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Approximately, 775,000 US Armed Services members served at least 1 deployment in Afghanistan; a new survey of 1250 of these 

 found that 70% of them have struggled with their mental health since serving in Afghanistan.

“Trauma can alter how people think about themselves, others, and the world,” said clinical counselor Danny Taylor, MA. “The current situation in Afghanistan is a painful reminder of the traumatic experiences service members may have had in Afghanistan. This can lead to ideas that nothing is safe, and no one can be trusted.”

According to the survey, 75% of Afghanistan 

 are experiencing new or worsening symptoms of depression, 74% have new or worsening outbursts of anger, 64% have new or worsening thoughts of suicide, and 58% have started or increased drug and/or alcohol use.

Additionally, a third of veterans with a history of mental illness have started seeing a mental health professional since the Taliban retook Afghanistan in mid-August.

Holly Schiff, PsyD, believes the decline in veteran mental health may be triggered by feelings of powerlessness or fear about the situation in Afghanistan: “Veterans are usually looking for meaning and how the conflict ends definitely holds some significance. These individuals made enormous sacrifices and the fall of Afghanistan had them reflect on if everything they did was worth it. This can lead to feelings of depression and anger.”

The fall of Afghanistan may also be triggering new or worsening thoughts of suicide in 64% of veterans coping with mental illness. Researchers reported 32% are experiencing new thoughts of 

, while another 32% indicate their suicidal thoughts have grown worse in the past few weeks.

“I have absolutely seen an increase in patients who are veterans since the fall of Afghanistan,” Schiff said further. “This makes sense given the fact that this situation may trigger unresolved issues or past traumas that they now have to address and deal with all over again.”

“The fall of Afghanistan definitely triggered some mental health issues for Afghan vets, some of which will have potential long-term effects and consequences,” Schiff told 

. “For those veterans already struggling with posttraumatic stress disorder, the fall of Afghanistan brought back up some unresolved issues for them, past traumas and some unpleasant thoughts, feelings, and experiences. They now have to address these and almost re-process them for a second time.”

 is an endless war, but the current events just made it worse,” she added. “They may feel anxious, depressed, angry, helpless, frustrated, and sometimes even experience suicidal ideation. Longer-term, some of these veterans may feel like some old wounds were re-opened with this event and it will take them some time to recover and process the range of emotions that they are now feeling. In reaction to the events in Afghanistan, veterans may feel like they need to expect or prepare for the worst. This can have long-lasting impacts as it may alter their behavior and moving forward, they may become overly vigilant, guarded and become preoccupied by danger.”

To see more on Afghanistan’s impact on mental health, check out 

Psychiatrists Concerned With the Afghanistan Situation: Ethical and Practical Issues

Have ideas on how to best serve the veteran mental health community? Share with us 

1. Following Taliban takeover, 9 in 10 Afghanistan vets have exacerbated mental health symptoms. Online Therapy. Accessed September 8, 2021. 

https://www.onlinetherapy.com/taliban-takeover-exacerbates-vets-mental-health-symptoms/

A recent survey found 70% of Afghanistan veterans have struggled with their mental health since serving. 

Afghanistan Veterans Struggling With Mental Health

“Now that I say it, yeah, I didn’t. I didn’t get a chance to really digest 9/11.”

- Retired US Air Force Col. and nurse counselor, Donna Lake

Though it may seem that the media coverage of the 20th anniversary of 9/11/01 was more than sufficient, at least 1 crucial perspective seemed missing from all the personal reflections and testimonials. That missing link is us psychiatrists and other mental health professionals. We want to rectify that. In 100-1000 words, we would like you to describe how you, both professionally and personally, reacted to what happened on 9/11/01 and its aftermath. What did this mean to you, your loved ones, your patients, your profession?

Actually, this delay seems fine and appropriate for psychiatry, for as with our patients, it is best to hear and listen in depth before we respond, hopefully with new psychological insights or queries. Now is the right time to do so.

We are hoping for a robust response like we received a few years back in our groundbreaking publication of 

. If you happen to be among those psychiatrists who were interviewed at Ground Zero by 

 after 9/11/01, we would especially love to have an invaluable update from you.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Professionally and personally, how have you reacted to and recovered from the tragic events on 9/11? 

A Call for Your Reflections on 9/11

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

I never met my paternal grandfather. We share the same name, hair pattern, and interests, and I am told we have similar personality characteristics. He died, aged 56 years, from small cell lung carcinoma before I was born. I treasure the stories shared by my father about him, as well as his diary from his tour of France and Germany in 

My grandfather had volunteered to go to the European front as long as he did not have to kill anyone, and so he served on the front lines as a medic in the American Expeditionary Forces, Third Division. He experienced the brutal trench warfare we have all seen dramatized in movies. My grandfather was gassed by the Germans on several occasions, and he returned home with no hair on his body. The secondhand stories shared by my father included horrific wartime events typical of WWI.

