This blog was originally published by Mad in America on Oct.21st, 2021.

A recent opinion piece in the Psychiatric Times by Joel Yager MD, a professor at the University of Colorado School of Medicine, envisions a potential future for psychiatry in the year 2500. You can find the article here.

As a psychiatric survivor, I was stunned to see a medical professional describe a dystopian nightmare as a vision of progress for psychiatric medicine. Here I offer a critique of that vision, and some hopeful thoughts towards an alternative future. I hope that my perspective as someone who was harmed by psychiatric treatment can provide something of value to the conversation regarding where psychiatry is headed.

First, a summary of Dr. Yager’s futurist vision is due. The opening words are bleakly telling: “Assuming humans survive and continue doing competent science…” Yikes. Having brushed off how existential threats like climate change will impact our understanding of mental health, the article goes on to describe how psychiatry has evolved to regard its previous iterations as archaic, and one can safely assume that by the year 2500, future students of psychiatry will likewise look back on our current age as one defined by groping in the dark for answers to questions that were fundamentally misunderstood.

It’s striking to me how much of Dr. Yager’s article seems to imagine a future psychiatry that is very similar to what we already have today, but worse. Allow me to summarize:

By 2500, Dr. Yager imagines that psychiatry will involve the following:

• Universal Profiling: Everyone’s medical records will include a detailed and nuanced psychological profile of the individual that begins with “genomic and epigenomic analyses in utero.”

• Data Mining: These profiles will “utilize massive data stores, integrating information about neurobiology, temperament, coping styles, personality, and life events derived from individual, family, school, social connection, AI usage, and other registry sources. To all this might be added information from responses to individualized, virtual reality–based scenario simulations and from high-definition, whole-brain, dynamic scans assessing connectivity among numerous interacting brain regions. Each fingerprint will be compared with those of billions of individuals going back for generations.”

• AI-Based Assessment: These highly detailed profiles, combined with the use of sophisticated artificial intelligence (AI) are hoped to somehow eliminate clinical bias in the assessment of mental illness, but how this is achieved remains unexamined.

• A Diagnosis for Everyone: Diagnoses will become redefined according to what Dr. Yager calls “precision psychiatry, encompassing individuals’ cell-specific diagnoses, brain functional neuroanatomy and connectivity patterns, interpersonal interactions, life events, and appraisals of deviant behaviors, all contextualized within patients’ micro- and macro-cultural frameworks…”

• Predictive Psychiatry: These precision diagnoses will be able to indicate “warning signs and risks, and predict the likelihood of … erupting in an episode of suicide or violence.”

• Implants for Surveillance & Treatment: Current forms of medical intervention will be replaced by technological solutions, such as “a host of wearable and implantable devices that both monitor ongoing status and administer experiential … and direct biological interventions.”

• Robots: Individuals will have access to personalized robots that provide companionship and constantly monitor for signs of mental distress, alerting medical authorities if they perceive a need “for triage to higher levels of care, including human clinicians.”

• Virtual Care: Face-to-face care will be dramatically reduced thanks to widespread access to these AI-powered robots and high-quality virtual-reality simulations (think Star Trek hologram technology) “which could use holographic avatars to re-enact earlier life events.” Most care will be delivered remotely through hyper-realistic holographic video-call technology.

• In-Person Care & “Sanctuaries”: Face-to-face care will still happen because “individuals who are highly disturbed will still be treated in specialized sanctuary-like medical treatment centers, usually for brief periods … For socialization, education, training, and rehabilitation purposes, actual live human gatherings are likely to endure, as they have for many centuries.”

• Brain-Engineering Technology: Psychiatry will also be able to exploit other technologies to physically re-wire the neural connections in the brain. These technologies include “stereotactic membrane–like skullcaps, capable of focusing deep ultrasound and other noninvasive stimuli at precise targets to promote local neogenesis,” and “Optogenetic-guided retroviral interventions” which might “sculpt specific brain nuclei and connection pathways.” Yager also imagines a futuristic version of CRISPR gene-editing technology which “might reverse neuropathological processes associated with excessive pruning, dysregulated emotional and attentional centers, impulsivity, habit formation, and craving.” No consideration is given to the ethical implications of this neuro-engineering.

