UN Special Rapporteur Dainius Pūras: Biomedical Approach “Still Has an Important Role to Play”

Jon Sedarati, MSc
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Earlier this year, the United Nations published a new report by Special Rapporteur Dainius Pūras. The report expands on a 2017 publication (also authored by Pūras), which called for “little short of a revolution in mental health care” to overturn the prevailing biomedical paradigm.

Highlights

Pūras begins by summarising some of the major issues he raised previously:

Mental health systems worldwide are dominated by a reductionist biomedical model that uses medicalization to justify coercion as a systemic practice and qualifies the diverse human responses to harmful underlying and social determinants (such as inequalities, discrimination and violence) as “disorders” that need treatment.

Addressing the consequences of medicalising misery (and other psychological experiences), the report goes on to state:

Medicalization deflects from the complexity of the context as humans in society, implying that there exists a concrete, mechanistic (and often paternalistic) solution. That reflects the unwillingness of the global community to confront human suffering meaningfully and embeds an intolerance towards the normal negative emotions everyone experiences in life.

Pūras later describes how psychiatry has neglected the principle of primum non nocere (or “first do no harm”):

Unfortunately, the burdensome side effects resulting from medical interventions are often overlooked, the harms associated with numerous psychotropic drugs have been downplayed and their benefits exaggerated in the published literature. (Emphasis added)

A common tactic used by proponents of (and apologists for) the status quo is to dismiss these kinds of criticisms as “anti-psychiatry.” In defence of said critics, Pūras writes:

It is troubling to see such voices dismissed by the conventional (and dominant) psychiatric profession and its leadership. Those who speak against coercion and support the view that alternatives are safe are not unethical, negligent or derelict in their duty of care, neither do they represent “anti-psychiatry.”

“The biomedical approach . . . still has an important role to play”

Occasionally in the report, Pūras uses words such as “overdiagnosis” and “overtreatment,” implying that a degree of medicalisation is appropriate. This seems at odds with his message to move beyond the biomedical paradigm.

In Pūras’ 2017 report, it clearly states:

The urgent need for a shift in approach should prioritize policy innovation at the population level, targeting social determinants and abandon the predominant medical model that seeks to cure individuals by targeting “disorders.” (Emphasis added)

However, on page 8 of the 2020 report, instead of abandoning the medical model, Pūras claims that “The biomedical approach to mental health conditions still has an important role to play” (emphasis added). It is unclear what role Pūras sees psychiatry playing, if not that of enforcer and drug dispenser.

In a recent interview with Mad in America, Pūras made some similarly conflicting statements. For example, he remarked that “It’s not about denouncing the biomedical model” and that there is an “overuse of the biomedical model and biomedical interventions” (emphasis added). Later in the same interview, however, he said “we have to abandon medicalized ways of addressing mental health conditions” and recommended “thinking of systems of support and care for people instead of diagnosing them.”

What is the biomedical model but a form of medicalisation—of the sort that Pūras recommends abandoning? There is a big difference between less emphasis on the biomedical model and calls to abandon it. Pūras seems to want both. Perhaps the former, more diplomatic approach, will help bring about the latter outcome. But it could also be argued that by refusing to call a spade a spade, by refusing to recognise that psychiatry is built on sand, the field’s lifespan will be needlessly prolonged.

Limbo

At the 2018 IFTA World Therapy Congress, I argued that the field of psychiatry is fundamentally superfluous. For those in need of psychological support, psychosocially oriented practitioners (e.g. therapists, social workers) can help (in addition to exercise, team sports, dietary changes, meditation, volunteer work, acting, workbooks, etc.). If an individual’s issues are biological in nature, then neurologists—doctors who actually treat pathologies of the human nervous system—can offer their expertise. Obviously, these options are not mutually exclusive; people grappling with a mix of psychosocial difficulties and neurological impediments may benefit from contact with both fields.

The problem with psychiatry is that it resides in limbo between the psychosocial realm and the field of neurology. It defines itself as a “medical specialty,” informed by neuroscientific and genetic research, dedicated to treating genuine brain diseases. But as psychiatrist Thomas Szasz wrote decades ago, “If all mental illnesses were shown to have organic causes, then all of them would be replaced by hitherto unknown bodily illnesses.” Psychiatry’s quest to discover the biological determinants of “mental illness,” then, is one that, if successful, would destroy the field. Its end is unlikely to come about this way, though, since “the existence of a disease of mental illness has never been established or satisfactorily defined” (emphasis in original).

Psychiatry functions as a means to coerce clients and prescribe pills. Interestingly, the majority of these pills are prescribed by general practitioners. And it’s not as if they have any less understanding of how these pills work than psychiatrists—many of whom haven’t a clue how to safely withdraw clients from the drugs they prescribe. Therefore, for those wanting to continue taking psychiatric drugs (voluntarily), abandoning psychiatry would not necessarily prevent them from doing so. Likewise, people with neurological pathologies—the real ones (e.g. brain tumours, Alzheimer’s disease)—would not be deprived of support from neurologists and other medical specialists. If anything, there would be more of them; since the medical students who would otherwise choose to specialise in psychiatry would opt for an alternative specialty, one based on valid science. This is exactly what has happened.

