycle in and out. I can’t remember most of their names or stories, because in our system they rarely had one. Most were unhoused and unemployed, presumed destined for this fate.
A typical shift went like this: People were sent upstairs from the emergency room, often handcuffed by police or chemically restrained. You admitted them. You checked their records for the last set of meds, and verified whether they needed suicide or violence precautions. You verified whether or not the worsening psychosis could be chalked up to substances or medication noncompliance. You adjusted the meds: left them the same, increased them, or changed them. You checked their legal status. And you spent 10 to 15 minutes with them, or no time at all if they were too sedated to speak.
Their mental status exam, the clinical snapshot, was almost always the same:
- Appearance: disheveled, poor hygiene
- Behavior: cooperative or uncooperative, depending on how easy they made life for you
- Speech: paucity of speech
- Mood: “ok”
- Affect: flat
- Thought process: disorganized
- Thought content: +AH/VH
- Insight: poor
- Judgment: poor
It was a factory-like approach. Admit. Medicate. Sedate. Discharge. Repeat.
During my intern year, a senior resident nudged me to discharge someone who did not seem in their right state of mind. When I pushed back, he smirked: “You think I’m being mean by asking him to go.” The implication was that my “being nice” was my naivete.
Spending two years on those units, I also learned why people diagnosed with serious mental illness carry so much medical illness. No one takes them seriously. One person, described as “chronically psychotic,” complained of chest pain every night on the overnight shift. They were checked out again and again, and it was nothing. Until the night it was ignored, and they were having a pulmonary embolism. They survived and were treated with anticoagulation.
And I accepted it. I accepted that these people would never get better, and that the process we had was what kept them safe. I was a model resident. I learned to do the assessments quickly, to enter the supporting documentation with precision, and to ramp up the meds to maximum doses fearlessly. Never once did anyone suggest that our interventions were compounding the harm.
Voices With Meaning
During residency, I worked as a research assistant at a center focused on American Indian and Alaska Native health. It was the opposite of the locked wards, offering the first glimmer that I might find a home in medicine.
One of the center’s leaders led a trip to the Pine Ridge Reservation, home of the Oglala Lakota and the site of the 1890 massacre at Wounded Knee. I did evaluations at a Bureau of Indian Affairs school, interviewing young people living the aftermath, and the ongoing present, of genocide.
One was a quiet, soft-spoken student in their late teens. They heard the voices of their parent and sibling, calling them to join them in the spirit world. Both had died by suicide.
The voices were not gentle. They carried this young person’s grief, guilt for surviving, and real danger. They also carried love. What held them to this world wasn’t a medication. It was their young nibling, whom they regarded as their own child, the younger kids they helped at school, and their pride in being Lakota.
When I wrote up my evaluation, I did something I had never done on the county units. I did not call their voices psychosis. I described them as culturally grounded and diagnosed depression without psychotic features. Because I knew their story, the voices became part of their story, not a symptom to erase.
On the county units, voices were one line in the chart: +AH. Here, the same experience meant something entirely different, because someone had taken the time to ask. If this young person’s voices had meaning, what had I been missing in all the others?
Nothing Dangerous About Them
It wasn’t until my third year of residency, when we moved to outpatient care, that I began to see people differently. In the outpatient world, I saw how much complex trauma lived alongside the voices. The women I describe here are composites, with details changed to protect them.
One woman had been abandoned at birth and taken in by strangers who abused her. Her voices were critical and derisive. They sounded like her abusers.
Another had been married off as a teenager, far from here. She was made pregnant against her will and had many children while she was still a child herself. She was beaten regularly. One day she woke up and all of her children were gone. Years later, she made her way to the United States. She heard their voices constantly.
Later, during my global mental health fellowship in Haiti, I met mothers whose babies had died during childbirth or shortly after.
What struck me in all of these women was less paranoia than “disorganization,” in exactly the way psychosis presumes. They were isolated. They struggled to eat, to attend to hygiene, or to find meaningful activity or social connection. Though charted as negative symptoms of schizophrenia, in the landscape of their lives these patterns read as the best compromise for surviving while carrying grief.
Many of these women, who had suffered profound loss or endured unspeakable violence, were on high doses of antipsychotics, causing substantial weight gain. And they were always at risk of being hospitalized on the very inpatient units where I had spent my first two years.
But there was nothing dangerous about them. For a mother who has lost her children, going on with the work of living can feel like a fundamental betrayal. What the chart called disorganization looked to me like grief, and the aftermath of lifetimes of violence.
So I made the relationship everything. I supported people in finding independence and meaning, whatever that looked like for them. They called the shots; I showed up to support. For the woman who had been abused, it was having a place of her own. For the mother whose children were taken, it was finding them. For the mothers in Haiti, it was space to grieve.
I hadn’t yet heard of the Hearing Voices Movement. I found my way to trauma literature, but it felt inadequate. It didn’t account for the stories I was hearing from these women of color.
