- The episode of the psychiatry podcast focuses on critical psychiatry and its practical implications on psychiatric practice.
- The hosts introduce themselves and their guests, Dr. Ilya Abidjawood and Lucy Costa.
- The learning objectives for the episode are defined, including defining critical psychiatry, reviewing core principles, and understanding its potential benefits and harms.
- The guests discuss their interest in critical psychiatry and how it aligns with the work of service users and the future of psychiatric care.
- Dr. Abidjawood shares his personal journey and how he became interested in critical psychiatry, starting with questioning the effectiveness of SSRIs.
- The discussion continues with further exploration of controversies and influences in the field of psychiatry.

- The speaker had a "shadow residency" where they learned about critical psychiatry alongside their regular residency training
- They became involved in teaching and academic work related to pharmaceutical industry bias and psychiatry
- They started a critical psychiatry reading group with other residents, which has continued for several years
- They have participated in various research projects and international collaborations in the field of critical psychiatry
- Their main clinical area is Tourette syndrome and related conditions
- Critical psychiatry is about being open to different ideas and questioning current practices in psychiatry
- Patients are now more literate and questioning their experiences and treatments
- Power dynamics and who holds knowledge in psychiatry are important aspects of critical psychiatry
- Some main issues in critical psychiatry include the pharmaceutical industry, custodial care, and the interaction between social context and psychiatric disorders
- Literature from people with lived experience is important for critical psychiatry in terms of patient engagement, research agendas, and ethical considerations in research studies.

- The video discusses the importance of conducting an ethical examination of research studies and their outcomes in relation to people's quality of life.
- Critical psychiatry emphasizes the need for a broad and open perspective, considering various factors such as political, social, economic, and cultural contexts in understanding mental illness.
- Coercion and the role of psychiatry in satisfying social demands are significant concerns in critical psychiatry.
- All interventions, including biopharmaceutical interventions, should be critically examined.
- Critical psychiatry aims to make psychiatrists better by encouraging openness to different perspectives and paradigms.
- The therapeutic relationship and holding truths lightly are key principles in critical psychiatry.
- The video emphasizes the need to be critical of both dominant and non-dominant paradigms in psychiatry.

- The speaker emphasizes the importance of maintaining critical thinking and considering the bigger picture in interventions and treatment.
- They highlight the advantage of being a resident in questioning established practices and remaining open to different perspectives.
- The case of a 13-year-old Syrian refugee in Canada is discussed, with the speaker suggesting the need to understand the individual's story and experiences before jumping to diagnoses.
- They emphasize the importance of considering the practical challenges and cultural differences the patient is facing, as well as the impact of her parents' strained relationship on her well-being.

The video discusses the challenges of linguistic barriers in psychiatry and the importance of delving into the complexities of patients' needs. It highlights the value of learning from multidisciplinary teams and the limitations of the current system in providing comprehensive care. The speakers emphasize the need for a holistic approach and the potential pitfalls of relying solely on guidelines and best practices. They also discuss the importance of considering individual circumstances and the potential risks associated with deviating from traditional treatment approaches.

- Practicing differently from the standard of care in psychiatry can be challenging and risky.
- It is important to be open and thorough in documenting decisions and explaining them to patients.
- The concept of standard of care in psychiatry is evolving and should incorporate the perspectives of service users.
- Reparation and forgiveness for mistakes should be considered in psychiatry practice.
- Critical psychiatry is not about making more mistakes, but rather acknowledging and learning from them.
- Openness and transparency with colleagues and patients can make a difference in how mistakes are perceived.
- The fear of appearing unknowledgeable should be challenged in the medical field.

- The need to challenge the notion of knowing everything and accepting mistakes in the field of psychiatry.
- The importance of discussing power within psychiatric medicine and incorporating critical psychiatry principles into curriculum.
- The podcast serves as a type of curriculum outside of the main curriculum.
- Learning objectives include defining critical psychiatry, reviewing its core principles, and understanding its potential benefits and harms.
- The field of critical psychiatry is evolving through the integration of ideas from different fields.
- The discussion also focused on managing the potential benefits and harms of taking a critical approach to practice.