I reread my grandfather’s diary as I began writing this editorial, and I was particularly struck by his entry on September 11, 1918. Previously I had never noticed the date.

“At 1 AM the great drive opened up. A heavy barrage was thrown up. Some jamey believe me. The flashes were seen very clearly. Barrage kept up till mid-day. Big naval guns, booming near here jarring doors open and rattling things in general. We were all kind of nervous at first but this gradually wore off. Patients began coming in and we were rushed to death, working day and night. Stories came from the front of different attacks. Lots of gassed. We gave our beds up to patients and slept on ground.”

Juxtaposed with my grandfather’s entry, the following is from my grandmother’s diary, written shortly after my grandfather had returned home from the war.

“Ah! If I could only make you see my darling when he came home to me. The lovely generous body, fit and solid, the same ruddy complexion (the army called him ruddy) and those beautiful blue clear eyes but for all that –The boy who went away was so calm, sunny and sure that everything nice was just around the next corner and the man who came home to me –uncertain, afraid of a sudden noise and timid of the dark in a building. So many days under fire without relief and exposure had left their tragic mark.”

20th anniversary of the 9/11 terrorist attacks

 on the World Trade Center and the Pentagon, as well as the resulting tragedy when the airplane crashed into a field in Pennsylvania. When the attacks began, I was on the phone with a patient, who was in a convenience store with a television on. As we were talking, he informed me that an airplane had just crashed into the World Trade Center. Turning on my TV, I was horrified to see the smoke pouring out of the first hit building. It was surreal to watch a second airplane crash into the second building with the backdrop of a crystal-clear blue sky.

Watching with confusion, helplessness, and disbelief, that horror was greatly amplified as both the World Trade Center buildings collapsed. As I reflect on 

 had on me, watching on a TV screen, I cannot imagine the intensity of emotions and the traumatic assault for those who were present as the terrorist attacks unfolded. Numerous books and documentaries have archived this event and its ongoing traumatic impact on countless individuals.

Sadly, this day of gruesome attacks, as well as all the pain and suffering they have caused, is but one of countless traumatic events that have been perpetrated on humanity over millennia: some by nature, others by accident, but many by people intentionally inflicting death, pain, suffering, and unimaginable loss on other people. During the brief history of our own country, we have already had our share: the Civil War, World War I and II, the Korean, Vietnam, and Gulf wars, and the Capitol insurrection on January 6, 2021, to name a few.

Some traumatic events occur over decades, affecting specific populations. During the colonization of North and South America by different European countries, the indigenous populations were unapologetically nearly exterminated through genocide. As the United States grew as an economic power after obtaining its independence from Great Britain, Africans were captured in their native lands, enslaved without individual rights, and transported in squalid conditions to become the property of landowners and others. What followed were centuries of forced labor, separation of families, torture of the worse kind, and murder without consequence. During World War II, Japanese Americans were taken from their established lives and homes and incarcerated in internment camps, while their family members or friends fought proudly as Americans overseas.

, such as hurricanes, tornadoes, earthquakes, and massive wildfires, are a constant and often unpredictable threat, leaving deep and enduring emotional scars on the affected individuals. Mass shootings, drug-overdose deaths, motor-vehicle fatalities, homicides, and suicides leave a long trail of posttraumatic pain and suffering on too many people whose lives will never be the same. Cable TV works hard to show us traumatic events of every kind—virtually daily—which must leave an emotional imprint deep in our unconscious that sculpts our moment-to-moment experience. The COVID-19 pandemic has been an unwelcome addition to this list.

Finally, each of us is influenced by traumas of many types, experienced by our families from generations past—family narratives that shape us in many ways, some of which we are aware, and others hidden. I would like to share one of my family narratives as I end this editorial.

My father shared with me how his father suffered from panic attacks, agoraphobia, and anxiety after his wartime service. He worked close to home at the United Shoe Machine Corporation in Beverly, Massachusetts, designing machines to make shoes. When his anxiety intruded, his supervisors allowed him to leave work and walk home to find respite and relief. My grandmother referred to herself as a “cellar widow,” as my grandfather would arrive home from work, have his evening meal, and then go down to his workshop in the basement where he found relief working on an endless trove of projects. There is no doubt that my grandfather’s trauma from WWI has had an impact on me.

Many of the traumas described are out of our control, a result of random natural occurrences or unfortunate accidents. War and murder, however, result from choices made by an individual or a government. I often reflect on a talk given during a meditation retreat by my friend, colleague, and meditation teacher Joseph Goldstein, who lives and teaches at the Insight Meditation Society in Barre, Massachusetts.

He said: “Imagine what the world would be like if every person agreed to not kill any other person.”

is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief, 

; staff psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts. 

