Hero

Videos

Slideshows

Articles

Podcasts

Poll

Laughter Therapy: Good Medicine to Make Your Heart Glad

Here's a couple ways you can get better...

Psychiatry Comic: Holistic Health Center

I was reading an article about 9/11 and learned that the first plane hit the North Tower of the World Trade Center at 8:46 AM. My mind immediately shifted to the symbolism of this time regarding the modern-day lynching of George Floyd. These are 2 eerie moments in our history in which the time to breathe was obstructed by crushing blows to humanity. 

May this poem inspire reflection and challenge us to inhale love.

is associate professor at the University of South Carolina School of Medicine - Greenville and medical director and division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health - Upstate. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

Two traumatic events... the same timing. 

8:46 Shock and Reflections

Twenty years ago I remember my college roommate walking frantically into our room to inform me that planes had crashed into the Twin Towers and the Pentagon. His news was initially met with incredulity, which quickly transitioned to sadness.

Today we pay homage to the families who lost loved ones on this day. We also express our sincere gratitude and appreciation to our first responders who were relentless in their pursuit to perform life-saving measures.

I pray and hope that we reflect on how far we have come as a country in the 20 years following 9/11. We are resilient, and we have gained perspective. Let us forge ahead as a nation that embodies love, unity, and growth.

It's been 20 years since the 9/11 attacks. What have we learned?

Posttraumatic Growth: Reflections on 9/11

We live in a world in which the philosophy of embracing our brothers and sisters of diverse backgrounds and perspectives with love has often fallen on deaf ears. I would like to introduce an African philosophy that emphasizes the importance of humanity. I recently learned the word "ubuntu." It has multiple translations, including “I am because we are” or “humanity toward others.” I embolden all communities to adopt and reflect on this philosophy that promotes kindness, compassion, and respect. 

Taking a page from African philosophy that emphasizes the importance of humanity into the psychiatric realm.  

Contagious Philosophy and Perspectives

Psychiatry Comic: Gene Editor

Psychiatry Comic: The Best Alternative Medicine

SPECIAL REPORT: MINORITY MENTAL HEALTH PART 1

The shocking Atlanta mass shooting in March 2021 that resulted in the deaths of 6 Asian American women brought the nation’s attention to the 

 since the advent of the COVID-19 pandemic. The increase in hate speech, property damage, and brutal attacks, coupled with the negative mental health impact of quarantine isolation, has led to an increase in feelings of anxiety and distress among Asian Americans.

 With this confluence of stressors, we anticipate more Asian Americans will present for psychiatric care. Given the shortage of psychiatrists with expertise in working with Asian American patients,

 it seems timely for us to share some insights on both acute and 

longer-term issues facing Asian Americans

Before we begin, a caveat: Asian Americans are an incredibly diverse group, representing more than 20 countries of origin and hundreds of languages and cultures. The needs of immigrants differ from those of American-born Asians. There are wide differences in socioeconomic status, insurance status, educational background, age, and degree of acculturation. Although 3 case presentations are inadequate to capture the diversity of this population, the cases are used to illustrate some of the issues with enhanced nuance and depth.

“Ms Cho” is a 37-year-old married professional Korean American woman with a history of major depressive disorder (MDD) and generalized anxiety disorder (GAD). Although she has been on a long-term stable dose of sertraline, her mood and anxiety have gradually worsened in recent months, and she reports feeling inexplicably “overwhelmed.” She finds herself struggling to keep up with work demands. Her psychiatrist, “Dr Williams,” who is not Asian, asks if this feeling has anything to do with the recent rise of anti-Asian violence. Ms Cho thinks for a moment, then nods. She discloses that she is constantly worried about the physical safety of her parents and her 2 school-aged children. She is also having intense memories of being bullied when she was in grade school. She finds herself thinking about these incidents, now with an adult’s perspective, and realizing the long-term impact these incidents have had on her life.

Anti-Asian racism in the United States began with the arrival of the first Asian immigrants in the 1850s. Frequently seen by Whites as “uncivilized, unclean, filthy beyond all conception,”

 Asians were labeled the “Yellow Peril” and “perpetual foreigners.” Over the subsequent 75 years, legislation such as the Exclusion Act (1882), Immigration Act (1917), and Johnson-Reed Act (1924) was passed to severely restrict immigration from Asian countries and to make those who did immigrate ineligible for citizenship.

In 1965, the United States relaxed immigration restrictions from Asia, and a second wave of more affluent, highly skilled Asians immigrated to this country. Perception of Asian Americans shifted from revulsion to admiration, as Asian immigrants attained educational and professional success. Asian Americans came to be known as a model minority, with success attributed to aspects of Asian culture, as compared with that of other ethnic minorities.

 reveals the fragility of the model minority myth. In the wake of COVID-19, Asians are no longer seen as educated hard workers worthy of admiration, but instead as carriers of disease, harkening back to the first racist insults. Furthermore, the attacks, which often take place in broad daylight with bystanders around, leave many Asian Americans feeling vulnerable and needing to be vigilant. One Asian American author eloquently describes the feeling of vulnerability: “I’m seen for my race above anything else,” she said. “I can be a Brown University student or a professor, but if I walk out onto the street, I will first and foremost be seen as an Asian and could still be attacked for that.”

There has been a recent recognition that the strife associated with racism can rise to the level of traumatic stress,

 which can cause symptoms characteristic of posttraumatic stress disorder (PTSD): intrusive thoughts and memories, anxiety, and feelings of being unsafe, as experienced by Ms Cho. Thus, we could consider Ms Cho’s current symptoms to be products of vicarious trauma, triggering memories of earlier childhood racial trauma. While Ms Cho’s symptoms may not rise to the threshold level of PTSD (Dr Williams would need to perform a more comprehensive evaluation to say so definitively), subthreshold traumatic stress symptoms can exacerbate preexisting comorbid conditions, such as MDD and GAD.

