Conversations in Critical Psychiatry

"Conversations in Critical Psychiatry" is my interview series for Psychiatric Times aimed to engage prominent critics within and outside the profession who have made meaningful criticisms of psychiatry and have offered constructive alternative perspectives to the current status quo.

Following interviews have been published so far. I will continue to update this page as new interviews are published.

1) Conversations in Critical Psychiatry: Allen Frances, MD

2) The Structure of Psychiatric Revolutions: Anne Harrington, DPhil

3) Skepticism of the Gentle Variety: Derek Bolton, PhD

4) Explanatory Methods in Psychiatry: The Importance of Perspectives: Paul R. McHugh, MD

5) Chaos Theory With a Human Face: Niall McLaren, MBBS, FRANZCP

6) The Rise and Fall of Pragmatism in Psychiatry: S. Nassir Ghaemi, MD, MPH
7) Integrating Academic Inquiry and Reformist Activism in Psychiatry: Sandra Steingard, MD & G. Scott Waterman, MD

8) Social Constructionism Meets Aging and Dementia: Pete…

The Degenerative Agenda of Explaining Away Genetic Research in Schizophrenia

Jay Joseph's guest post on Duncan Double's blog – criticizing the notion that schizophrenia has a substantial genetic component – reminds me of the distinction between progressive and degenerative scientific programs from philosophy of science. Progressive scientific programs show a growth of theoretical frameworks, development of new research methods, generation of novel findings, and validation of predictions. Degenerative programs lack these features; instead, they are engaged in the never-ending task of explaining away findings.
I marvel at the vacuousness of the efforts to deny the overwhelming scientific consensus that a substantial portion of the risk of development of schizophrenia comes from aggregate genetic factors, and that these genetic factors don’t confer this risk in isolation but rather through complex interactions with non-genetic and environmental factors.
In order to appreciate the progressive nature of genetic research into the nature of schizophrenia, co…

Defending Aggregate Genetic Effects in Psychiatric Disorders

This post is in response to Duncan Double's commentary on Ken Kendler's paper "The dappled nature of causes of psychiatric illness: replacing the organic–functional/hardware–software dichotomy with empirically based pluralism".

I disagree with much of Double's characterization and interpretation of Kendler's paper and I find the responses wholly inadequate. Unpacking and addressing each and every point will take a long time, so for the purposes of illustration of the inadequacies of Double's comments, I'll consider his response to the discussion of aggregate genetic effects.

To demonstrate what aggregate genetic effects are, let's look at what Kendler writes about schizophrenia: "Adoption and twin studies show consistent and strong evidence for aggregate genetic effects in schizophrenia with the best estimates of heritability being quite high (~80%).34 To date, only a very small proportion of this risk has been indexed by known molecular var…

What is a “functional” psychiatric disorder?

I have recently between engaged in a twitter discussion with Duncan Double (a retired British psychiatrist), who insists on using the organic/functional distinction when it comes to psychiatric disorders and seems to think that this distinction justifies the claim that functional psychiatric disorders have no biological causes and have only psychosocial causes.
In order for this debate to go anywhere, I think we need to be very specific about the meaning of the terms. What exactly does “functional” mean?
For the record, I am not in favor of using the term “functional” as a general descriptor for psychiatric conditions. I think it is too conceptually muddled and has a lot of unsavory philosophical baggage. Nonetheless, I need to define it first if I am to meaningfully discuss the concept.
I think there are two broad ways of defining the term "functional".
Meaning 1 (M1): A psychiatric condition is functional if it cannot be attributed to an “independently diagnosable cerebr…

Social Misuse of Disorder Designation

My 3-part articles series for Psychiatric Times in which I explore the question: what conceptual means are available to us to prevent behavioral conditions from being diagnosed as mental disorders as a result of social bias and stigma?
Social Misuse of Disorder Designation, Part I: Conceptual Defenses
Social Misuse of Disorder Designation, Part II: The Dysfunction Defense
Social Misuse of Disorder Designation, Part III: Harm and Ethical Validity

The Virtuous Psychiatrist: Meditations on Success and Flourishing

The July issue of Psychiatric Times contains a brief reflection piece by me titled 10 Meditations on Succeeding—and Flourishing. Since the published version is a revised product with editorial modifications, I would like to make my preferred text of the article available here.