The long trail of posttraumatic pain and suffering leaves behind too many people whose lives will never be the same...

Reflecting on Trauma

On August 26, 2021, 13 US troops took their last breath after being attacked at 

 Airport. These were brave men and women who dedicated their lives to protecting a sacred treasure: humanity in the form of love, liberty, and happiness. They are military disciples whose spirits will live on in the hearts of their families and the many lives they touched during their service.

I hope this poem emboldens reflection as we pay homage to the fallen 13.

Carnage from bombings leaving the fallen with faces of pallor.

Stewards of freedom and humanity may we remember your sacrifice.

Soldiers clothed in raiment bedecked with grace

American vessels scorched knowing their loved ones cannot be replaced.

Stewards of mercy and altruism may we remember your sacrifice.

United States troops embraced God’s precious youth.

Twenty years protecting a country still in search of identity and truth.

Stewards of advocacy and resilience may we remember your sacrifice.

Thirteen coffins decorated with red, white, and blue.

Tragedy has deflated hearts seeking an antidote for war flu.

Stewards of patriotism and perseverance may we never forgot your names.

We must not forget the cost of fighting... the lives of the brave men and women who serve and aim to protect lives. 

Paying Respect

In the Wake of 9/11: Mental Health Statistics of First Responders

What toll does trauma take on police officers, firefighters, and EMT workers? 


new study by Georgia State University researchers

, rates of intimate partner physical and psychological aggression increased significantly after the enactment of shelter-in-place orders at the COVID-19 pandemic’s outset. Published in the journal 

, the study is one of the first to document increases in aggression among couples following the start of the pandemic.

The study found aggression in US couples was 6 to 8 times higher due to the pandemic, with physical aggression increasing from 2 acts per year prepandemic to 15 acts per year once shelter-in-place restrictions began, and psychological aggression increasing from 16 acts per year to 96 acts per year. The findings reveal that pandemic-related stress was strongly associated with perpetration of intimate partner aggression, even among those considered at low risk.

“If you think about it, that [increase] represents an enormous shift in people’s day-to-day lives,” said Dominic Parrott, professor of psychology and director of the Center for Research on Interpersonal Violence, and the study’s lead author. “It’s the difference between having a bad fight with your partner once a month versus twice a week.”

During the height of US shelter-in-place orders, April 2020, researchers recruited 510 participants and asked them questions about their community both prepandemic and after the onset of the COVID-19. Participants answered questions about COVID-19 stressors, physical and psychological aggression towards their partner, and heavy drinking.

“People were suddenly under an enormous amount of stress, and we felt relatively certain that this was increasing aggression and violence,” said Parrott. “There’s data showing that after natural disasters, for example, when basic resources are lost and people have to live in close proximity, intimate partner violence goes up. Our fundamental aim was to document what was happening as a result of the pandemic.”

Rates of intimate partner aggression were high among heavy drinkers, but it seems nonheavy drinkers were most affected by COVID-related stress: the association between physical aggression after the onset of the pandemic and COVID-19 stress was most apparent in individuals who consumed fewer drinks per day. However, the findings indicate a focus on couples’ acute and chronic stress is critical, regardless of their average alcohol consumption.

“People who aren’t heavy drinkers may be able to prevent stress from affecting their relationships under normal circumstances, but we hypothesized that the extreme events of the pandemic might change that. And that’s how the data played out,” Parrott said. “Pandemic stress didn’t really tip the scales towards violence among heavy drinkers, but for nonheavy drinkers, all bets were off.”

Policies designed to assist with the negative effects of the pandemic, such as economic relief packages or polices that provide increased access to health care, may reduce stress and perpetration of intimate partner aggression, according to the study’s authors.

“Most people wouldn’t think about intimate partner violence as a reason to offer an economic relief package, but our data suggest that it has potential to be an effective measure,” Parrott shared further. “The data also suggest that typical high-risk groups are not the only ones at risk of perpetrating violence in this kind of crisis environment. The stress of the pandemic is so profound and so ubiquitous that you need interventions or policies that hit big swaths of the population.”

recognizing and addressing intimate partner violence

1. Georgia State University. COVID-19 pandemic linked to an increase in intimate partner aggression, study shows. News release. August 16, 2021. Accessed August 18, 2021. 

https://news.gsu.edu/2021/08/16/covid-19-pandemic-linked-to-an-increase-in-intimate-partner-aggression-study-shows/?utm_source=press-release&utm_medium=meltwater&utm_campaign=health-wellness&utm_term=pandemic-linked-to-an-increase-in-intimate-partner-aggression

First of its kind study found aggression in US couples saw a 6- to 8-fold increase during the pandemic. 

Study Shows Pandemic Resulted in Increases in Intimate Partner Aggression

Addiction, while a mental health disorder in its own right, often covers deeper wounds. Treating addiction often requires a willingness to delve deep into a patient’s psyche and find the traumatic experiences that are motiving the substance abuse.