The psychiatry podcast episode discusses critical psychiatry and its implications on psychiatric practice. The guests share their interest in critical psychiatry and its alignment with service users and the future of psychiatric care. They explore controversies and influences in the field, emphasizing the importance of questioning current practices and being open to different ideas. The video highlights the need for a broad perspective and considering various factors in understanding mental illness. They discuss the challenges of linguistic barriers, the importance of holistic care, and the potential risks of deviating from traditional treatment approaches. The concept of standard of care in psychiatry is evolving and should incorporate service users' perspectives. The speakers also emphasize the importance of acknowledging and learning from mistakes, challenging the fear of appearing unknowledgeable, and discussing power dynamics within psychiatric medicine. The podcast serves as an additional curriculum, with learning objectives including defining critical psychiatry and understanding its potential benefits and harms. The field of critical psychiatry is evolving through the integration of ideas from different fields.

Welcome to Psyched, the psychiatry podcast for medical learners by medical learners.

This episode covers the field of critical psychiatry.

While this topic could be very philosophical and expansive, we're gonna focus our discussion by considering the practical implications of this field on psychiatric practice.

What do you need to know about critical psychiatry as a trainee and how might it impact your clinical practice?

I'm Gaurav Sharma, a fifth year psychiatry resident at the University of Toronto and I'll be hosting this episode.

I'm joined by my colleagues who will be co-hosting.

Hi, I'm Nikita Singhal, also a senior psychiatry resident here at the University of Toronto.

Hi, I'm Monisha Basu, a second year psychiatry resident at the University of Toronto.

Hi, I'm Sajjad Jabri, I'm an international medical doctor from the United Arab Emirates, currently living in Toronto.

So as always, we have some experts among us.

Abidjawood is a staff psychiatrist at the Hospital for Sick Children, as well as assistant professor and clinician investigator in the Department of Psychiatry at the University of Toronto.

Lucy Costa is a Deputy Executive Director at the Empowerment Council.

The Empowerment Council provides a voice for clients of mental health and addiction services, primarily at the Center for Addiction and Mental health in Toronto.

And by the way, you know, thank you for referring to us as experts and I like to think of myself as an expert.

But, you know, I just want to say in line consistent with the theme of critical psychiatry.

Critical psychiatry is all about questioning things and really, I guess I've thought a lot about these things for a while, but you guys are thinking about them too.

And I think in this respect, we all have expertise and all have to learn from this and we can all ask and pursue and come up with interesting questions in this regard.

Thank you, Ilya, as always for grounding the discussion and living it.

For today, we'll start off with some learning objectives before we get into the meat of the questions.

The learning objectives for this episode are as follows.

Number 1, define the term critical psychiatry and describe how the field has evolved over time.

Number 2, review core principles of critical psychiatry and apply them to a clinical situation.

Number 3, understand the potential benefits and harms of critical psychiatry and understand how the field is continuing to grow.

Okay, so maybe I'll start off with the questions.

So, you know, we know that there's such a significant body of critical psychiatry literature and writing, but it's not a part of mainstream psychiatry or mental health professions education all the time.

How did each of you end up exploring this field and how is it now a part of your day-to-day work?

I think that to begin with, we probably should sort of define the scope of what we mean by critical psychiatry.

Because there's been other intersecting developments in psychiatric medicine over the years.

And so my understanding of critical psychiatry is that it is distinct from other work that's happened such as anti-psychiatry.

Critical psychiatry is not anti-psychiatry and critical psychiatry works to ask important questions about practices as they're unfolding today as opposed to anti-psychiatry which is interested in the abolition of psychiatry overall and that has had a different trajectory and so it's important to make that distinction because they're different goals as well as the way that I guess critical psychiatry interfaces with other areas of practice historically, psychoanalysis and psychotherapy, etc.

That's helpful, Lucy, and I think it's great to start off with the definition.

And I'm curious about your story of how you got interested or involved in this work?

Well, I'm interested in critical psychiatry insofar as how it works or aligns with the work, scholarship, cultural care work of service users themselves, which is not what we're talking about today, but there's obviously an interface between the way in which people with lived experience have informed and continue to inform psychiatric care and how really in the last probably 15 years some of those silos have broken down where like psychiatry was very siloed area or discipline and there's been more interfacing with other disciplines.