In that context, the idea that these women “lacked insight” felt absurd. How could anyone have insight into experiences that violent? Surviving them on their own terms was the real accomplishment, a testament to endurance, not pathology.
Presumed Dangerous… and Unfit
The presumption of dangerousness tagged to those labeled psychotic or schizophrenic matters urgently in 2026. Legislation and policy at the state and federal levels are moving back toward more coercive care and the warehousing of people. A 2025 executive order directs federal agencies to expand civil commitment for people who are unhoused and to seek the reversal of court precedents that stand in the way.
This past summer, the Justice Department signaled that it will no longer defend the integration mandate at the heart of Olmstead, the Supreme Court decision that recognized unjustified institutionalization as discrimination. New York, California, and Oregon have made commitment easier. Utah is planning a campus with hundreds of beds for people under civil commitment. Warehousing is no longer a metaphor. Presumptions of dangerousness are being written into policy and built into architecture.
I’ve seen who got presumed dangerous on the units. White patients labeled psychotic called staff the n-word, and it was ignored, their slurs and violence attributed to their “mental illness.” Black patients who were terrified of being in institutions that had historically harmed and violated their communities were charted as agitated. Not infrequently, people arrived in handcuffs or the back of a patrol car. People in mental health crises are far more likely to be killed by police, and Black people bear the brunt of it.
None of this is new. In 1851, the physician Samuel Cartwright coined “drapetomania” to diagnose enslaved people who fled as mentally ill. In 1968, two psychiatrists writing in the Archives of General Psychiatry coined “protest psychosis” to pathologize Black men in the Civil Rights Movement, as Jonathan Metzl has documented. The overdiagnosis of psychosis in Black people that followed persists today.
In my work on oppositional defiant disorder, I have traced a youth-to-adult diagnostic pipeline: ODD in childhood, then conduct disorder, then antisocial personality disorder or psychosis. These labels compound across schools, courts, and prisons, greasing the machinery of mass incarceration. Even the DSM-5-TR now warns that people who have experienced discrimination can report fears that may be misjudged as persecutory delusions. The warning sits in the text. The overdiagnosis continues.
Psychiatric labels do not just strip civil liberties on locked wards; they serve as administrative weapons to dismantle families. In my family policing work, I’m hearing more and more stories, nationwide, of mothers labeled psychotic around childbirth and having their children taken away. One common trajectory begins with a mother disagreeing with a medical decision, for her child or for herself during pregnancy. Her questions become paranoia and “noncompliance.” Her paranoia and noncompliance become a concern about her state of mind. A psychiatric label follows, and so does child welfare.
In that moment, a mother is expected to normalize what is happening to her. She’s supposed to treat the removal of her baby as inherently right and just, and to comply with recommendations to accept a psychosis diagnosis and take antipsychotic medication. When she responds with emotional distress, her distress gets labeled as pathology. An instinctive emotional reaction to having your child taken away is weaponized against you.
When child welfare orders a psychiatric evaluation, the evaluator is often in cahoots with the agency, validating its punitive stance. Mental health providers are not taught to critically question diagnosis, least of all when it is racialized. Diagnostic and practice standards for psychosis say nothing about its collusion with structural racism and their resulting harm. So a Black mother’s compliance with the system gets read as evidence of sanity and insight, and her refusal as evidence of illness.
The scale is staggering. More than half of Black children in the United States experience a child protective services investigation before age eighteen, most often for poverty-related neglect, not abuse, according to a 2017 study by Hyunil Kim and colleagues. Black people are overdiagnosed with psychosis. Black mothers are overpoliced by child welfare: reported more, investigated more, their children removed more. Those two inequities meet in the same delivery rooms and courtrooms, yet no one names that meeting point as a public health issue.
A psychiatrist asked to evaluate a mother whose baby has just been taken must start from those inequities. They must understand that what they were taught to see as child protection functions as a policing entity, and that their evaluation is one of its instruments. Closing that exact gap, and building an antiracist clinical standard for psychosis, is a core focus of my work.
The Lifelong Sentence
Looking back, I’m struck by how much these labels presume we are all talking about the same thing. Were the veterans I saw on inpatient units in Colorado, men carrying trauma from their service and the alienation that met them when they came home, really experiencing the same thing as the Black mothers in Haiti who had lost their babies? Was Haldol ever going to fix either of them?
The one-right-way model is part of what makes our predominant approach to schizophrenia so brutal, especially in crisis and inpatient care. As a child psychiatrist, I have seen the trauma these interventions wreak on families when parents feel they have no choice but to force care on someone they love. Parents come in believing the doctor knows best, so they do what providers tell them. They send their kids to the emergency room and the inpatient unit, then into partial hospitalization programs, or to locked residential facilities in other states. Kids tell me about having five medications piled on, or being forced to share their thoughts and feelings in a group. The more it fails, the more forceful the interventions become, until it annihilates both people and their relationship. Never once is the “treatment” identified as the source of failure. The wreckage is broken trust between parents and their kids, but the providers don’t have to take responsibility for it.