While no empirically validated treatment models exist yet for managing symptoms associated with ethnoracial trauma, experts do recommend a few ground rules (

In addition to the above general principles, consider some of the interventions described in 

“Mr Sok” is a 58-year-old Cambodian American man referred by his primary care doctor to psychiatrist “Dr Smith” for chest pain with unremarkable cardiac workup. Because the clinic is without a Khmer translator, Dr Smith asks the accompanying daughter to provide translation.

The patient describes that he is worried that his chest pain could mean that he is developing, in his words, a “weak heart.” He also worries about tension in his body, which he takes to be a sign that his body is “falling apart.” Dr Smith, believing Mr Sok to be suffering from somatic symptom disorder, prescribes escitalopram. She explains the neurobiology of anxiety disorders; she notes the medication will help with his anxiety and suggests he return in several weeks. Mr Sok looks visibly puzzled but agrees to the treatment plan. Mr Sok does not fill the medication and is lost to follow-up.

Many Asian American immigrants have spent more time outside of the United States than in it. Consequently, a patient’s experience of their illness—their beliefs about its cause, its treatment, its meaning—is more likely informed by their culture of origin than by Western concepts like psychiatric diagnosis. Clinicians would do well to mind the gap between the psychiatric explanation and their patient’s. Ignoring this gap can lead to problems such as misdiagnosis, medication nonadherence, or early treatment rupture, as in Mr Sok’s case.

We recommend explicitly soliciting the patient’s cultural understanding of their illness using the 

 or the Engagement Interview Protocol (EIP).

 The CFI operationalizes the process of elaborating a cultural narrative of the patient’s illness by reframing the query: “Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?” In our experience, the CFI or EIP opens new opportunities for building a patient-clinician alliance and improves patient trust in the treatment.

It is also important to provide a culturally sensitive disclosure of diagnosis. Dr Smith could begin the discussion by relaying her understanding of the patient’s concern about a wind imbalance, and then wonder with him whether a medication might help bring his wind back into balance.

, particularly elders, vary in their degree of English language proficiency. Access to mental health care conducted in a patient’s primary language is limited in the United States and represents a serious barrier to care. Use of family members as translators, while necessary in limited resource settings, has considerable drawbacks ranging from omission of information to traumatizing the family member acting as translator.

 For this reason, we recommend the use of professional staff to perform translation.

“Ms Elizabeth Chen” is a 17-year-old Chinese American high school senior who presents following a brief inpatient stay for self-harm by cutting; her mother, who discovered the cutting, arranged for emergency evaluation. Elizabeth angrily relays the episode: “I’m so embarrassed. It’s actually her fault that I’m cutting. If she didn’t put so much pressure on me to succeed and if she took the time to understand my emotions, none of this would have happened.”

Elizabeth was born in the United States after her parents immigrated from China 20 years ago. Elizabeth describes the challenges of never feeling like she fits in. She describes one instance when she brought lunch from home and how some of her classmates teased her and said her food had “odd smells.” From that point on, she bought her lunch from the cafeteria.

“Dr Santos” speaks with Elizabeth’s mother, who describes her view of the problem: “Elizabeth tries to do too many things at once. She studies hard, but also wants an active social life—I always tell Elizabeth that she will feel better if she doesn’t spend so much time around her friends, but she never listens to my advice and then gets so mad.”

Many American-born Asians struggle navigating 2 cultures: They strive for acceptance from the host culture on the one hand, and they strive for acceptance from their family and the culture of origin on the other. This added conflict can complicate the already onerous process of identity formation in adolescence, setting the groundwork for psychiatric symptoms and problematic behaviors.

Furthermore, Asian American immigrant parents tend to judge their child’s behavior and actions by the cultural standards of the country of origin and are apt to make suggestions that may miss the bicultural nature of the conflict. For example, Mrs Chen’s suggestion to minimize socializing and focus on schoolwork may be well-received by a student who grew up in China, but to Elizabeth, this suggestion is likely to feel invalidating of her desire to acculturate, fueling further frustrations that her mother does not understand.

What can a treating psychiatrist do to help the situation? In addition to recommending standard behavioral treatments for problematic behaviors such as cutting, Dr Santos might also suggest a family intervention, using the Bicultural Effectiveness Training framework as an approach.

 Specifically, Dr Santos could gently reframe the problem as a conflict of cultural perspectives rather than a conflict of individual personalities and reflect with both parent and child on the advantages and disadvantages of each cultural perspective. For example, Dr Santos might ask Elizabeth and Mrs Chen to reflect on situations when spending less time with friends might be a good solution to stress and when it might not be a good solution.

Elizabeth’s case also illustrates the damaging effects of the model minority stereotype on the individual. Asian Americans like Elizabeth can feel immense pressure to live up to an image of success, exacerbating academic stress and leading to concealment of mental health symptoms. Of all US racial groups, Asian Americans are the least likely to seek mental health care, and while the reasons for this inequity are complex, the perpetuation of the model minority myth likely contributes to this disparity.