I'm interested in how critical psychiatry interfaces with the work of service users themselves.

And by service users, I'm just using the term that is normally used across literature to describe people who've interfaced with various facets of psychiatric care.

As someone who is myself, someone who has been in the psychiatric system and used services, in fact, when I was young I used psychiatric services at the hospital for sick children, so I had those experiences there and then later.

So I'm interested in how we can work together to think quite critically and radically about the future of psychiatric care.

So thank you, Lucy, for sharing your experiences and your interest in this.

I would say it very much overlaps in terms of, as you say, it's about thinking critically about how to improve things, right?

As opposed to anti-psychiatry, which is about abolishing psychiatry.

I did not think of myself as a quote unquote critical psychiatrist until at some point I realized that a lot of what I was doing falls under this umbrella.

And I've thought, and I've tried to understand at some point, I tried to understand why, how did I get here?

Like personally, is it because I'm a critical person?

I kind of like see the negative in things and like to criticize in life in general.

I'm not sure, maybe there's a bit of that, but I'm not sure it's about being critical that way.

It's critical in the sense of critiquing, but another way to look at it, I would say it's about openness to alternatives, as opposed to getting attached too strongly to a certain paradigm and way of thinking.

It's about being open to different ways of thinking and then by virtue of that you then are going to question things and whatever the current paradigm is.

And I would say for me personally this started very early even way before medicine.

So you know if we're talking personal just before we started, Sajja was asking about my background.

And I immigrated from Lebanon 25 years ago now, but because I wanted to leave, because I was done with the, I grew up in the Civil War, there's a lot of people very entrenched in their beliefs about this, things should be 1 way or another, and I was open to the various beliefs and the various perspectives, and there wasn't much room, I felt, for this kind of openness, because you either had to belong to 1 group or another.

So I was eager to leave and explore the world.

And I would say this is the attitude that I've taken with me since then.

So in my psychiatry residency, it started very early on.

I came across a paper, I think it was PGY1 at the time, possibly PGY2, but anyhow, I came across a paper that was a paper by Irvin Kersh, 1 of his early papers, questioning the effectiveness of SSRIs relative to placebo for depression.

And I can't remember how I came across the paper, but, and the title of the paper was provocatively, The Emperor's New Drugs.

And he basically was someone who was interested in the placebo effect, not so much necessarily in antidepressants.

So he was doing the study mainly to study the placebo effect, and was surprised to find there was barely any difference if he took the FDA data that contained all the data as opposed to just the positive trials.

And I was quite shaken up by the paper, and I wanted it dismissed.

I wanted it criticized, And so I would take it with me, I would discuss it with supervisors, and they would dismiss it but not in any meaningful way.

Like there was no 1 that was able to make a solid critique of the paper, why it was wrong.

I wanted it to be wrong so I could move on and it was difficult.

So that's at the time, I remember I carried the paper around with me in my backpack.

And that kind of continued and evolved into kind of questioning things, starting to learn more and more about issues, controversies in the field and not shying away from them.

1 area that I became more particularly interested in is the influence of the pharmaceutical industry in recent decades in terms of how we do see and do things in psychiatry.

And then I came across some of the work of the current quote unquote critical psychiatrist people like Joanna Moncrief and Sammy Timimi in the UK.

And I was reading the stuff throughout my residency.

So it's almost like I had a parallel education.

I was learning the stuff from my residency, but I was also at the same time I was thinking a lot about all of these things.

Yeah, a shadow residency, like we've put together, actually, which brings me actually to what's happened since.

So after residency, it's not like I was thinking actively I want to pursue these things, but things just kept coming up, you know, like opportunities or, you know, like there was demand for these things, you know, there's, It's not like I was some internationally recognized expert in this area.

So, for example, I was asked to do some teaching on pharmaceutical industry, bias and psychiatry.

And then I ended up starting to do academic.

My interest was cognitive neuroscience throughout.

In fact, I pursued my PhD in cognitive neuroscience at the end of residency.

But this was initially a side interest, but increasingly, based on demand and opportunity, it became increasingly a big interest.

At some point, for example, there were 2 wonderful residents that were both junior PGY1s, Luam, Gavreel Hariat, and Artie Rana, who are now both graduated practicing psychiatrists here in Toronto.