I fault the providers, not the parents. We sell families a lie: that this is the only way. Families are told that untreated episodes of mania and psychotic episodes can result in permanent brain damage.
And the labels carry their own sentence: It will never be the same. You will never hold full employment, or marry, or reach your highest potential and happiness. Your life as you knew it is over, and you should settle into a second-class life. I saw that sentence handed down most often during my child psychiatry training, to kids who had had manic episodes and were presumed to have bipolar disorder. If you are sick enough to land in those inpatient facilities, you are often told to expect a lifetime of medication.
The evidence does not support that sentence as a certainty. The World Health Organization’s cross-national studies found that people diagnosed with schizophrenia in some lower-income countries seemed to have better outcomes than those in wealthy ones. Martin Harrow’s twenty-year follow-up in Chicago and Lex Wunderink’s trial in the Netherlands both found that some people do well, and recover, with less medication or none over time. These findings are debated, and they are rarely shared with families sitting terrified in consultation rooms. But at the very least, the lifelong sentence is not a law of nature.
I know that sentence personally. I was never given a psychotic diagnosis. But at the severity of the one I was given, psychiatrists and psychologists in positions of power told me to drop out of medical school because I needed an “easier path.” They suggested that my unwillingness to accept my decline and inferiority was part of my illness, and that my determination to keep going was itself a lack of insight. I refused to accept their verdict. I stayed, graduated, and earned double-board certification in the very specialty that tried to write me off, not because the system understood me, but because I knew its prognosis was a lie.
If I could say one thing to a twenty-year-old just handed that diagnosis, it would be this: You are in a world of suffering right now. Your brain is changing a lot, and you are sensitive to things. Let’s look at all the variables. An episode like this, at this stage of life, does not sentence you to a lifetime of medication and sub-existence. To hand someone that sentence can be damning—and certainly carries at least as much risk of harm as it does benefit.
A House With No Locks
At the end of 2020, I left mainstream mental health settings. During COVID and in the aftermath of George Floyd’s murder, the ways our treatment of psychosis collude with structural racism became undeniable. I decided I could no longer participate.
Since leaving, I have become much more connected to alternatives to the biomedical framing of psychosis and schizophrenia. Through the peer movement and disability justice, I learned about the Hearing Voices Movement, and eventually about Soteria. Over the years, I’ve come to see that my own belief in one right way began in residency. I was never taught these alternatives.
The Soteria House model, in particular, has offered an opportunity to remake the role of psychiatry and the psychiatrist, even as I contemplate whether it should exist at all. I recently began collaborating with Kiva Soteria in Las Cruces towards that end.
I decided to be part of it because it is unknown and evolving, which is exactly the makeover and innovation the psychiatric profession needs. Not another failed medication or fancy technology or app, but a revision of the role and the practice.
The model is simple. You stay in a home. People don’t judge you. You get to decide. We show up for you, and we don’t force you. I often wonder how that could have changed the trajectory of my own life more than twenty years ago.
Everything that got me in trouble as a medical student, being so fully human, egalitarian, warm, and engaged, is precisely why they wanted me there.
The space is beautiful. It’s a gorgeous home, fully furnished through grassroots generosity and community care. Nothing about it is plastic or sterile. There are no cards or clanging sets of keys to get in and out. No suicide or violence precautions. Instead of staring through the glass of a fishbowl typing notes into an EMR, people sit together on the porch, share meals, and drink tea. It’s warm and inviting, full of artwork and plants, open, spacious, and airy. On the inpatient units, especially at the VA, I remember there was no outside time whatsoever. People were literally locked inside for months. It was worse than prison. Here, it is the opposite.
We are still learning how to do the work and how to show up for people. We’re figuring out how to help people taper off medications safely, and how to navigate standards of care and insurance that were never built for a place like this. And even with strong support from the New Mexico legislature and Kiva Centers’ leadership, parts of the local community have been fearful. The presumption of dangerousness follows people right up to the front door.
I don’t know exactly what this will become. That’s the point. We are co-creating it with people from many different experiences. Removing psychiatrists from the top of some fabricated pyramid, and having us work side by side with the people we serve, feels like the most lifesaving intervention yet, particularly given the times we are living in.
I still have questions, and I think they are best explored with curiosity rather than certainty.
Why do we offer the biomedical model as the only right way, without giving individuals and families a realistic and honest appraisal of the risks and benefits of engaging it, or of choosing to leave it altogether?
What are we actually naming when we say psychosis or schizophrenia? The medical framing suggests we are all talking about the same thing: dopamine dysfunction. What I see is one tag for a breadth of human experiences. We are not talking about the same thing.
And what do psychiatrists in training deserve to know? I believe they deserve to learn this model alongside its critiques: the data on people diagnosed with schizophrenia in other parts of the world, the criticisms of the model itself, and alternatives like Soteria. I was never given that. They should be.
The story of schizophrenia as a lifelong sentence is done. What comes next, we will have to write together.