• Virtual Training: The training and certification of psychiatrists will be done with the aid of virtual-reality simulators, and the administrative duties of psychiatrists’ offices will be handed over to sophisticated AI assistants.

In other words, Dr. Yager’s article is a technocratic vision in which AI and sophisticated advances in telecommunication and neuro-editing technologies allow for a dystopian personality profiling regime, the widespread delivery of virtual-reality and remote care, and a host of interventions that physically restructure the brain. This is a vision that remains dogmatically attached to a bio-reductive model of mental illness, and therefore pins all of its hopes for the future in an ever-more-precise scientific understanding of the biological causes of mental disease.

There is scant mention of how the social and environmental determinants of mental health may change and affect this future vision of psychiatry, except for this short comment on the evolution of psychiatric theories: “By 2500, scientists may have clarified the mechanisms and impacts of genetic, epigenetic, and … elusive physical and psychosocial environmental forces … As more nuanced mechanisms are delineated, old theories will drop and new ones will emerge.”

I take issue with Yager describing the psychosocial and environmental forces that contribute to mental distress as “elusive”. We know, for example, that wealth inequality is a primary driver of poor health, both mental and physical. So is social isolation. We also know that reliance on a mass-delivery education system designed for neurotypical learners plays a role in exacerbating and perpetuating mental health challenges for neurodivergent students who are not ill or deficient, but merely different. Social injustice also plays a major role in declining mental health, as evidenced by the disproportionately high rates of distress, illness, and avoidable deaths in marginalized communities.

It is also naïve at best to suggest that a more nuanced understanding of the mind and brain will lead to old theories being dropped. Today it is clear, as the U.N. and W.H.O. issue global calls to redefine mental health care in a way that guards the human rights, dignity, and agency of patients, that psychiatry as it is commonly practiced by physicians and psychiatrists in the “developed” world is no longer based in the most reliable and up-to-date evidence. Instead, it too often clings to a bio-reductive model of previous generations, at the expense of patients seeking care for mental suffering.

Major risks remain for patients seeking equitable mental health care. We are likely to find ourselves diagnosed and prescribed by a general physician, or a psychiatrist who remains dogmatically attached to a biomedical model that pathologizes traumatic and other experiences of altered states and emotional distress. Common interventions like antidepressants and benzodiazepines have been well documented as only moderately effective at best, often comparable to placebo, but carrying with them severe dependence and withdrawal risks. It is absolutely scandalous that antidepressant withdrawal syndromes like akathisia are not typically disclosed to patients prior to prescription. This is morally unacceptable, yet Dr. Yager makes no mention of these avoidable harms and how a future psychiatry will rectify its practices to prevent them from happening.

Other ethical dilemmas are conveniently ignored in Dr. Yager’s article. He envisions a future in which individuals have their genome sequenced in utero, deeply specific psychological profiling exists as part of every individual’s medical records, and every aspect of our lives and experience is somehow monitored and incorporated into that profile by AI algorithms. In other words, Yager’s vision for the future of psychiatry assumes the widespread adoption of medically-justified mass surveillance, and yet offers no thought to the ethical issues of personal privacy and autonomy. He suggests that by 2500, somehow AI technology will have become perfectly unbiased, and do most of the diagnostic work for clinicians before they even encounter a patient, even though we already know that today, AI and other forms of technology carry with them the prejudiced biases of their programmers, and the audiences for whom they are developed – primarily white and middle-class.

How will inherently biased human beings program a perfectly unbiased medical AI? To my thinking, proposing an assessment technology that is free from bias requires that we assume a cultural shift in the tech sector, or even throughout human civilization, which would somehow allow us to program a computer to be as perceptive as a perfectly ethical human could be in any cultural context, in any geographic location, in any set of circumstances. Such advances remain squarely in the domain of science-fiction and hifalutin philosophical thought experiments.