By presenting these 3 cases with patients of varying ages, national origins, language proficiencies, and presenting problems, we hoped to capture a 

 and showcase some of the main issues facing this population. The techniques highlighted might be helpful not only for Asian American patients, but across cultures as well. In fact, we might think about these techniques as ways for clinicians to assume a general attitude of cultural humility—a position of openness, self-awareness, and curiosity—that is useful in all encounters with patients, regardless of race or cultural background (

We hope that some of the strategies in this article may help in that effort to treat Asian American patients. However, when it comes to treating symptoms that are produced by systemic forces like racism and alienation from mainstream American culture, bearing witness to a patient’s experience of racism is like treating the symptoms without addressing the underlying cause. A truly comprehensive treatment plan for Asian American patients ultimately requires us to address the root cause by participating in advocacy for systemic change outside the consultation room.

is an assistant psychiatrist at the Behavioral Health Partial Hospital Program at McLean Hospital, a supervising psychiatrist to residents in the Adult Outpatient Services, and a member of the faculty at the Massachusetts General Hospital Center for Cross-Cultural Student Emotional Wellness.

 is a psychiatrist at Massachusetts General Hospital.

1. Kim M. For Asian Americans bearing racism’s psychological toll, mental health experts have advice. 

. April 19, 2021. Accessed June 2, 2021. 

https://www.kqed.org/forum/2010101883007/for-asian-americans-bearing-racisms-psychological-toll-mental-health-experts-have-advice

2. Kumar N. Rise in Asian American discrimination and violence during COVID is causing mental health crisis. 

. April 27, 2021. Accessed June 2, 2021. 

https://www.healthline.com/health/rise-in-asian-american-discrimination-is-causing-mental-health-crisis

3. Evans M. After Atlanta-area attacks, Asian communities reckon with mental health crises. 

. March 31, 2021. Accessed June 2, 2021. 

https://www.latimes.com/california/story/2021-03-31/atlanta-attacks-asian-community-mental-health?utm_id=26381&sfmc_id=4217677

4. Weissman JS, Betancourt J, Campbell EG, et al. 

Resident physicians’ preparedness to provide cross-cultural care.

6. Gagosz A. Grappling with identity as an Asian American woman, one story at a time. 

. Updated April 7, 2021. Accessed June 2, 2021. 

https://www.bostonglobe.com/2021/04/07/metro/grappling-with-identity-an-asian-american-woman-one-story-time/

Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress.

8. Williams MT, Metzger IW, Leins C, DeLapp C. 

Assessing racial trauma within a DSM-5 framework: The UConn Racial/Ethnic Stress & Trauma Survey.

A therapeutic approach to the treatment of racist-incident–based trauma.

10. DeSilva R, Krishan Aggarwal N, Lewis-Fernández R. 

The DSM-5 Cultural Formulation Interview and the evolution of cultural assessment in psychiatry.

11. Lewis-Fernández R, Krishan Aggarwal N, Lam PC, et al. 

Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: mixed-methods results from the DSM-5 international field trial.

12. Yeung A, Trinh N-HT, Chang TE, Fava M. 

The Engagement Interview Protocol (EIP): improving the acceptance of mental health treatment among Chinese immigrants.

13. Leanza Y, Miklavcic A, Boivin I, Rosenberg E. Working with interpreters. In: Kirmayer L, Guzder J, Rousseau C, eds. 

Cultural Consultation: Encountering the Other in Mental Health Care.

 Springer Science and Business Media; 2013:89-114.

14. Szapocznik J, Santisteban D, Kurtines W, et al. 

Bicultural Effectiveness Training: a treatment intervention for enhancing intercultural adjustment in Cuban American families.

15. Szapocznik J, Rio A, Perez-Vidal A, et al. 

Bicultural Effectiveness Training (BET): an experimental test of an intervention modality for families experiencing intergenerational/intercultural conflict.

Discrimination and mental health-related service use in a national study of Asian Americans.

17. Abe-Kim J, Takeuchi DT, Hong S, et al. 

Use of mental health-related services among immigrant and US-born Asian Americans: results from the National Latino and Asian American Study.

Healing ethno-racial trauma in the Black community: cultural humility as a driver of innovation.

19. Learning for Justice staff. How to respond to coronavirus racism. Learning for Justice. March 20, 2020. Accessed June 2, 2021. 

https://www.learningforjustice.org/magazine/how-to-respond-to-coronavirus-racism

20. Cultural Formulation Interview. American Psychiatric Association. 2013. Accessed June 2, 2021. 

https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview.pdf

The rise in anti-Asian violence will likely lead to a rise in Asian Americans presenting for psychiatric care. Here is how best to address the longer-term problems they face...

Asian American Mental Health: Treating a Diverse Population at a Crossroads

Psychiatry is associated with the brain, but there is so much more to it than that. We are the field within medicine that deals with humanity. As such, we can be the field that serves as a conduit toward dismantling racial and social injustices in health care. Indeed, psychiatrists are equipped with the tools to engage in a healthy discourse when discussing topics that may have a proclivity toward inspiring defensiveness and fragility. And we recognize that when there is division in the body, all parts suffer.

What our field does today regarding the topics of diversity, equity, and inclusion will reverberate throughout the walls of the inpatient wards, residency/fellowship programs, ambulatory clinics, and community mental health centers for centuries to come. I embolden us to practice humility and to cultivate a growth mindset that diverges from the status quo. Answering the call of these exhortations is vital if the health care disparity gap is be narrowed.

With that in mind, I hope that this 2-part series will help improve our cognitive flexibility and our ability to rethink how we provide care for our patients using the bio-psycho-social-cultural-spiritual model. Over these Special Reports, we aim to share insights and tips to support you in providing meaningful care to those from minority populations and backgrounds.

I leave you with some food for thought in the form of this haiku:

is associate professor at the University of South Carolina School of Medicine - Greenville and medical director and division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health - Upstate. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for 

By recognizing the importance of minority mental health and caring for all types of patients, psychiatrists depict the epitome of humanity.

The Epitome of Humanity

Too much time on phones is tearing the family apart... 