In this Mental Health Minute, Gray talks about her efforts to treat the traumas that often lurk behind addictions. She offers tips for building strong therapeutic alliances and recommends using eye movement desensitization and reprocessing to help patients with comorbid substance abuse disorders and trauma.

is a licensed therapist and recovery coach at Hand in Hand Counseling in Greenwich, CT.

The potential role of eye movement desensitization and reprocessing.

Treating Comorbid Substance Abuse and Trauma

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.

Janice Haaken, PhD, is professor emeritus of psychology at Portland State University, a clinical psychologist, and a documentary filmmaker. Dr Haaken has published extensively on psychoanalysis and feminism, the history of psychiatric diagnoses, interpersonal violence, the social psychology of remembering and storytelling, and documentary methods. Her books include

 Pillar of Salt: Gender, Memory and the Perils of Looking Back

Hard Knocks: Psychology and the Dynamics of Storytelling

Psychiatry, Politics, and PTSD: Breaking Down

 (Routledge, 2020). She has directed 6 feature films: 

Queens of Heart: Community Therapists in Drag

Mind Zone: Therapists Behind the Front Lines

Milk Men: The Life and Times of Dairy Farmers

Necessity: Oil, Water and Climate Resistance

. Dr Haaken has received numerous awards for her filmmaking, most recently the Lena Sharpe Persistence of Vision award at the 2019 Seattle International Film Festival.

 is a fascinating critical analysis of posttraumatic stress disorder (PTSD) as a diagnosis, the turbulent debates surrounding the role of trauma in psychiatry that led to its creation, and the institutional and sociopolitical functions it serves in a wide variety of settings such as the military, veterans’ affairs, war zones, refugee camps, and criminal justice system. I was impressed by the adeptness with which Dr Haaken tackles the ambiguity, uncertainty, and the internal contradictions present in the subject matter while resisting the temptation for simplistic answers. This interview delves into some of the broader conceptual and sociopolitical issues surrounding PTSD and psychiatric diagnoses discussed in the book.

: You wear many different hats (psychoanalytic clinician, critical psychologist, documentarian, and field researcher), which offers you a unique advantage in being able to approach psychiatry from a variety of different perspectives. Can you tell us more about your background and how that has influenced your critical inquiries?

: My first professional career was in psychiatric nursing, beginning in the early 1970s as a staff nurse in a treatment program for children, and later in medical training centers in California and Oregon. My nursing background was formative to my identity as a professional, even in the course of pursuing a PhD in clinical psychology. Nursing is a traditionally female job, but one that is very hands-on and close to bodily experienced suffering. I value that. As a clinician, I was influenced early on by the women’s movement and its rejection of a lot of the old diagnoses, with hysteria the prototypical example. I have always approached the diagnostic process as a form of storytelling that requires attentiveness to social contexts of mental suffering and to the language available for communicating distressed states. In addition to feminism, I was influenced by the radical psychiatry, critical psychiatry, and the antipsychiatry theories of the 1960s and 70s, all of which shared a critique of the medical model that underpins psychiatry.

When I joined the faculty at Portland State University, my research methods—grounded in critical theory, psychoanalytic-feminism, discourse analysis, and qualitative field research—were considered quite radical, although the department moved to incorporate more qualitative methods over time. I joined the faculty in the era when academic psychology was moving in a more applied direction. During the year that I joined the faculty, the animal lab (which took up an entire floor of our building) was in the process of shutting down. My department was migrating to field studies and taking up messy data and real-world problems that were central to my own program of research. My documentary films grew out of my field studies where initially I used cameras to capture more of the communicative language of participants than audio recordings permitted.

. What did you set out to do and where do you think you ended up in terms of your analysis?

: This new book extends a line of analysis pursued in 

Pillar of Salt: Gender, Memory, and the Perils of Looking Back

, a book that focuses on narrative aspects of psychiatry and how social movements shape diagnostic thinking. In the later decades of the 20th century, trauma disorders, from multiple personality disorder, dissociative identity disorder, to posttraumatic stress conditions, gained enormous currency in the mental health field. There were intensely heated debates over a widening array of symptoms thought to be disguised symptoms of trauma.

, I revisit some of those debates and the historical and cultural dynamics that shaped the way trauma models took hold late in the 20th century. With the rise of neoliberalism, and the push to marketize everything in sight and the dismantling of public services, the dramatic and morally charged accounts associated with trauma represented an effort to break through the high threshold for responding to more mundane forms of suffering. With PTSD narratives, I was interested in how this diagnosis migrated through this same era and how the scientific disputes over the diagnosis seemed to be symptomatic of a deeper problem in the field. I came to think of PTSD as a forensic diagnosis as it was used in settings where clinicians were enlisted in adjudicating the fates of individuals. There is some consensus that PTSD is a redemptive diagnosis in the sense that it assigns causality to an external force and does not implicate the sufferer. Many progressive clinicians embraced the expanded use of the diagnosis because it seemed to offer a form of sanctuary or protection from more damning labels. I was interested in what was excluded in the differential diagnostic process as clinicians were using this diagnosis, and particularly in the military and the Department of Veterans Affairs (VA), the courts, and other institutional settings.

