The “MD” embroidered on my fresh white coat still feels foreign to me, but the heaviness of the fabric I feel when I slip it on suggests that it may really be true. In just a few days, I will begin the next phase of my training, starting as a psychiatry intern. Based on my medical school experiences, I can imagine what life will generally look like for future me. I can hear the echoes of my feet reverberating on dark, empty halls as I head down to the emergency room for yet another consult on an already busy night. The trials of navigating a new practice setting and new professional role, I can intellectually wrap my head around. What has been rather more disorienting is that I cannot predict the way I will respond to these new challenges. Just a month ago, I graduated from an MD/PhD program in the history and philosophy of science. Virtually every day for the past eight years, I have devoted myself to the study of medicine as a social enterprise and a human-centered practice. And yet, even given my background, my passions, and my commitments, I still fear that my humanistic spark and my interest in medical history and the social sciences will be dimmed, or worse, snuffed out, amid the practical and emotional tempests of a career in medicine.

I worry because others have fallen sway to darkness. There is extensive documentation—by clinicians, social scientists, and patients alike—of the terrible ways that psychiatry has wielded its special social status through history. In the twentieth century, as psychiatry’s star ascended, so did its excesses multiply, as psychiatry time and again threw in with those in power to disempower the socially vulnerable. The wards of Hadamar were early trying grounds for the Third Reich’s T-4 program, site of euthanasia of “life underserving of life” [1]. A few years later in 1949, António Egaz Moniz won the Nobel Prize for the development of the frontal lobotomy. In the Cold War era—an epoch of proxy wars, decolonization, and social mobilization—psychiatry again sided with established power structures. Psychiatrist and theorist Franz Fanon reflected upon how psychiatry supported colonial regimes by pathologizing rebellious “subjects” fighting for freedom, as in Algeria [2]. Similarly, in the United States, tying the quest for Black civil and social rights to clinical insanity led to the yawning racial disparities of schizophrenia, leading it to become “the Protest Psychosis” [3]. In areas of gender and sexuality, psychiatry trafficked in misogyny by its reliance on the trope of the schizophrenogenic mother [4], while its pathologization of homosexuality lent systemic homophobia the veneer of respectability for decades—with a contemporary echo with the diagnosis of “gender dysphoria” [5]. Today, our patients disproportionately fill jails and prisons, and often live in tenuous social conditions, as the profound failures of our structures of care fester.

The disquieting social-political role of psychiatry through recent history is enough to drive outright nihilism about the field I now enter. Will I—but a humble intern—have the moral courage to negotiate ethical challenges when so many legendary psychiatrists have failed? Will I lose my way amid real darkness?

In these moments of doubt and fear, I try to nurture the spark of hope that I have about a career in psychiatry. Somewhat paradoxically, my exposure to history has been a source of optimism about our field. Far from encouraging fatalism, history has taught me to recognize the openness of the future. It has taught me to identify the concrete impact that individuals and communities have to—quite literally—alter the course of history, for ill yes, but also for good. In hearing my co-interns speak passionately about how they think about psychiatry’s role in supporting patients’ personal and social liberation, I cannot help but be sanguine about the future of our field. We imagine a psychiatry committed to using the lessons of the human sciences to pursue redistributive justice and structural advocacy, earnest community engagement and antiracism, expanded access and inclusivity, and economic solidarity with our patients.

A commitment to learning from the social sciences will enable our field to respond to the needs of our patients in ways that palliate suffering, rather than exacerbate it. Granularly, departments can cultivate ethical responsibility by means of regular morbidity and mortality conferences and Grand Rounds lectures that engage community and patient groups. They also can make deep change by facilitating and even incentivizing engagement in patient advocacy efforts by their faculty and residents. In medical education, residents’ didactics can have a social science thread, with lectures in the history of psychiatry, structural determinants of mental health, and psychiatric ethics and the law. Their journal clubs can read not merely the latest developments in psychopharmacology, but also works exploring the social dimensions of patients’ lived experiences. To accomplish this, programs can leverage the expertise of faculty in non-clinical academic departments, as well as embrace the rich experiences of local community partners.

I do not think this vision is Pollyannish. Because our future is open, we as clinicians define what psychiatry is, for ourselves, for our patients, and for broader society. We can nurture a humanistic psychiatry by holding each other to the high social and ethical standards that our patients deserve. Their social existence can be our north star. Though some anxiety lingers about navigating those first nights as a newly-minted psychiatrist, I can confidently take my first few steps by orienting myself to their brilliant light.