Psychiatry Comic: Digital Family Tree

Conversations in Critical Psychiatry is an interview series that 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.

Wouter Kusters, PhD, is a Dutch linguist and philosopher. He is the author of 

; Lemniscaat, 2014). An English translation of 

 was published in 2020 by MIT press with the title 

A Philosophy of Madness: The Experience of Psychotic Thinking

 (translated by Nancy Forest-Flier). Dr Kusters works as an independent researcher, writer, teacher, and consultant in Gouda, Netherlands. For details, see his website 

 was based on Dr Kusters’s own experience of a psychotic episode in 1987. It won a pair of prizes in the Netherlands: the Van Helsdingen Award (2004) for the best work on the intersection of philosophy and psychiatry, and the Socrates Award (2005) for the best and most inspiring Dutch philosophy book of the year. After the publication of this book, Dr Kusters made a career switch from academic linguistics to a career as an independent writer and researcher, and started studying again as an undergraduate philosophy student, during which time he published his second book on psychosis 

 (Lemniscaat, 2007). Shortly afterwards, in the summer of 2007, he experienced his second episode of psychosis, which led to a psychiatric hospitalization, and provided further impetus for him to continue his work on philosophy and madness. He finished his Masters’ thesis in philosophy in 2010, which formed the basis of an updated version of 

. His books were a success in Netherlands and were met with widespread acclaim. The publication of the English translation of 

 has brought his work to the attention of the English-speaking world, and it has prompted a renewed debate on philosophical and phenomenological perspectives on psychosis as well as the relationship between philosophy and psychosis.

: I imagine you may be getting tired of introducing your book again and again! Perhaps we can spare you some of that repetition by linking to sources where such introductions are available, but I think it would be prudent for us to begin with at least a few words regarding the nature of inquiry you are undertaking in 

, and how that relates to your own experiences of psychosis.

: My book is a philosophical treatise in the tradition of Montaigne’s 

; in the vein of Nietzsche’s and Kierkegaard’s approaches to thought, writing, and life; and with affinities to the early works of the French existentialists, Sartre and Camus. What brings these works together is the focus on philosophical problems of good and evil, life and death, I and the other, without getting lost in arid, abstract, academic reasoning for the sake of reasoning itself. On every page the driving question with these authors is: “what does all this thinking, reflection, and all these ideas, actually mean for my life as a writer, and for the life of the reader?” My book does not have the form of problem-solving argumentation, let alone that of a psychopathological theory, with a set of propositions about a clearly delineated empirical phenomenon. It could be categorized as 

, with inclusion of the darker aspects of spiritual travelling. It has also been called auto-ethnography: a description of personal experiences and reflections, undertaken in order to examine the wider ethos against which the experience takes place. The particular ethos that is at stake in my book would be the ethos, the mores, the habits, and discursive practices that are called philosophy in relation to madness.

My book does not present a psychopathological theory, but it does focus on madness as a lived experience, as a concept in philosophy, and as a phenomenon called psychosis in psychiatric practice and theory. By stressing the experiential character of psychosis, which I have access to via my own memory, as well as via all kinds of reports and first-person narratives, the direction of my exploration is towards comparable experiences and their expressions. This brings us to all kinds of philosophical thoughts, bordering on reflections around religion, mysticism, and spirituality, but also to important themes of language, fiction, and nonfiction. For any psychiatrist educated a little beyond the mainstream medical illness, cure, and therapy narratives, it must be clear that my exercise brought me into the small but highly professional and well-informed tradition of phenomenological psychiatry.

For a further overview of what my book is all about, I recommend the short interview in the 

: You have argued that a philosophical investigation of psychosis provides a better and less prejudicial approach than many mainstream psychological and psychiatric accounts. What sort of prejudices do you have in mind?

: The main prejudice concerns the usual way of approaching psychosis as a negative or a lack and leaving it there. That is, seeing it purely as a deficit, a disorder, a nonfunctioning of some aspect of the mind/brain/body that is supposed to be well-functioning in the nonpsychotic individual. Take for example the idea, found in various kinds of mainstream accounts, that psychosis is some kind of 

. Such a judgement implies that there is good, proper thought, and that psychotic thought can be sufficiently defined as a disturbance, a disordering of this normal, natural way of thinking. It may be said that the disorder is one of jumping too fast to conclusions, or a dysregulation of perceiving salience properly, or an inability to synthesize information coherently, or it is just being plainly illogical. All such approaches share the assumption (the prejudice) that psychosis can be sufficiently defined by what it is not.

The implication of such accounts is that the psychosis is just a disruption that should be suppressed and taken away in order to let the normal flow of experience run again uninterruptedly. It is assumed that there is a healthy, sane part, and an insane, psychotic part, both manifesting themselves in various contexts and intensities. Therapy then consists in identifying and annulling the psychotic part (eg, by medication, by CBT, or by so-called ‘psychoeducation,’ and stimulating the healthy part). The patient then eventually learns to associate him- or herself with the healthy part, dissociate from the disordered part, and to consider the psychosis as the illness, not belonging to who he or she really is, but as something that was intruding from the outside. They learn to say: “the psychosis disturbed the real me.” Instead of: “the psychosis showed a different aspect of me.” It thereby dissociates them from their own experiences, memories, and past.

So, the assumption in much theory, and the accompanying practices, is that the life-world of the individual is affected by a natural disorder, which eventually impairs the individual in his or her freedom, in his or her meaningful interaction with others, and in his or her sense of being a conscious individual. What most of these accounts simply miss is that the psychotic experience itself is meaningful. In fact, psychotic individuals often experience more freedom, instead of less, and they feel their consciousness is not troubled or darkened, but they report all kinds of experiences that are phrased with positive light metaphors. By defining psychosis basically as a certain lack, mainstream psychiatry and psychology imply that meaning, freedom, and truth are only found in the nonpsychotic way.