And they approached me about starting a critical psychiatry reading group, so we did that.

And then wonderfully, as they graduated, Gaurav Yu took over along with Kelly.

So that's continued and we've had several years of this.

That's been also, if you just look at the things we've covered in the group, it's been a wonderful curriculum.

And I've been participating in various different research projects at this point, international collaborations of various sorts in this area.

Meanwhile, I will just say my main area, my core clinical area has been that of Tourette syndrome and related conditions.

So it's not like I thought, oh, I want to be a critical psychiatrist.

This was basically, you know, it's part of what I do.

And I think it's a much more stimulating and interesting way to do psychiatry.

I can say a little bit more now, if you'd like about what that's like, you know, basically in the day to day being, but I've been going on for a while.

Yeah, I mean, I think I'd like to reflect for myself and maybe for our listeners that in both of your descriptions, what stands out is, there seems to be like a critical approach that you weave through your day-to-day work in your respective fields, right?

Like Lucy in your work with regards to lived experience, and Ilya in your day-to-day work as a child psychiatrist.

So it seems to be something that people can integrate no matter what area of mental health they are working in.

I mean, I think this should be psychiatry.

I mean, unfortunately, it's called critical psychiatry, because this should be how we practice anything that we do.

But in truth, we're human beings, and we do tend to get attached to certain paradigms and heuristics.

And then it becomes the more we get attached to these and become entrenched to them, which is a normal part of being human, the harder it is to question them and be open to alternatives.

So I guess that's where the term critical psychiatry comes in.

It's within a very deliberate fashion, not shying away from controversy, the opposite, embracing it and then being very humble about our current tools and the things that we can do in the hopes that things can improve.

Well, it sounds like that openness to experience that you were talking about.

I like the way that you framed it as rather than it about being somebody who's used to being critical or wanting to critique things, it's more so this desire to have openness to different ideas and curiosity.

And I'm going to jump in just to let Monisha take it away there, because we've got a lot of other interesting questions to throw both of your ways.

Yeah, so thank you, Lucy, for defining what critical psychiatry is and sort of differentiating it from anti-psychiatry.

So just to recap, it sounds like to me what I'm hearing critical psychiatry is really like an openness and approach to psychiatry where you look at what you're doing, the practices in a critical lens, and you aim to challenge some of the most deeply held beliefs of the specialty.

And that differs from anti-psychiatry, which argues for the abolition of psychiatry altogether.

Maybe to clarify a little bit, we could talk about some of the main questions that critical psychiatry tries to ask or answer.

I just wanted to add also that to what I was saying previously about openness that I think it's also the patient population has changed over the last 20 years.

So as we've moved from the era of, you know, very paternalistic custodial care, there's been much more literacy from people who use psychiatric services.

And as a result, they too are questioning either their experience or their rapport, or wanting more information about the treatments that are offered and wanting that information honestly so that they can have and they make an informed choice.

So I think as psychiatry has changed and some aspects of it have become more open.

So too, I think, have patients been asking more questions and also doing so in a way that also encompasses their intersectional identities.

10 years ago, I remember working in the hospital and somebody had bitten a whole bunch of homophobic things on the wall, and nobody did anything.

That just stayed as graffiti on the wall for quite a long time.

Now that would never happen, that there would be somebody in charge that would go and attend to that graffiti on the wall.

So this is an important aspect, and I wanted to add in that I think we need to also at some point talk a little bit about power, because it is about asking critical questions, but it is also about who holds the, who's developing, who's creating the knowledge, how are those questions answered, and how does power circulate in that kind of dialogue.

And just from your perspective, what are some of the main issues that are of discussion in critical psychiatry today?

Abhijay talk a lot about, for example, the pharmaceutical industry, but there are also other things, you mentioned custodial care, and I've read a lot about, for example, the interaction between social context and psychiatric disorders.

So what exactly are the questions that critical psychiatry tends to try to answer?

Well, you might know more about that than I do, Ilya.

I'm always been asking critical questions by virtue of trying to be a voice for the experience of people who are interfacing with different psychiatric systems.