: It was fascinating for me to read in your book about how the diagnosis of PTSD emerged from a union of research studies in stress and trauma, and how different the cultures of these traditions were. Stress research had adopted a very mechanical view of psychology, as you point out in your book: “People, like machines, are subject to breakdown under conditions that exceed their operational capacities.” While on the other hand, “To speak of psychic trauma is to position the problem within a moral community of responsibility as well… Whereas stress speaks to the machinery of mind, trauma evokes images of the ghosts in those machines” (p. 8-9).

 How do you think this tension has played out in subsequent research on PTSD?

: Early in my career, I was highly critical of machine metaphors, associating them with masculinist assumptions in science and dehumanizing modes of intervention. My own field of feminist psychoanalysis holds some affinity with the trauma models in their focus on storytelling, and the ghosts in the machine! Trauma therapists often speak of hauntings, which can be a meaningful way of representing the ineffable or elusive aspects of mental disturbances. But I do think it is a mistake to align metaphors too readily with conventional gender dichotomies, or good vs bad metaphors. The Yerkes-Dobson law, for example, developed by military psychologists during the First World War, is based on what could be described as a machine-model of stress and it remains the closest thing we have to a natural law in psychology. It still explains some aspects of the relationship between increased stress plotted against performance and breakdown. But military psychologists soon realized that the model failed to account for the complex dynamics and factors that mediate stress responses.

You also asked about how the tensions between stress research and trauma studies have played out over time. Until recently, stress has lost ground to the more mesmerizing stories associated with trauma. For a very long time, child sexual abuse, deserving of our attention as it is, has stirred far more public outrage and clinical interest than do the much bigger and prevalent problems of child poverty and neglect.

There have been a number of campaigns since the entry of PTSD into DSM III in 1980 to expand the diagnosis to include chronic or what came to be termed complex traumatic stress disorders. These campaigns failed in my opinion because PTSD has become such a marker of the societal boundary separating the deserving and the undeserving, good individuals who are victimized through no fault of their own from the willfully deviant, and complex trauma attempts to expand and redraw that boundary. PTSD retains its taxonomic legitimacy and forensic status by keeping the diagnosis pretty closely tied to a discrete event or set of events that depart from some demarcated expected realm of normal experience.

: Your critique is one that is sympathetic to the practicing clinicians, appreciative of the demands and the pressures under which they work, and the bureaucratic systems they are forced to navigate to help the patient in front of them. You write about “how practitioners were enlisting the PTSD category as a way of managing seemingly impossible clinical tasks – situations where they were negotiating various institutional, political, and psychological demands.” (p. 3).

Another example of this sort of dynamic that comes from your book is that of personality disorders. You discuss how prior to the official acceptance of PTSD as a diagnosis, military psychiatrists were pressured to diagnose traumatized veterans with personality disorders because the traumatic reactions could then be dismissed as deeply rooted character problems. You write, “Some of these troubles were indeed likely influenced by personality factors. But the political context made this avenue of exploration more of a tool for the military than a means of understanding the struggles of soldiers” (p. 9).

 The identification of maladaptive personality styles coming from an empathetic psychoanalytic clinician could be immensely psychotherapeutic in the right setting, but the same identification of personality dysfunctions in a different setting could be wielded as a weapon to silence, stigmatize, or discriminate. This suggests to me that the fundamental problem may really be these institutional, political, and psychological demands. Do you think that critical inquiry in psychiatry sometimes gets sidetracked by focusing too much on these diagnoses rather than on the institutional structures in which they are employed?

: Yes, I think the enormous investment of resources and campaigning to expand PTSD research has more to do with pressures on the field and professional marketing than it has to do with addressing the sources of mental suffering. One of the interesting boundaries that I take up in a chapter of the book is the line between PTSD and personality disorders. I trace the history of efforts to widen trauma diagnoses as a corrective to over-diagnosing personality disorders, including in the military. One of the reasons that psychiatric casualties were so low during the Vietnam War was that so many service members were dishonorably discharged under the character disorder labels. Doctors were seen by many veterans as complicit in the disciplining of rebellious soldiers through these diagnoses, just as they had during World War I. But PTSD depends very heavily on the concept of normalcy, the claim that this is a normal response to an abnormal situation. This leaves many other individuals and problems outside of the protective fold of the diagnosis.