What philosophy has to offer here is an examination of both sides, an inquiry into those notions that are so often assumed to be absent in psychosis. Philosophy investigates the power and implications of the negative: for instance, in what world does the psychotic live, when it is claimed that s/he does not live in a real world? How is this supposed unreality experienced? Why does it often feel more real than so-called ordinary reality? And so on. Only by letting go of our own prejudices about reality and thought, about how language and meaning operate, may we gain a deeper understanding of other (psychotic) kinds of organizations, other kinds of being-in-the-world than that of the nonpsychotic individual.

To be sure, I do not have any principled criticism of the use of medication or cognitive behavioral therapy in itself. But the pretension that often accompanies the provision of effective treatment, that the clinicians know and understand what psychosis is better than the persons themselves—

 can have a negative impact on people’s lives. I mean, the reason why I receive a continuing stream of all kinds of emails and reactions from those who underwent psychosis, sometimes even more than 40 years after their psychosis, is significant here. If psychosis were really just like diabetes or a broken leg, a temporary natural disturbance of the mind, why would so many remain so puzzled afterwards? Why do they want to go back there, consciously or unconsciously? What is this mysterious, seductive quality of psychosis? Psychosis is not only a disorder. It is also the basis for thinking towards a different order.

: How do you think such prejudices can be avoided?

: It is not so difficult to avoid these prejudices. The essential thing is to drop the assumption that those who are called psychotic no longer have meaningful consciousness, are no longer competent language users, uttering meaningless sentences. This kind of prejudice may partly be overcome in psychiatric practice by not approaching patients with psychotic symptoms from a purely scientific perspective, with all its supposed application of evidence-based knowledge. Instead, we ought to engage with psychotic individuals as unknown human beings, who are basically thrown into the same puzzling world as yourself, a world in which we are entangled, which defines us, but which at the same time is defined by us, and in which we experience freedom.

In fact, psychopathological theories that start from this perspective are numerous, but no longer mainstream in our age. We may think of all kinds of psychoanalytic theories, phenomenological theories, enactivist theories, and so on. But the danger with any of these alternatives is (and that is due to the fact that it concerns scientific theories or models) that they reduce and categorize the psychotics again under just another determining and defining order, and treat them as having some kind of deviant mind, ruled by just another set of natural laws. A theory may be helpful for the first steps towards contact, but all too soon they become obstacles, closures of the mind, that prevent the soul from seeing another soul, outside of his own, outside of the theory.

Nothing in this negates or takes away from the fact that these individuals may be greatly distressed and impaired, and they may be in need of clinical care. To say that psychosis is meaningful is also not to deny that there are differences from ordinary states of consciousness. On the contrary, this difference and its exploration is what the whole engagement with psychosis starts with, both in psychiatric practice as well as in my book. There is a paradox here. There is simultaneously a continuity in experience between psychosis and non-psychosis, as well as a discontinuity, a definite break and identifiable difference, between psychotic and non-psychotic experience.

: How does this inform the philosophical approach you take in your book?

: My philosophical approach tries to avoid such theorizing. I do not seek to construct yet another theory about empirical patterns of behavior and thought in psychosis. Instead of a theoretical monologue about some scientifically well-defined object, my book is a philosophical dialogue between several undefined subjects. My book is essentially dialogical, notwithstanding the fact that many of its dialogues are internal dialogues. These dialogues represent a kind of dance, and sometimes a battle, between on the one hand the rational philosopher or curious researcher, and on the other hand, the psychotic, the madman—with inclusion of relatives like the religious zealot, the mystic visionary, and the nihilist skeptic, who in the course of the text change position. Meanwhile, it remains unclear who is leading, who is following, who is analyzed by whom, and who is stimulated by whom.

The knowledge or theory that my book might yield, and that might be transmitted to a reader, only emerges by following this dance from a starting point in a third position, that of the reader, who can only extract sense from my book when he or she is open for internal dialogues from within him- or herself. This dialogical character (some use here the term 

), by the way, is the basis for all philosophy. It is a way of essentially opening, disclosing, of bringing thoughts into the spotlight (also discussing this spotlight), of exploring hidden perspectives and possibilities. It is different than the closing character of scientific discourse, which is more interested in defining, reducing, ordering, and controlling. In this respect, my book differs widely from the methods and ends of psychological or psychiatric theories. Scientific discourse is successful when the theories and predictions are confirmed by observation in practice, and when these theories are implemented in new regimes of social order, psychological management, and action schemas. My book will be successful when the fundamentals of all regimes of order are suspended into disbelief during a momentary glimpse in the mind of the reader, and the reader is able to see that we all just dance in the void.

 (the snake that eats its own tail) and the 

 play a central role in your discussion of psychosis. Can you elaborate on the significance of this motif?

: The Mobius ring is indeed an important image. It helps me visualize an underlying motif in my book. Let me explain: Initially, in my book, there is a difference between, let’s say the meta-level, the thinker (philosophy), and the data, or object level (madness). On the theoretical meta-level with its numerous concepts, argumentations, and analyses, I try to make sense of the data: how do time and space change in psychosis, what happens to reality, the self and the other? This concerns Part One of my book, in which I present an introduction into the findings of phenomenological psychiatry, with help of philosophers like Edmund Husserl, PhD, Maurice Merleau-Ponty, PhD, Ludwig Wittgenstein, PhD, and René Descartes. At this level in Part One of my book, the front side of the Mobius ring, where the philosopher-narrator meets the reader, is clearly philosophy, and the (hidden) back side is madness. With philosophy as a tool, as a way of thinking, I try to capture something of that enigmatic hidden domain of madness. So far so good.