Do we need better assessment and diagnostic tools? Of course. But to put our faith in some cyberpunk psychiatric utopia is utterly naïve at best, and darkly cynical at worst.

It is astonishing to me that any psychiatrist could describe a dystopian surveillance state as the holy grail of psychiatry without even acknowledging that it would constitute a life-long invasion of privacy and autonomy. The absolute control in framing an individual’s experience and understanding of their world is a horrifying power that I hope psychiatry never discovers. This type of thinking speaks to modern psychiatry’s moral ambivalence: whatever harms might arise in the pursuit of some idealized and perfected medical treatment are inconsequential, so long as we can provide “better care” to our most desperate patients.

And who are the desperate patients? In the scenario described in Dr. Yager’s article, it’s unclear that these futuristic assessment tools wouldn’t pathologize every form of human distress. Is it really a sign of progress if the DSM becomes obsolete only to be replaced with an infinitely expandable catalogue of human conditions to be matched up with various forms of “precision” intervention? Is this more accurate assessment and diagnosis, or is this expanding the definition of mental illness to give a diagnosis to everyone? Is this better medicine, or the continued pathologizing of the human condition?

It was the section of Dr. Jager’s article subtitled “Looking at Treatments” that most boggled my mind. No mention of therapeutic communities like Soteria houses, no mention of ending income inequality, homelessness or unemployment as social treatment strategies, no mention of making education and employment accessible to mad, neurodivergent, and disabled people, no mention of addressing trauma as a cause of mental illness, and certainly no mention of addressing the harms that psychiatry has already created, i.e., over-prescription, incarceration, iatrogenic injuries, widespread social stigma, and the list goes on (and on).

This vision of psychiatry suggests that it is too much to ask that we eliminate poverty, provide safe housing for all, or create communities where people feel safe, but it is not too much to ask that everyone gets a personal robot therapist and a sensor implanted in their body that links up to their smartphone. Rather than working through trauma in therapy, CRISPR-like technology might re-wire our brains to reverse the effects of that trauma. Maybe that sounds convenient, but it is also deeply invasive and risky.

Re-wiring the brain through mechanical means might be an acceptable treatment in cases of extreme suffering. This is already the justification used in trials involving deep-brain stimulation as a treatment for severe treatment-resistant depression and other conditions, but to regard this kind of intervention as the gold-standard of the future is skipping over generations of important ethical questions that would first have to be addressed.

On top of all that, Yager suggests psychiatric wards and involuntary incarceration for “highly disturbed” individuals will continue to be a reality, but “usually” for brief periods. If there is one thing I want to see in a future vision of psychiatry, it is abolishing carceral forms of care. I can only assume that Dr. Yager is not as familiar with contemporary criticisms of psychiatry as a complicit arm of a white-supremacist carceral state, as he must be with developments in holographic telecommunications.

Don’t get me wrong, I would love to see a future that includes Star Trek-style holodecks in which we can access a variety of hyper-realistic therapeutic scenarios, but if we’re really going to embrace sci-fi visions of a future utopia, we have to also acknowledge that before any such technological advances can be enjoyed by all, we need to completely dismantle and re-imagine our economic, social, and political institutions.

The utopian vision of Star Trek’s creator Gene Roddenberry included no poverty, no working-for-a-living, a society united by a common goal of living in peace and exploring the cosmos. Without discussing socio-political-economic changes, what Yager’s article really proposes is a luxury technology for the rich, and widespread surveillance and control for the poor.

Even Dr. Yager’s comments on “The Promise of Prevention” reads like another take on a literary dystopia: “By 2500 (with hopefully few biases), public health programs might identify and conduct more intensive assessments of high-risk neighborhoods, individuals, and families, and better provide indicated social and individual-based treatments. Thanks to immediate diagnoses of new pregnancies … precision interventions could assist with repairs based on advanced gene- and epigene-manipulation techniques, while other individually tailored preventive interventions may be implemented.”