The Virtuous Psychiatrist: Meditations on Success and Flourishing
Awais Aftab, MD
When it comes to happiness, success and moral well-being, I have been deeply influenced by the Greek philosophers, particularly Aristotle. Aristotle speaks of eudaimonia ("flourishing") – a sort of moralized happiness, distinct from mere pleasure – and virtue is excellence in his eyes (arete: virtue/excellence), signifying qualities necessary for living well. To borrow words from Emrys Westacott, in so far as we fail to cultivate and exercise virtues – wisdom, curiosity, intellect, aesthetic sensitivity, compassion, empathy, generosity – we fail to exemplify human flourishing [1].
One is not likely to flourish as a psychi…


"I try to translate the Aramaic of the sky."
Sean Thomas Dougherty, Tamir Rice


"Death is such a monumental breakage in our logical understanding of the world that it fractures our language, our behavior — it excuses, in its way, almost anything. To touch a relative stranger’s beard suddenly seems perfectly reasonable — a weirdly urgent affirmation of life."
Sam Anderson, writing for NYT New Sentences

Fleeting Associations

"How many fleeting associations combine to make up a life? How many rusty pipes do we mistake for owls? A vast majority of our waking hours are filled not with witty jokes or brilliant thoughts or epic feelings but with tiny, private mind-motions — thoughts that are hardly even thoughts at all, that don’t rise to the level of sharing with another human being. That millisecond when — again and again — a rusty pipe looks like an owl, or a newscaster’s voice reminds you of a long-gone uncle, or a daily routine sets off a small chain of involuntary associations. These things are almost nothing, and yet they are who we are."
Sam Anderson, writing for NYT New Sentences


"Like atoms, words are always looking to combine, floating around with their meaning-tendrils extended, probing the air for compatible partners."
Sam Anderson, in New Sentences

Against Marriage

"State-recognised marriage means treating married couples differently from unmarried couples in stable, permanent, monogamous sexual relationships. It means treating people in sexual relationships differently from those in non-sexual or caring relationships. It means treating those in couples differently from those who are single or polyamorous. It expresses the official view that sexual partnership is both the ultimate goal and the assumed norm. It expresses the assumption that central relationship practices – parenting, cohabitation, financial dependence, migration, care, next-of-kinship, inheritance, sex – are bundled together into one dominant relationship. And so it denies people rights that they need in relation to one practice unless they also engage in all the others and sanctify that arrangement via the state.
State recognition of marriage is thus discriminatory against the unmarried. It is also anachronistic. While some people do bundle together their relationship prac…

What They Do

“People know what they do; frequently they know why they do what they do; but what they don't know is what what they do does.”
― Michel Foucault, Madness and Civilization

Romanticizing Stress

"Every episode [of the tv show House Hunters] I've seen (there are nearly 2,000) is a thrilling cultural artifact, a tiny parable about the way we romanticize the stresses of modern American life and pile on more in hopes of assuaging those festering below."
Bobby Finger, House Hunters

Small Murders

"twenty-seven kisses
on my neck, twenty-seven small murders of you"

Aimee Nezhukumatathil, Small Murders

Yearning for Strange Ideas

"Is it disappointing that “Midlife” arrives at the conclusion that “living in the present” is the solution to middle-aged unhappiness? A little. One might wonder if all that philosophy was really necessary. Setiya has the whole history of thought at his disposal. Drawing on Heidegger, he could have urged middle-aged people to find new ways of “disclosing” the world to themselves, perhaps by acquiring new or deeper skills. Adapting the work of Derek Parfit, he could have argued that selves are less real than we think, and that midlife crises are, therefore, about nothing. With Douglas Hofstadter, he might have concluded that it’s relationships that matter, since the patterns of thought and feeling encoded in our neurons will repeat themselves in the brains of the people we love, like musical echoes. Who knows what other intriguing suggestions Setiya might’ve come up with if he’d pillaged the history of philosophy with abandon? While reading “Midlife,” I yearned for such strange a…

Tomorrow will bring us shame

"Eventually, all of our heroes become villains. George Washington owned slaves. Famed suffragette Nellie McClung was a vocal advocate for sterilizing women with disabilities. Eleanor Roosevelt was wildly anti-Semitic. Winston Churchill? Utterly racist. Christopher Columbus? You don’t want to know.
Even the most virtuous among us right now, the pink-hatted protesters and the hemp-wearing vegans, will one day be seen as contemptibly, perhaps even criminally unethical. One ate meat. The other owned a car.... We have no reason to feel smug and self-righteous with our enlightened, modern sensibilities. Tomorrow is guaranteed to bring us all dishonour and shame."
James Bond was a rapist

Ontological Unease

"We live somewhere queasier—a world in which technology is developing in ways that make it increasingly hard to distinguish human beings from artificial things. The world that the Internet and social media have created is less a system than an ecology, a proliferation of unexpected niches, and entities created and adapted to exploit them in deceptive ways.... In other words, we live in Philip K. Dick’s future, not George Orwell’s or Aldous Huxley’s.... what he captured with genius was the ontological unease of a world in which the human and the abhuman, the real and the fake, blur together. 
In his novels Dick was interested in seeing how people react when their reality starts to break down. A world in which the real commingles with the fake, so that no one can tell where the one ends and the other begins, is ripe for paranoia. The most toxic consequence of social media manipulation, whether by the Russian government or others, may have nothing to do with its success as propagan…