Then in Part Two the narrator, the philosopher notices that with this philosophical theorizing there remains a distance between 1) the meta-level of philosophy with its concepts and learned discourse, and 2) the object-level where madness rules, with its anxieties, delusions, ecstasies, and its word plays and other-worldliness. Then from Part Two on until the end of Part Four of the book, the philosopher converges closer and closer to the madman. The philosopher no longer stays on the firm shore of his identity and self-assured discourse, but embarks with the madman, in order to not only describe and explain madness, but to think/experience him- or herself what it is like to be psychotic. In other words, the philosopher engages in some serious (psychotic) thought experiments and becomes entangled in the same quagmires as the madman. In the end, the philosopher has become mad and has reached the other side of the Mobius ring, the back side.

So, the Mobius ring is hidden in the book, and also reflects my own paradoxical experiences. I was doing serious research as a philosopher about psychosis (in fact, a substantial portion of the first part of my book is based on the papers I wrote during that time) while having in the back of my mind the data of my own psychosis from 15 years before. Then during that study of psychosis, my philosophizing intensified, and philosophy led to madness, and madness emerged out of philosophy.

: Even since becoming familiar with your book, I have been wondering about the relationship between psychosis and philosophy.

: I would say so! In my mind, one way to approach it would be to treat psychosis as a method of inquiry into the nature of reality such that, at the end of it, something is revealed about the nature of the world and our existence. Another approach might be more negative. In this approach, psychosis by itself does not tell us what reality is, but it throws our everyday epistemic complacency into disarray. We can no longer trust our sensory inputs, our perception of space and time, our social instincts, etc, and this provokes a state akin to Cartesian doubt, where we can no longer take our ordinary understanding of the world for granted. With some poetic license and over-simplification, perhaps I can refer to these positions as the 

, respectively. Certainly, there can be all sorts of interesting combinations and variants of these approaches. Would you consider this to be a useful framing? And if so, do you lean towards a particular position?

: That is a very illuminating framing indeed, and relates to the power of the negative, that I referred to above. Let me comment on both positions and their relation to madness. In the original version of the Cartesian thought experiment, the one described by Descartes himself, a subject throws himself into full doubt, distrusts his senses, and searches within his own thought for a firm ground for existence, an undeniable truth, beyond all doubt. Descartes describes how in this process of radical doubt, everything is rejected because of its principled uncertainty, mutability, and transiency. The only thing that cannot be doubted, is that there is me, enveloped in a doubting process. And then from this elementary given, the famous rationalist adage follows, 

: “I think, therefore I am.” In the dark nights of the mad soul (compare for instance my autobiographical notes at the end of Part Two of my latest book), the individual with psychosis may have an analogous thought process, and he or she may end up in a kind of intellectual and existential despair, driven by radical self-doubt. But this despair may also take the form of an experience of perplexity about the undeniability and givenness of one’s own existence. The argumentative structure in Descartes’ texts shows similarities with the existential doubts the madman is in.

What is often forgotten in popular considerations of Cartesianism is that building on 

, Descartes goes on to prove the existence of God as well as reality, using arguments that are today seldom accepted as self-evident truths. Descartes draws the conclusion that from being able to think an utterly perfect being (God), we must conclude that this utterly perfect being exists, otherwise it would not be utterly perfect. Now the madman may in myriad ways follow, mirror, and deviate from such ways of thinking, and may get fully lost in all kinds of imaginations that are very difficult to understand for an outsider. However, when we are aware of these philosophical problematics and this basic scheme of Cartesian reasoning, we might come a little closer to some understanding.

Of course, there are also many differences between the Cartesian and the mad thought experiments. An important difference is that for Descartes this was simply a thought experiment, an epistemological exercise, but for the madman the radical doubt is a serious matter; he is drowning existentially, losing all firm ground, and desperately searching for an anchor. We might say indeed that Descartes performs an epistemological experiment, while, following the ideas of the Dutch psychiatrist and philosopher Antoine Mooij, PhD, the psychotic is involved in an ontological experiment.

Let’s look at mysticism in comparison. In the older days of Christianity, mysticism was an intellectual and theological way to argue, to contemplate, to pray, to envision, and eventually to experience awe at the greatness and the power of the Almighty God. Then there was no essential difference between mysticism, theology, and philosophy. It was only much later that mysticism became associated with visions in the West, in an epochal historical change in which visual hallucinations also became ascribed as a dominant characteristic of psychosis. Just as I stress the partially passive, experiential character of the active Cartesian doubt experiment, I view mysticism as a more active and intellectual undertaking than it is usually considered to be. The usual distinction made between active thought and passive perception (and their counterparts in psychopathology, delusions versus hallucinations) is too rigid, and it is in mad philosophy and philosophical madness that we see a continuing doubting of both, and a crossing of the separation between them, by way of the viability and flexibility of language signs and experience.