I mean, I do feel aware that I think 1 of the, again, critical questions that gets asked, especially in psychiatry, is also psychiatric models are exported to other jurisdictions.

There are sort of global critical questions about the export of particular models of psychiatry to other other sites, but my my feeling is that critical psychiatry is interested in really questioning practices and how those practices are useful and helpful to patients themselves.

And just to kind of tag along on that, Lucy, are there particular questions in the space of literature from people with lived experience that are important for critical psychiatry?

Yeah, I mean, I think, again, things have evolved insofar as that we now have this discourse of like patient engagement and service user engagement.

And what that actually means on the ground is something that I'm infinitely fascinated by.

I think that areas of tension might be specifically around the production of knowledge and who gets to be an expert and inform processes.

At the same time, like how do we engage with medicine and science and get accurate information, particularly when we're dealing with treatments that are more controversial and interface of bodily integrity of our patients.

So I think the future of psychiatric medicine, in my view, really sort of pivots on, is there a role for patients to actively play in the dissemination of information in research processes and also research agendas.

Who's deciding what we're going to research and what meaning that has for actual people?

That's really, I think that's really moving, even just to hear the importance of deciding research agendas and, you know, how much that influences what we know, is what we choose to study.

Like we've had, how do we do like an ethical examination of what research studies have gone forward, what they've produced, and what the outcome is for people and their quality of life, contemporarily speaking.

I mean, you're touching it nicely, Lucy, in terms of who controls the knowledge, who controls the, who decides on what needs to be questioned, the pursuit of the knowledge and all of that.

And I would say from a critical psychiatry perspective, there are so many unknowns, there's so much complexity to the human experience and how it interfaces with what we consider is a mental disorder, that it's something that is not, cannot be just based on, you know, the medical profession or psychiatrist.

It's something We need to be very broad and open to different perspectives, even how to start looking at this.

What is the influence of political context, social context, economic, cultural context on the human experience and what we decide is a mental illness.

And as you can imagine, these such broad questions, these are not just questions for psychiatrists.

These are the things that we should be open to, talking, interacting with sociologists, anthropologists, philosophers, and, God forbid, psychiatric patients themselves or service users.

We don't have to look back very far before we get to points of things, the practices, ways of viewing and practices that we now we can shake, wag our fingers on or shake our heads at.

And I would say a lot of these things are ongoing and we need to be open and doing these things.

1 of the things I think you touched on, Monisha, was coercion.

How does psychiatry interplay with some of our diagnoses and interventions?

How much of it is about improving the wellbeing of the individual, how much of it is satisfying social demands, societal demands, some people would say, like cynically maintaining social order kind of thing.

And then, you know, coming to our interventions, I think all of our interventions should be looked at critically.

Now, you know, the biopharmaceutical interventions get a lot of critique for a good reason.

But the reason they get a lot of critique now is because they are our dominant intervention, whether we like it or not, they are.

But if we were being critical psychiatrists 50 years ago, maybe it was psychoanalysis that would be getting the heaviest critique.

But we really need to be questioning a lot of these things.

And we can practice, even as long as we question.

It's not like we're going to be paralyzed because we don't know anything.

It's so stimulating, makes it much more interesting, and it's highly rewarding when you're open this way.

Thank you both for those very detailed and helpful answers.

It sounds like there's a lot of different questions that critical psychiatry attempts to answer from the very premise of what is a psychiatric illness, how is it different from the human experience, where does that differ and become a disorder as opposed to a normal or expected response to stressful situations, What is the role of coercion in psychiatry?

And does our coercion seek to serve the patient or does it seek to serve social norms and expectations?

And then as you've talked about the role of medications, our treatments, their effectiveness, and critically approaching and analyzing the things that we're doing.

I just wanted to add too, because as I'm listening to ourselves speak, I'm thinking, how can we encourage residents to become interested in critical psychiatry.

And I think 1 of the things critical psychiatry can do is make you a better psychiatrist, again by virtue of being open to different perspectives, paradigms, ways of understanding.

Priya Raju, who I consider a friend and respect, listening to her teach residents and talking about the need to hold truths lightly.

And I thought that was a very powerful phrase about holding truth slightly.

