June 29, 2023

Navigating the Landscape of Critical Psychiatry: A Conversation with Dr. Awais Aftab

Written by

Dr. Carlene MacMillan, MD

Exploring Critical Psychiatry

The field of psychiatry is in a constant state of evolution, necessitating nuanced dialogues about its history and present trajectory. Dr. Awais Aftab, Clinical Assistant Professor of Psychiatry at Case Western Reserve University, lends his voice to this conversation, offering insights as a clinician and prominent writer for the Psychiatric Times and his popular newsletter, Psychiatry at the Margins.

In our interview with Dr. Aftab, we'll explore:

  • Understanding the landscape of critical psychiatry and contrasting it with the divisive term "anti-psychiatry"
  • The role of cultural movements and groups like mad pride, service users, and psychiatric survivors—in shaping language around how we conceptualize mental illness
  • The role of service users in advocating for better care, especially regarding involuntary hospitalizations and crisis hotlines
  • How practicing psychiatrists can move the field forward in a meaningful way
  • Tips on navigating social media in psychiatry and not feeding the trolls

Critical Psychiatry vs. Anti-Psychiatry

Critical psychiatry is an approach that scrutinizes systemic and structural issues in mental health care, advocating for meaningful change and ethical practices. By challenging conventional paradigms and examining the impact of social and contextual factors, critical psychiatry helps shape a more patient-centered and nuanced trajectory for the field of psychiatry.

As we explored the concept of critical psychiatry, Dr. Aftab emphasized the importance of distinguishing it from the often-divisive term "anti-psychiatry." He explained, "Critical psychiatry is not anti-psychiatry. It's not anti-medicine, anti-medication. It's a more nuanced approach that is open to exploring and critiquing the assumptions and practices of psychiatry"

The Need for Community Support and Crisis Hotlines (and the Risks)

Crisis hotlines, such as the 988 hotline, have become a vital resource for individuals facing mental health emergencies. The 988 hotline, established by the National Suicide Hotline Designation Act and signed into law in 2020, is a designated three-digit phone number for mental health emergencies and suicide prevention in the United States. By dialing this easily accessible and memorable number, individuals experiencing a mental health crisis or suicidal thoughts can connect with trained mental health professionals for confidential support, crisis intervention, and resources.

Despite the essential role of crisis hotlines, there are potential pitfalls and challenges that must be considered. Dr. Aftab notes, "The problem with crisis hotlines is that they often end up becoming a referral service for hospitals, and that's not necessarily what people are looking for. They want to talk to someone, they want support, but they don't want to be told to go to the hospital." 

Reimagining Inpatient Psychiatric Care: A Shift from Risk Management to Therapeutic Focus

Inpatient psychiatric care serves as a critical component of mental health services. However, Dr. Awais Aftab expressed his concerns about the current state of inpatient care in the US, which tends to prioritize risk and liability over therapeutic considerations. 

"The unfortunate reality of inpatient psychiatric care in the US right now is that it is so focused on minimizing risk and liability that it is ignoring the therapeutic side of things," Dr. Aftab shared. He further explained how this risk-based framing has led to limitations in treatment options and a lack of autonomy and dignity for patients seeking help.

To address these challenges, Dr. Aftab emphasized the need for a reorientation of inpatient psychiatric care to prioritize therapeutic outcomes. He highlighted the potential for creativity in the delivery of mental health services, including the concept of home hospitalization, where medical services are brought to patients in their own residences. This approach could help prevent unnecessary higher levels of care and provide individuals with care that respects their autonomy and dignity.

Additionally, Dr. Aftab underscored the importance of advocating for changes in the structure and policies of psychiatric hospitals to create more patient-centric environments. "People want to receive inpatient psychiatric care in a way that offers them autonomy and dignity," he said, but the current model of accessing care through emergency rooms often involves involuntary admissions and the surrender of patients' rights.

Ultimately, a shift in the focus of inpatient care from risk management to therapeutic considerations could result in more meaningful and effective treatment experiences for patients. This reimagined approach to inpatient psychiatric care has the potential to transform the field and improve patient outcomes.

The Role of Technology in Continuity of Care

Technology plays a crucial role in enhancing continuity of care, and we discussed the potential of telepsychiatry in improving patient access. Dr. Aftab praised the benefits of telepsychiatry, stating, "So many people who were not able to access mental health care for a wide variety of reasons...are now able to access care in a timely and safe manner." He also expressed concerns about potential regulatory challenges that could restrict access to telepsychiatry.

As we navigate the era of telepsychiatry, we must advocate against regulatory changes that could limit access to telehealth services, such as the ending of the Ryan Haight Act. The DEA's proposed rule changes could significantly impact the availability of telepractice in mental health care. 


Our exploration of critical psychiatry with Dr. Aftab has highlighted the necessity for a more nuanced, patient-centric approach in our field. Psychiatrists must prioritize genuine support over simple referrals, advocate for therapeutic-focused inpatient care that respects patient autonomy, and champion the continued accessibility of telepsychiatry against regulatory threats.

So, let's engage, question, challenge, and transform our practices. The evolution of psychiatry is in our hands, and we have the opportunity to shape it with compassion and thoughtfulness.

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