To come back to what you said, a kind of claim, or at least, something that is often argued for, is that within mysticism [quoting you:] “at the end of it something is revealed about the nature of the world and our existence.” Now, what I demonstrate, especially in the second part of my book (called 

), are the analogies between such a mystic path that seeks revelation, and the psychotic rollercoaster, that also traverses a world where things are revealed, signs are given, and the transcendent sacred, as well as its dark counterpart, the horror, seem to become immanent. It is then as if you have found a way out of the restricted ego or self, out of your own private thoughts, your historically accidental mindset, towards an outside, a real, that presents itself as more real than anything, and that consists of both good and evil forces, both personal as well as mechanical and impersonal. I use this mystic path, with its semireligious language, to shed light on a range of terms and kinds of discourse that we also find in psychosis, like 

I argue that there is a lot of overlap between what is going on in that spiritual branch of experience and language, and what is going on in the psychotic world. But I never argue, not in my book, neither anywhere else, that there is a special secret path towards truth, and towards ultimate knowledge of reality. Nor do I argue that the mystic or the madman are simply affected by a 

. To understand what they/we/you say in various kinds of exalted, psychotic, spiritual language, it is just not enough to assume that the psychiatrist knows beforehand what kind of language game, and what kind of experience, is at stake in a conversation with a psychotic.

I understand the daily, down-to-earth problems in psychiatric practice, so it is not the actual practitioner my criticism is aimed at. Instead, it is aimed at those who pretend to have insight into the deepest questions and perplexities about reality, meaning, language, and who from there then judge that other individuals’ ways of expression are nonsensical or illogical. Here lie also further social and political implications: What voices have the right to expression and to be part of the common world of sense and meaning, and what kind of communication and interaction is deemed to be sick, meaningless, illogical, psychotic, and is therefore given no place in the space of reasons

: From a phenomenological and philosophical perspective, does it matter what the source of, or the cause of, the psychotic experience is? For example, does it matter that psychosis is a result of substance intoxication or a result of metabolic delirium? Or does any psychosis, regardless of origin, offer the same possibility to explore philosophy? In other words, is the philosophical value of psychosis independent of the etiology of the psychosis?

: Yes, it does matter, but not for everybody. Let me give an analogy here. Suppose we are all used to and educated within a tradition of classical realist paintings. And then we meet this quite varied but troublesome group of modern paintings, some recognized by us as art, but others, we just do not know what they mean. We suspect some of them to not be paintings at all, but canvases on which paint has been randomly thrown, a kind of fake Jackson Pollock. In addition, consider that the painters of some of these paintings acknowledge an inability to paint in a realist way. They miss the right brushes, do not have the right paint, are not skilled in painting, or do not have proper motor control over their fingers. However, we will not be able to determine whether the painting is problematic (and if it is, the exact nature of the problem), simply by examining the paint, because it is always possible that what appears to us to be failures of the artistic method are deliberate and perfectly executed works of art. The meaning and value of the famous 

 painting, cannot be reduced to properties of the paint or the finger movements of the painter. This distinction between levels is so easily grasped when discussing art, but so often not understood or forgotten when we talk about the life of the soul in madness. In other words, the material (the neurobiological dimension) is of course an important aspect of psychosis, just like the brushstroke technique or the choice of paint are important aspects of painting. I am more interested in the history and meaning of art than in the artistic skill of painters or in the chemical analysis of paint.

I do not think in terms of hypotheses of causation with respect to psychosis, but only in terms of plausibility of interpretations. There may be facilitating circumstances that bring individuals into various states of madness and psychosis. These facilitating circumstances can be anything, from using of certain drugs, to having a traumatic childhood, to having a certain neurobiological disposition, to having been in war, to abruptly losing a significant other, to living in socially and culturally painful and oppressive circumstances, and so on, and so on. But what I am interested in is not the explaining of the illness, but the understanding of the individual, and his or her ontological position. And in that latter exercise, we must follow the individual with psychosis down the rabbit hole of those fundamental questions.

: How do you approach the experience of delusions, which on the surface represent the antithesis of philosophical thinking? Instead of an on-going grappling with a confusing reality, in the case of delusions we see a closing down of inquiry, resulting in what has traditionally been described as a fixed, false belief, unshakeable in the face of reasoning or contrary evidence. Perhaps it is only after the delusional force of the beliefs has dissipated that we can begin to philosophically understand the meaning of that experience?

: I think that delusions in the way you describe them here are only one side of the delusional story. Unlike many superficial cognitive accounts of delusion, I think that so-called delusions are better analyzed as reactions to an underlying, and temporally preceding, delusional mood, which is in fact also the position of most phenomenologists as well as psychoanalysts. A famous adage of the latter is that delusions are not the problem, but they are instead the first attempts to express and deal with another problem, of a quite different order. Nevertheless, I fully agree that a philosophical understanding, in the common understanding of this phrase, can only happen 

. A self-understanding and a philosophical elaboration that is intelligible to others, communicable in common language, must handle and circumnavigate the seduction to remain trapped by the awe for the ineffable, both in its ecstatic as well as despairing forms. The paradox of any such understanding, including mine, is that with this understanding, the thing itself, the psychosis, is in danger of retreating beyond the horizon. And this same striving towards understanding may attract and provoke psychosis to rise up again from the invisible. I know that some readers of my book put it down, but then had to resist being drawn back towards that enigma.

, you say at one point: “Philosophy never promised you a rose garden, neither do I. Furthermore, it could well be argued that there is some kind of antihuman tendency in extreme philosophical and psychotic thought. Both philosophy and madness may have intense ‘superhuman’ or ‘a-human’ powers that burn anything substantial, anything meaningful, away into a hole of nothingness. But, well, the interests of life are not necessarily those of philosophy.” Can you comment more on this misalignment between the interests of life and the interests of philosophy/psychosis?

: Most modern philosophy starts from and leads back to common sense assumptions. Many are rooted in the Age of Enlightenment and have the overt values of modern society as their implicit background. They assume that what is argued by human thought (including the findings and results of philosophizing) are and should be beneficent for (human) life. We find that assumption under all kinds of moral and political philosophies, but also under so-called philosophy of psychiatry. However, it is not so obvious that philosophical thought should lead to beneficial effects on society or the individual.