I think it's really important for that relationship between a patient and a psychiatrist to feel that the psychiatrist they're working with is actually open and listening and has a breadth of knowledge to bring to the table that includes really trying to make sense and continuing trying to make sense over a longitudinal time as a professional in the field to what a person is bringing in and what the nature of that distress is and what do they need to improve the quality of their life.

I've never heard the phrase before, I love it, hold your truth slightly.

Roger is incredible at getting to work with her a bit now.

And it applies not only in that, like individual patient encounters, having that humility of whatever we're thinking is holding that lightly and more broadly as a field.

As was mentioned earlier, we do have these kinds of paradigm shifts and we talked about it in our previous episode on kind of the history of psychiatry.

You know, right now, a lot of the debate might be around for the biological and previously there was like backlash towards more of the psychotherapy.

And yeah, so definitely gonna keep that in mind.

I guess kind of shifting, and I know we do have a case that Saja is gonna bring up later on.

As we think about that, Is there any core messages or maybe some principles that you would be able to distill critical psychiatry to that could kind of be practically applied by learners in the realities of our current clinical settings?

I think like what I've been thinking about is and feeling fully aware of sometimes the tenuous positions residents can be in and even sometimes if you're part of a team.

I think it's finding ways to support each other in the work, particularly in those moments where you have to take a position.

And those are the hardest, I think, I mean, critical Psychiatry can become like this interesting, fascinating thing that people get involved in and read different things, but the rubber hits the road when you actually encounter a messy situation, a situation where ethics arises, and how do you as a practitioner take a stand or position on that.

I also experienced that in my own work, not turning away or not finding ways to put time and energy into taking a position and figuring out how to creatively resolve something that I feel like is problematic.

Yeah, I mean, I think, and I guess we'll get into more specifics when we talk about specific, the case or specific conditions, but to talk a little bit still sticking with kind of principles, we're talking about being so open to exploring everything, embracing controversies, all of that.

This is not just talk, like this is in your day-to-day practice.

And it also means you can take positions, as Lucy's saying.

You have to take positions, even if you don't know anything.

If you're spinning, even if it's about spinning a coin, the coin is going to land heads or tails.

So you've got to call 1 or the other, but you've got to be prepared for the possibility that it might not be what you called.

It's about being realistic and humble about the role of our tools, whatever our tools are.

In particular medications, it's not just medications, it's really all of our tools, whether there's screening, diagnostic, psychotherapeutic medication, you name it.

But I say in particular medication because this is probably by far the most used tool in psychiatry today.

And it's used in a very simplistic way, I have to say, with a very simplistic understanding of what exactly these medications are doing.

And this is coming from someone, you know, I know my, I know a thing or 2 about neuroscience.

So I can, I feel confident in my critique of that?

It's neuro babble, to be honest, that's, that's, that's, it's, it feels often, you know, just as accurate as talking about alignment of the spirits or the stars or the energies and all of that.

And our culture is 1 where we are very focused on the neuroscience.

And this is kind of what makes us, I can say the exact same thing, and not refer to your brain.

But if I say the same thing and refer to your brain, all of a sudden becomes more believable, even though I added nothing just by saying your brain does that.

But anyhow, it's about really being humble about this and being 1 of the...

And then there are some core principles like the therapeutic relationship is key, like keen attendance to the role of the therapeutic relationship.

And I would say the other thing is I would say, just like we are being critical of dominant paradigms, but also being critical of non-dominant paradigms.

Not saying, oh, this is outside of the mainstream, must be interesting, this is the way to go.

No, we need to keep, because I find sometimes this is a caveat, a pitfall, no, we need to maintain the same kind of critical thinking about the whole thing.

And always thinking about the bigger picture.

When we're thinking about interventions, we're dealing with the individual in front of us.

And we need to focus and help the individual in a collaborative way as Lucy reminds us for sure at the same time we need to be thinking broadly about what are the the the context the social political systems context and then what what can we do if anything about this So these are some of the principles that are applicable in a day-to-day practice.

I will say 1 more thing, sorry, just in terms of the resident role, because sometimes people feel, oh, I'm just a resident.

I have a supervisor, my supervisor decides everything.

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PsychEd Episode 59 - Critical Psychiatry with Dr. Elia Abi-Jaoude and Lucy Costa