A 2016 study reported a 10 percent decline in the median number of psychiatrists per 100,000 in the US between 2003 and 2013. This coincided with a 16 percent increase in the median number of neurologists per 100,000. Recruitment problems in psychiatry are not unique to the US. As I noted in a previous article, the Royal College of Psychiatrists sees “recruitment into psychiatry at a crisis point.” In England, psychiatrist vacancies have doubled in four years. And several other European countries have reported that too few medical students are entering the field. Commonly cited reasons by medical students for not pursuing psychiatry include “poor prognoses” and a “lack of science and evidence base.” In sum, regardless of whether psychiatry is ever formally disbanded, students have already begun voting with their feet.

Interlude

Remember that scene from the 1999 comedy, Office Space, wherein an incompetent office worker is incapable of explaining his purpose at the company—the one to which the classic line “What would you say . . . you do here?” is directed?

An analogous conversation with a psychiatrist might go something like this:

Interviewer: What you do as a psychiatrist is you meet with people who are having psychological difficulties.

Psychiatrist: Yes, that’s right.

Interviewer: So, you work with them to explore their issues and help them solve problems?

Psychiatrist: Well, no. I usually refer them to a psychotherapist for that.

Interviewer: Well, then, I just have to ask: Why couldn’t they just meet directly with a psychotherapist?

Psychiatrist: Well, I’ll tell you why: Because . . . psychotherapists are not good at diagnosing mental illnesses and can’t prescribe psychiatric drugs.

Interviewer: So, you actually conduct tests that objectively establish whether or not an individual has a brain illness?

Psychiatrist: Well . . . no. I have a neurologist do that—or other medical specialist.

Interviewer: So then, you must treat the people who are confirmed to have neurological diseases with the drugs you prescribe.

Psychiatrist: Well . . . no. I mean, I treat the ones that don’t have neurological diseases.

Interviewer: What . . . what would you say . . . you do here?

Psychiatrist: Well, look, I already told you. I deal with the goddamn mental illnesses so the psychotherapists and neurologists don’t have to. I have specialised medical skills! I’m good at diagnosing and prescribing! Can’t you understand that!? What the hell is wrong with you people!?

Interviewer: . . .

Afterword

Pūras’ comment about psychiatry still having an important role to play contrasts starkly with his fervent opposition towards the field’s coercive practices and zealous use of drugs. If Pūras gets his wish and psychiatrists abandon these practices, how will they be spending their time? We know that there are few psychiatrists willing to offer psychotherapy to all of their clients. Taking drugs and coercion off the table would perhaps leave them no choice but to provide therapy. In this scenario, though, it’s hard to imagine what the title “Psychiatrist” would even mean.

Psychiatrists are defined by their ability to dispense pills ostensibly designed to treat diseases of the mind. Take that away, along with their right to coerce, and what is left?

Editor’s Note: To view the complete list of footnotes, click here.

***

Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

26 COMMENTS

      • Psyche is not a model, it is a forgotten perspective. Polytheistic reality is not a box, it is a map stolen by monotheistic culture. We must have a psychological map to talk about where is ego. There is a difference between simple rational archetypes and the psychological reality. For psyche, for polytheistic reality, psychosis is a proper language. And rationalism or fixation over ego control is a fallacy.

        The problem is that, for monotheism, psyche perspective does not exist. That is why it is so important to write about James Hillman. His perspective, polytheistic one, is a proper perspective. We can’t talk about psyche without psyche. Theology, religion, spirituality, materialism, science and nature are not the psyche. Without psyche, each of these perspective is an anti psychological fundamentalism. It is so important to read about archetypal psychology. Psyche is psyche, the word belongs to pagan mythology, itself. Not to religion, medicine or materialism.

  1. As long as we use the words “over”-“diagnose”, “over”-“MEDICATE”….and the word “medicate” is of course the big lie. Within psychiatry and surgery, the word is “drugging”. A surgery is never performed while being “medicated”.
    I can imagine that Dainius Puras is aware, but is pushed to use those words since he is hoping that his message will lead to change. He is most likely trying to stay away from being too “radical”, after all he has all the shrinks and the WHO on his back.
    The language he is having to use is because he would not even have a seat at the UN if he used the truth.
    All he can do is engage with other shrinks with the pretentious “over” words, with the shrinks pretentiously agreeing and then back to regular practice under the guise that it was, this time, “medically” needed.

    I’m glad he speaks up but at his stage of the game I think he’s got zero to lose by calling out psychiatry for exactly what it does. He knows people are being hurt but I guess he thinks being hurt a little is better than being hurt a lot or killed. But that “little hurt” has been minimized too long.
    Psychiatry is in the business to hurt, defame, slander people in ways where they mean less than a pound of pork.

