Practicing in the In-Between: Notes on a More Honest Psychiatry

In mental health care today, there’s often pressure to pick a side.

On one end, conventional psychiatry offers structure: diagnosis, medication, and evidence-based protocols. On the other, integrative and functional approaches explore trauma, root causes, inflammation, and mind-body relationships. Each offers value. And -- each has limits.

Both models can drift into both groupthink and black-and-white thinking. Psychiatry sometimes reduces distress to symptom clusters and quick-fix medications. Functional medicine can over-rely on supplements, expensive testing, or one-size-fits-all protocols. And both, in different ways, are shaped by industry—whether that’s pharmaceutical funding or supplement and lab marketing.

There is also a growing trend in wellness spaces to position all of conventional medicine as harmful or misguided—often as part of a marketing strategy. While many critiques of the medical system are valid, dismissing everything within conventional care can become its own form of dogma. People can be helped by psychiatric medication. Lives are saved in hospitals every day. The danger lies not in critique, but in absolutism.

Philosopher and Psychiatrist Awais Aftab offers a different lens in his book, Conversations in Critical Psychiatry. It doesn’t reject psychiatry, but asks it to become more honest about its limitations. It encourages clinicians to practice with humility and flexibility. I appreciate Dr. Aftab as he is able to beautifully articulate in writing what I can only intuit. He writes: “We need to move beyond the binary of 'psychiatry is valid' or 'psychiatry is bunk' and start grappling with what a better psychiatry could look like.”

Critical psychiatry doesn’t oppose diagnosis or medication, but it reminds us these are tools, not truths. Labels and diagnoses from the DSM-5 can be helpful for communication and treatment—but they also shape identity, influence future care, and can stick long after an acute crisis has passed. Especially in inpatient settings, where decisions are made quickly, a diagnosis can do harm if used carelessly or without context. It's something I try to name when I am with medical students and other learners on our inpatient unit. Aftab emphasizes this nuance when he says,

“There are real disorders. There is real suffering. But there is also a real danger in pretending we know more than we do.”

On inpatient units, there’s often a push to act quickly: stabilize, diagnose, discharge. But even in this setting, there are opportunities to slow down, to ask questions like: What do you think is going on? What has helped you before? What feels intolerable right now?

This isn’t about avoiding care. It’s about co-creating it. It's as important to figure out what someone needs and what they are experiencing than to get a diagnosis hammered out.

Many patients we see have past experiences of psychiatric harm. They’ve been restrained, overmedicated, or dismissed. For those who already carry trauma, small shifts matter: asking before prescribing, naming uncertainty, involving the patient in the plan. As Aftab notes, “Power in psychiatry is real. That means it should be shared carefully.”

In outpatient care, these ideas apply just as strongly. Working with people who have complex, chronic, or misunderstood symptoms requires a wide lens. Sometimes inflammation is part of the picture. Sometimes trauma is. Often both. No one model explains everything. And that’s the point.

Critical psychiatry calls for pluralism—an openness to multiple ways of understanding and approaching suffering. In Aftab’s words: “What we need is a psychiatry that is scientifically grounded, philosophically informed, and humanistically engaged.”

The kind of care I aim to offer doesn't fit into any one box. It is not anti-medication. It is not anti-psychiatry. It is care that is curious, collaborative, and is about holding complexity.

As psychiatrists, we just don’t have all the answers—whether we’re working in inpatient units or outpatient settings. But we can do better. We can choose to listen more closely, collaborate more openly, and move away from rigid frameworks. We can aim for care that fits the person, not the diagnosis.