: You write, “For those suffering harms more diffusely located in history or based on more systematic forms of violence or neglect, for example, polluted neighborhoods or poorly run schools, the diagnosis failed as a register of their claims” (p. 7).

 I do not know if any diagnosis can register these sorts of claims in a manner that is also adequate for clinical and scientific tasks. Perhaps our collective mistake is to think that we should look to diagnosis as a tool for the purpose of acknowledging systemic oppression?

: Yes, I do think that the over-expansion of DSM and its burgeoning taxonomy is part of the problem. But PTSD carries a unique history as a disorder in that it was specifically thought to be caused by societal conditions. Progressive clinicians largely embraced the category as a corrective to the systemic problem in psychiatry of over-pathologizing, as well as sexism and racism. Because the diagnosis carries a long history of morally charged campaigns, its expansion has had this inadvertent effect of reproducing some of the moralizing tendencies in psychiatry. PTSD was not simply discovered through some enlightened path of medical progress. It emerged as a kind of compromise formation (like an individual neurosis) at the frontlines where progressive clinicians used the tools of their profession to intervene in what are basically social problems.

The situational stress reactions of prior eras carried expectancies that normal individuals are able to move on quickly from disturbing events. For me, the question is not whether PTSD or any other diagnosis can adequately address societal forms of violence or oppression, but rather why these problems get so loaded onto this category and its exclusionary criteria. Proponents tend to focus on what PTSD includes and exposes in terms of societally produced suffering. I was interested in what this diagnosis tends to exclude.

: Your discussion of the antipsychiatry movement was quite interesting. You describe it as “a loose collection of intellectual and political projects focused on challenging the societal basis of psychiatric authority” (p. 10).

 You go on to comment with reference to Michel Foucault, PhD, “From a Foucauldian perspective, a critical psychiatry works to decenter the authority of psychiatric discourse by exposing its own historical contingencies” (p. 177).

 It seems to me that any framework that is utilized to deal with the realm of human distress, disability, and deviation will have historical contingencies and will be susceptible to having the societal basis of its authority challenged. Would you agree that even if the authority of psychiatric discourse is given to some other kind of discourse, an ongoing critique of a critical and Foucauldian nature would continue to be necessary?

: The legacy of Foucault in psychiatry and the social sciences most decisively includes rejection of master narratives of all sorts, whether in Marxism, psychoanalysis, psychology, or other human sciences. There is some recognition, written into ethical guidelines, that mental health professionals must attend to cultural differences and societal factors, and are required to recognize misuse of professional authority. These caveats are included in the preface to recent editions of the DSM. But the traditions of critique that I draw on require a more sustained and deeper engagement with both the ideological side of our professions, the ideas that take hold, and the material conditions of our work, which include things like how services are provided and paid for.

I also draw on critical traditions to recognize how social justice movements have profoundly shaped, even transformed, and how we think about boundaries between normal and abnormal, for example the issue of homosexuality. The APA was pushed by the gay rights movement to remove homosexuality in 1973 from DSM II. I also try to recover some of the ethos of the early antipsychiatry movement that has been marginalized in the mental health field; for example, the idea that patients suffering from delusions or hallucinations have something to say worth hearing.

: You acknowledge the influence of Peter Sedgwick on your views, referencing his contention that the antipsychiatry theorists often approach mental suffering from too much distance “rather than from the hard seat of the waiting room or the casualty department’s stretcher.”

 The impression I seem to get in this regard is that you are saying: yes, we need to problematize the role of psychiatric and psychological explanations with reference to what we consider to be abnormal, disordered, or dysfunctional, but we should not use this problematization to argue against the rights of individuals to have their distress and disability be registered and the right to receive adequate care within some framework of health or social welfare. Is this an accurate characterization?

: I do try to hold these complexities in mind and to draw out both the insights and blind spots of those early movements. This is a very interesting time we are living in now, and in many respects, a very hopeful one. After a long era of meager resources for public health agencies (the poor stepsister of medicine and private health insurance), public health and calls for investment in social welfare have gained enormous public support after this horrifying pandemic. The Black Lives Matter movement has pushed for a different vision of society than we have been fed over the past 50 years, particularly in the area of policing. There are calls around the country to move away from policing to a greater focus on crisis services and interventions outside of the criminal justice system. But I also think that a progressive vision of psychiatry requires more in terms of attitudes and thinking about patients suffering from mental illness. As mental health professionals, we should be working to build more receptive spaces in the community for individuals who may seem odd or who process reality differently.

: You write, “the obsessive tendency in psychiatry to ‘pin down’ PTSD within a stable, trans-historical taxonomy is itself symptomatic of the anxiety associated with this diagnosis” (p. 6).

 Subsequently you write regarding psychoanalysis, “psychoanalysis departs from medical psychiatry in widening the interpretive lens for diagnostic storytelling. It allows for ambiguity, for dynamic shifts in the meaning of events over time, and for the symbolic and metaphorical registers of symptoms” (p. 179).