Past Selves

"My eyes welled up. There was some sadness — the memory of a fall that had been so hard. And an aching sympathy for a woman who was so heartbroken that she fantasized about throwing her body off a bridge.
Who was that woman? I had come so far that I felt like I no longer knew her."
Elaisha Stokes, writing for Modern Love

Ingredients of Temptation

"We’re often the most stubbornly attracted to those who represent forbidden, or unresolved, aspects of our personality.... Perhaps being with this man allows you to indulge certain darker aspects of his personality that dwell within you while also disavowing them.... Nobody knows the precise ingredients of temptation. We can only attempt to know ourselves."
Steve Almond and Cheryl Strayed


"[The Americans] is about delusions—romantic, political, bureaucratic, tactical, marital, fashion (the year is 1981). And parental: Can Elizabeth really think that her children “understand” a father whom they believe is a travel agent but is actually a spy and assassin who’s just staged a sham wedding with a deluded F.B.I. secretary at which their mother pretended to be his sister? Can the K.G.B. really think that Al Haig might attempt a military coup after John Hinckley shoots Ronald Reagan—a major plot element in an early episode? Maybe they can.
It’s often said, admiringly, that “The Americans” is a show about marriage that is dressed up as a spy drama. One of its premises is that marriage itself is a matter of dressing up and performing, and that those enactments, particularly when children are watching, can be its most genuine part." 
New Yorker: The Secret of “The Americans”

I live my life in widening circles

by Rainer Maria Rilke

I live my life in widening circles
that reach out across the world.
I may not ever complete the last one,
but I give myself to it.

I circle around God, that primordial tower.
I have been circling for thousands of years,
and I still don’t know: am I a falcon,
a storm, or a great song?

Witch Trials

"... the Salem witchcraft trials, in which a person was guilty because accused, since the rules of evidence were such that you could not be found innocent....
This structure – guilty because accused – has applied in many more episodes in human history than Salem. It tends to kick in during the "Terror and Virtue" phase of revolutions – something has gone wrong, and there must be a purge, as in the French Revolution, Stalin's purges in the USSR, the Red Guard period in China, the reign of the Generals in Argentina and the early days of the Iranian Revolution. The list is long and Left and Right have both indulged. Before "Terror and Virtue" is over, a great many have fallen by the wayside. Note that I am not saying that there are no traitors or whatever the target group may be; simply that in such times, the usual rules of evidence are bypassed.
Such things are always done in the name of ushering in a better world. Sometimes they do usher one in, for a tim…

Gazing Out of the Window

"Plato suggested a metaphor for the mind: our ideas are like birds fluttering around in the aviary of our brains. But in order for the birds to settle, Plato understood that we needed periods of purpose-free calm. Staring out the window offers such an opportunity. We see the world going on: a patch of weeds is holding its own against the wind; a grey tower block looms through the drizzle. But we don’t need to respond; we have no overarching intentions, and so the more tentative parts of ourselves have a chance to be heard, like the sound of church bells in the city once the traffic has died down at night. 
The potential of daydreaming isn’t recognised by societies obsessed with productivity. But some of our greatest insights come when we stop trying to be purposeful and instead respect the creative potential of reverie. Window daydreaming is a strategic rebellion against the excessive demands of immediate (but ultimately insignificant) pressures – in favour of the diffuse, but v…

Fara On Vagueness

NYT magazine on Delia Graff Fara:
"Fara’s theory, which she presented in a 2000 paper called “Shifting Sands,” had an answer. She argued that vagueness was an expression of our ever-changing purposes: that there is a precise point at which a heap becomes a nonheap, but it “shifts around” as our objectives do. In fact, because the act of considering two comparable heaps accentuates their similarity, “the boundary can never be where we are looking.” No wonder we think it doesn’t exist.
Imagine that a gym teacher has hastily divided a large class of students into two groups according to height. If you enter the gym, you will have no trouble declaring one group the tall students and the other the short ones. But had you been presented with the undivided class and asked to say where the tallness boundary was, you would have despaired of an answer. Tallness is not just a matter of height, Fara concluded. As with all such properties, what gets to be tall is also shaped by our interests …


"Many psychoanalysts think that lovesickness is a form of regression, that in longing for intense closeness, we are like infants craving our mother's embrace. This is why we are most at risk when we are struggling with loss or despair, or when we are lonely and isolated... 'People who are lovesick put off testing their fantasies against reality.' But given the anguish that lovesickness can cause - the loss of mental freedom, the dissatisfaction with one's self, and the awful ache - why do some of us put off facing reality for so long?
Often it's because facing reality means accepting loneliness. And while loneliness can be useful - motivating us to meet someone new, for example - a fear of loneliness can work like a trap, ensnaring us in heartsick feelings for a very long time."
Stephen Grosz, The Examined Life