Towards the end of Dr. Yager’s article, it becomes clear why this dystopian vision may be so attractive to psychiatry: he doesn’t seem to have much faith in human nature. Regarding “What Will Endure” between now and the year 2500, Dr. Jager admits his own bias in attributing to human nature the bleak unavoidable reality that “some citizens will still be prone to intermittently go off the rails; psychiatric disorders are still likely to be stigmatized; and psychiatric gurus are still likely to believe that there are too many patients, too few clinicians, too little knowledge, too few resources, and too little money for what they do. And, given human nature, in 2500 a high value will still be placed on deep, confiding, empathic interpersonal relationships, including clinician-patient relationships.”

Curious then, that nowhere in this vision of a future psychiatry, is there an explanation of how empathic interpersonal relationships will be prioritized as part of psychiatric practice.

Conclusions

As a psychiatric survivor, I know that I come across as acerbic and bitter regarding the field. It is not my intention to be dismissively snide in my analysis, but to insert a voice of dissent, a voice that is too often ignored by psychiatry and its practitioners: the voice of someone who was harmed by its failures. The purpose of sharing my discontent is to constructively contribute to a conversation about how psychiatry and our general understanding of mental health can evolve into something better than it is now.

In closing, Dr. Jager writes “If any of these fanciful visions of future psychiatric practice seem worthwhile, they might provide aspirational goals, and motivation to realize these goals. And, if any of these fanciful visions seem dystopian, they might provoke us to develop better alternatives.”

My assessment of these fanciful visions is indeed that they are dystopian in the extreme. So what is the alternative? Here I offer a brief snapshot into my own vision of a utopian future for psychiatry:

By the year 2500, we have successfully responded to the existential threat of climate change. Having reversed its effects, we began a global process of healing, truth, and reconciliation that held the worst perpetrators of ecocide accountable for their actions, while providing reparations to the most heavily afflicted populations. Psychiatrists researched the relationship between ecological health and mental health, and lobbied for educational tools and government regulations that would prevent humanity from ever again exploiting the natural environment at the expense of our collective wellbeing.

In 2500, wealth inequality has been eliminated, along with homelessness, poverty, and unemployment. A universal basic income combined with accessible and sophisticated social programs ensures that everyone is included in an economy of care that puts people before profits.

Schools have been transformed into democratic institutions in which children, educators, and parents work together to establish learning communities that meet the individual needs of each member. Students are no longer coerced into a role that serves the demands of the market, but encouraged and supported into pursuing a vocational path that serves their interests, goals, and their community.

In the year 2500, research has advanced to the point that we have completely eliminated the unnecessary misdiagnosis of mental illness in what are ordinary experiences of mental distress. Society has accepted neurodivergence, madness and disability as natural and welcome parts of the human experience that enrich the human condition by adding to its diversity, and recognized the unique gifts of these non-conformists as valuable to everyone.

Arts and recreation are well funded across the globe. Our food systems follow the principles of sustainability and care for future generations, rather than being motivated by profit-hungry corporations, resulting in more nutritious foods and healthier ecosystems. A personal connection with nature, the plants and animals of the region in which a person lives, an understanding of oneself, a sense of belonging in society, the world and cosmos in which we exist, are all understood as essential to a healthy mind.

In 2500, psychiatrists understand that bio-reducible mental illness is in fact quite rare, and no longer conflate distressing social, moral, and political circumstances with deficiencies or pathologies in the distressed individuals they encounter. When it comes to those conditions that are confirmed to be strictly biologically based and debilitating, a wealth of non-invasive therapies and interventions are available, and riskier interventions are withheld for all but the most severe and intractable cases.

That is my psychiatric survivor vision for psychiatry. Granted, I am not a medical professional; I’m a philosopher and artist by training, and my vision is certainly naïve and idealistic in its own way. But I hope my particular flavour of naivety offers a counterbalance to the bleak future envisioned in Dr. Yager’s article. I want to believe in a future for psychiatry in which patients are not at risk of being harmed and marginalized when seeking care for mental/emotional distress, but with psychiatry producing visionaries like Dr. Yager, it’s a tall order.