 I can think of at least 2 sources of the sort of obsessive tendency that you describe, 1) the need for operationalization of constructs for the purposes of scientific inquiry, and 2) the categorical needs of the health care and legal system (such as, to reimburse or not to reimburse, to declare criminally sane or insane). Psychoanalysis has been able to allow for ambiguity, perhaps by distancing itself from these needs and restricting itself to a more clinical role. What do you think mental health systems can do differently to allow for the sort of ambiguity that you value?

: That is a fair critique of tendencies in clinical psychoanalysis—that its attentiveness to ambiguity and to the layers of meaning and the overdetermined aspects of mental life can feel like a luxury or privilege available to professionals who are remote from the hard decisions and demands of those living precarious lives. My book does include a critique of psychoanalytic interventions, noting that the diagnostic process for PTSD runs counter to many psychoanalytic principles. PTSD tends to focus on single causal factors, an emphasis that also runs counter to much of the scientific literature. But there also are rich traditions of social psychoanalysis and psychoanalytically informed community practices that I draw on.

Some of the problems you describe are bound up in the market economy and how deeply capitalist logic shapes medical training and its ledgers of value. I do think socializing mental health services and moving away from our dependency on private insurance and fees-for-service would be a good thing. Many of the storefront clinics that were part of the anti-psychiatry movement included treatment approaches that were quite nuanced in recognizing the complexity of patients and their problems. It was understood that individuals could be self-defeating and destructive, both victims and perpetrators. I also think there are some wonderful programs carried out in Vet centers and the VA by staff clinicians, programs that I describe in the book. The Hearing Voices movement is also an example of groups drawing on some of that same ethos and working outside of the medical model.

: At one point you comment, “Disorders can be both socially constructed… and at the same time valid ways of understanding mental functioning” (p. 13).

 I think that is an important point because there is a tendency to think that if something is socially constructed then it cannot be valid. Can you elaborate more on this?

: I am not anti-diagnosis, but I do generally view them as provisional and contingent on a community of shared meanings, rather than as entities readily objectified and operationalized through the tools of science. But diagnoses also hold currencies, both material and ideological, that are important to recognize. Much of my work focuses on the history of psychiatric diagnoses and forces that shape the migration of categories across some moral divide. I have also written about folk maladies such as codependence and love addiction, as well as syndromes bridging feminism and clinical research, such as the battered woman syndrome. PTSD grew out of the anti-war and feminist movements, and so it interested me as a category bridging social movements, popular culture, and DSM taxonomy. I like working at the messy borders between diagnostic categories. PTSD has this messy etymological and social history, with its collapsing of stress and trauma, present and past.

: One of my favorite sentences from your book is, “like many religious texts, the DSM is rife with contradictions. Practitioners bring their own interpretations of its arcane truths to the messy world of human experience” (p. 5).

 That is a rich analogy. I would add that like many religious texts, practitioners not only take it more or less literally, but also take it more or less seriously! (I have also observed how there is substantial disagreement when it comes to the philosophical foundations of the DSM, what sort of notion of mental disorder does it have, what it means by 

, and so on.) One of my dissatisfactions with a lot of popular critiques of the DSM is that they take the manual way too literally and way too seriously, perhaps because our system does too in some ways, but I feel any robust critique has to take into account these contradictions and the varying interpretations they provoke. Your thoughts?

: Yes, amen to that! After leaving the fundamentalist Christian fold of my youth when I entered adulthood, I developed a deep allergy to religious zeal, including in those fields where I hold allegiances and attachments. But the over-investment in the DSM seems more tied to its use in institutional settings and how decisions are made about patients’ lives when there is some consideration of mental states. There is a great deal at stake. Clinicians working with the courts, military, and in VA settings, including disability evaluations, are required to have considerable fluency in the DSM and its obsessive logic. Clinicians in private practice are required to enter a code on an insurance form, but can remain pretty agnostic about the taxonomy itself. They can bypass the disciplinary side of this manual.

In the last chapter of my book, I tell a story from interviews I carried out with both patients and clinicians at the Oregon State Hospital for my film, 

. One patient, sentenced to the state hospital for 20 years under the insanity plea, had killed his boss after falling from the roof on a construction site. He was diagnosed with a psychotic disorder, based on his preoccupation with numbers and codes. His psychiatrist, a compassionate clinician who frequently spoke on the patient’s behalf before the Psychiatric Security Review Board, was also preoccupied with numbers and codes. At hearings, he cited the canonical DSM criteria and the elaborate codes associated with Oregon Statutes in describing this case. I could not help but see the psychiatrist and patient as each registering some of the madness of the world they both inhabited, a psychiatric hospital that was also a prison. Of course, a crucial difference between the psychiatrist and the patient was in how many of their signifiers were legible to others. That difference decidedly favored the normalcy of the doctor.