There are a range of extreme critical philosophical views, such as views of ultra-conservative, nationalist, racist, antihumanist, transhumanist, and even antinatalist nature. While some of these views are considered dangerous to society, they still remain sustained within a broadly defined space of reasons, although this may be contested by others. Some philosophical ideas go even further and have the paradoxical capacity to be self-undermining for the thinker who thinks them. They may be detrimental to what we usually consider the space of reason; they are contra (human) life. That is, they argue in quite sophisticated ways that 

. They use notions of emptiness, the void, and nothingness, not to draw positively flavored, so-called 

 conclusions, but only to affirm annihilation, death, suicide, destruction, and (auto-)extinction. Such philosophies can be seen as a variety of nihilism (although this term refers to a much larger range of philosophies) with important names such as Friedrich Nietzsche, PhD, of course, but also Emil Cioran and especially Ray Brassier, PhD, with his devastating book 

. Just being against life does not mean that these ideas are untrue or can be excluded from the realm of philosophical thought. When we take philosophical thought seriously, we cannot reject conclusions just because they do not fit our restricted human-centric point of view. That is what I mean by saying the interests of life are not necessarily those of philosophy.

In the context of the relation between psychosis and philosophy, this is important to consider, and this also sweeps away all romantic humanist notions of both philosophy and psychosis. Consider the case of someone like Anders Breivik, the Norwegian terrorist and right-wing extremist. Some particular philosophies or world views, as well as some particular forms of madness, are thoroughly destructive and devoid of good intentions. They are closer to the darker variety of the mystical aspect of madness. American philosopher William James, MD, described it as 

In delusional insanity, paranoia, as they sometimes call it, we may have a diabolical mysticism, a sort of religious mysticism turned upside down. The same sense of ineffable importance in the smallest events, the same texts and words coming with new meanings, the same voices and visions and leadings and missions, the same controlling by extraneous powers; only this time the emotion is pessimistic: instead of consolations we have desolations; the meanings are dreadful; and the powers are enemies to life.

In such cases, the philosophical aspect of the psychosis would not only consist of the strange ineffable character of an experience filled with awe and puzzlement, but also of an intra- and interpersonal struggle between life-affirming forces and life-denying, a-human or antihuman forces. The implicated question is whether we must eradicate such poisonous ideas, or must we taste and experience them ourselves, to examine the enemy, and immunize ourselves against them, with all kinds of risk of contamination? The implicated practical problem for psychiatrists is to make responsible decisions in matters that comprise both philosophical, theological, as well as political complexities. What is demanded of the psychiatrist here has hardly anything to do with scientific knowledge, is also difficult to be captured in ethical guidelines, and can only be referred to with notions like prudence.

: Something that has struck me watching how various individuals engage with you on various platforms is that there appears to be a desire (conscious or unconscious) on the part of your many interlocutors—I would not consider myself immune either!—to co-opt your views for their own agendas, and there are certainly many competing agendas vying for power, resources, and respectability in the mental health arena. Is this something you are also cognizant of? If so, how do you feel about being thrown into this state of affairs?

: Yes, I know. When I wrote my book, I had in the back of my mind a reader like myself, but then many years younger. I wanted to show where thought may lead you, what the extremities of existence and experience are, and what the attraction and the repulsion of madness (and philosophy) are. Whereas Thomas Nagel, PhD, titled his famous paper on consciousness, “

,” I wanted to write a “What Is It Like to Be Mad?” The only thing I strongly oppose is the idea that everything that is said, everything that is experienced in psychosis, would somehow be unreal, epiphenomenal of a sick brain, illogical, and so on. This does however not imply that I would defend some kind of alternative theory of psychosis—not psychoanalytical, not phenomenological, not antipsychiatric. I am simply not interested in making theories about psychosis when these do not somehow also contain dialogues with psychosis. I give advice and courses about psychosis and philosophy to all kinds of professionals and nonprofessionals in the Netherlands and Belgium, and I do not have a kind of ideological or philosophical stance about what the world is, what psychosis is, and how psychiatric practice should be. I prefer to think and talk more about what is going on in madness than about the best way for the professionals to do their work, although the latter is often a theme that results from considerations of the former.

: You have warned against romanticization of psychosis. From what I can tell, while you seem to be in favor of controlled explorations of psychosis by means of philosophy or mysticism, you do not seem to wish the clinical, raw experience of psychosis upon anyone. While you have derived insights from your experience of psychosis, I imagine that you are also glad to have come out of psychosis. How do you think we can reconcile the tension, to the extent that it exists, between the clinical and philosophical attitudes towards psychosis? Individuals with psychosis are often tremendously distressed and impaired, and they typically require some form of clinical care to help navigate this distress and impairment. How do we reconcile this with the romantic image of the madman as a misunderstood mystic or an unrecognized philosopher or with the more prosaic image of a deviant whose deviance has been pathologized?

: I think that the clinical attitude should incorporate the philosophical attitude, and clinicians should be educated in this. In fact, [laughing] I would recommend that they should all read my book, or perhaps follow the 

 I teach about my book! In my book, they would indeed meet these images of the misunderstood mystic, the unrecognized philosopher, and the pathologized deviant. However, my book does not want them to accept these images as the essence of psychosis, but as starting points from which a dance, dialectic, or conversation may begin between philosophy and madness, the rational and the irrational, without being condemned to one position or the other.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

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

Dr Aftab has no relevant financial disclosures or conflicts of interest. Dr Kusters receives royalties from the sales of his book and generates income from the online course he offers on his website.

. The Varieties of Religious Experience: A Study in Human Nature

Cultural Psychiatry