: You comment in the book that the critique of the medical model in the 1960s was complemented by an embrace of alternative states of mind. There is an on-going revival of interest in the use of psychedelics, this time largely within a medical model, with PTSD being one of the conditions of interest. You discuss that the development of the therapeutic use of psychedelics invites us to revisit the work of Timothy Leary, PhD. What is your assessment of current investigations into the therapeutic use of psychedelics for PTSD and what insights do you think Leary has to offer?

: Campaigns to decriminalize psychedelics and other Schedule I drugs have been vital to the racial justice movement in the United States. In my own State of Oregon, a pair of ballot measures were passed last fall to decriminalize possession of small quantities of Schedule I drugs that have been a leading gateway into the criminal justice system. Many young people of color get arrested on minor drug charges. In my book, I take up some of the history of how drugs migrate across the good drug/bad drug boundary, often through the medical model. In the late 20th century, the trauma movement emerged as a site of rebellion against what many viewed as the excessive use of pharmaceuticals in the mental health field. Trauma required intensive, long-term listening. Perhaps inevitably, PTSD emerged as the modern-day poster condition in this new effort to bridge that divide, partly through its redemptive association with normalcy. It was interesting to me that a small group of multidisciplinary psychiatrists, founded in the 1980s to champion therapeutic use of psychedelics, moved quite quickly from the margins to the mainstream of public policy, if not to the mainstream of the field of psychiatry itself. It is a fascinating story that still unfolds—one that I would love to follow as a documentary filmmaker. There are many cultural dynamics operating here, including widespread interest in alternatives to the mind-numbing and anti-libidinal drugs so often dispensed by the medical profession.

I am glad you asked about Timothy Leary, whose legacy as icon of the 1960s often surfaces in campaigns to promote therapeutic use of psychedelics. In my book, I use this case of psychiatry’s recent romance with psychedelics to revisit the early research of Leary and his lesser known contributions to psychology and psychiatry. Through his studies on the use of psilocybin in group treatment settings in a prison outside of Boston, Leary advanced his theory of what he termed 

, with the former referring to the attitudes of practitioners, including to the drug itself, and the latter referring to the environmental context, including the aesthetic and social context of drug administration. Prisoners were provided psilocybin in special rooms with music and group support, and encouraged to set their own goals for self-development. Many of the current protocols for therapeutic use of psilocybin similarly involve long sessions with music of one’s choice, social support, and rituals, including some associated with Indigenous practices. The important insights that grew out of Leary’s work on these contextual influences on drug effects have had little influence on psychiatric administration of drugs in general, and they typically register as confound effects, although some of the focus on social support and aesthetics have been incorporated into protocols for therapeutic use of psychedelics, including here in Oregon.

If these protocols open larger questions about cultural practices and market forces in the mental health field, I think this could be a good thing. It will also be important to attend to how debates over the therapeutic use of psychedelics shape treatment options for patients suffering from major mental illness where clinical sets and settings—to borrow the phrase again from Leary – have been so impoverished.

: We have seen a lot of discussion around mental health over the past year, especially in the context of the COVID-19 pandemic. I think there is a certain unease in a lot of these popular discussions, where the desire to acknowledge the magnitude and prevalence of suffering coexists with concerns about medicalization of this suffering. Do you have any thoughts on how we as a society can have more meaningful conversations around mental health?

: The pandemic has indeed opened space for more meaningful conversations around mental health, particularly in the renewed focus on chronic stress as a public health and mental health problem. The internet is awash now with discussions of 

, and PTSD has emerged again as a signifier for shared suffering not born of individual failures or deficits. But I view much of this as a diagnostic containment strategy and a distraction from the real issues at hand. Dispensing diagnoses as an intervention in the pandemic is not very illuminating, even with PTSD as the site where societal sources of misery are narrowly acknowledged.

More than offering just a critique of the PTSD diagnosis, psychiatric diagnoses in general or the medical model, I hope my book contributes to self-reflection in the field about how the histories of our disciplines are embedded in larger societal histories, and on our roles in reproducing the very suffering we aim to control. Following psychiatry through military history was particularly instructive in bringing into bold relief the contradictory forces we face as clinicians in keeping individuals healthy in unhealthy places. It is not a conflict we can deliver ourselves from by simply refusing to be part of the system. Those in secure private practices can opt out, but many of us are part of institutions that offer less distance from how we are implicated in the difficult lives of others. But many of these institutional sites, where psychiatry is closest to the heartache and hard problems that exceed its reach, carry potential for greater creativity in a field that has suffered its own inhibiting obsessive conditions. That is why I am so delighted to be part of your Conversations in Critical Psychiatry. Thank you for inviting me!

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 and Dr Haaken have no relevant financial disclosures or conflicts of interest.

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