  2. Interlude.

    Office Space is funny but ……

    https://www.youtube.com/watch?v=poMWgGC82bw

    Notice the assumption that someone who is speaking the truth a psychiatrist doesn’t like is going to be violent? “That chair is screwed down with large screws isn’t it?”

    Puras lives in a place most of us think of as science fiction. So far out of touch with reality he may as well be on a space ship. I say we simply stop listening when the Generals talk. It’s worked for them with ‘us’.

    And since when did being anti psychiatry become the equivalent of ‘Aryan diluted’? They need a way within the ‘Party’ to describe people whose purity is in question? They might even start thinking for themselves Mr Orwell? And consider that what is being discussed is supposed to be a ‘field of medicine’ and yet it sounds suspiciously like a totalitarian political Party meeting. And as gatekeepers of ‘therapy’ and ‘medicine’ they wield precisely the sort of power we have seen in the past turn really sour, really quick.

    Boans wanders off into the bush singing along with John Lennon’s Gimme Some Truth and realises the One thing I can’t hide is that I’ve been crippled inside……. deliberately. That’s real power when the State can afford to do that to it’s citizens.

  3. Jon, you are jumping to conclusions. Wait…that gives me an idea for an invention…https://www.youtube.com/watch?v=sDEL4Ty950Q

    I really appreciate the great work you do. Thank you for contributing this article. The reference to one of my favorite movies was great. “What . . . what would you say . . . you do here?” That is a good question.

    I think one take-away message is that as long as any amount of biomedical model/psychiatry exists, it will cannibalize everything else in it’s sphere of influence.

  4. Thanks Jon for this report and all the work you do. This step backwards is very disconcerting. I agree with Sam and Oldhead in that Professor Puras must be under pressure to conform. The saying “you attract more bees with honey” is sometimes applicable when working to implement important change but can never work with psychiatry. Psychiatry’s vested interests have proven NOT to be in a patient’s best interests, but rather what’s in psychiatry’s best interests, and that is the maintenance of a very profitable livelihood through labelling and drugging (or ECT) with a no-brainer ‘one size fits all’ mentality. That’s all they’ve got and it has done far more harm than good.

    “But it could also be argued that by refusing to call a spade a spade, by refusing to recognise that psychiatry is built on sand, the field’s lifespan will be needlessly prolonged.”

    Yes, the longer psychiatry is not called out for what it really is, the damage and destruction of lives is prolonged.

  5. “…Psychiatrists are defined by their ability to dispense pills ostensibly designed to treat diseases of the mind. ..”

    We all know people that have recovered. Did they Recover through taking pills, or not taking Pills?

    As well as not taking Pills they would have utilised some type of “saving practise” – would this have been Psychotherapy or Something Else? I think Something Else.

    Most recovered people probably found their own way.

    *It’s important to only come off ‘medication’ VERY carefully.

  6. Oh, there’s room for biomedical models, all right, but not for psychiatric pseudo diseases like “schizophrenia”‘ “depression” and such, but for directly identifying underlying physical causes for the states that are thus “diagnosed” in psych terms, such as lead poisoning for hyperactivity and mania wherein the symptoms lead to the identification of the cause and correct treatment.

    • I had this image of all the people at Looney Gas (Standard Oil Refinery) being treated with the latest anti psychotics for years BCHarris. The insurance doesn’t pay out for ‘pre existing conditions’ which it would seem they brought with them to the Company lol Fortunately some real science was used in that instance and the genetic flaw in the employees established and they were sacked …… oh wait , that’s not what happened.

  7. Gotta remember boans, that I’m one of those weirdos who takes his niacin every day and avoids shrinks like the plague, knowing that they’d see vitamin consumption as the sign of serious pending delirium. I also read Forbidden Literature, in which “mental” illnesses don’t exist except as indicators for unusual physically based conditions- in fact, the Journal of Orthomolecular Psychiatry changed its name to the Journal of Orthomolecular Medicine a few years back- it’s third name change since it first appeared 60 or so years ago, I believe, and now devotes much of its space to such illnesses as HIV and ebola.

    • HIV and Ebola are mental illnesses now? Guess it just depends how you think about it really lol

      Seriously though, what ever happened to the right to bodily integrity? It’s a major concern for certain groups who seem to get slandered if they even mention that they might not agree with doctors. See for example the JWs and their refusal of blood transfusions. Or my people who do not wish to be intoxicated being ‘spiked’ with date rape drugs without their knowledge and having prescriptions written for the drugs hours after they were administered by doctors they hadn’t even met. A drug my brother went through Hell with now my “Regular Medication” without me even knowing.

      What I know from observation is that if the amount of mistakes that were made in my instance (and which resulted in what I believe to be a large number of unnecessary deaths) it is a wonder anyone comes out of their hospitals alive. The 26 “mistakes” or “errors” I documented and which ALL resulted in these matters going unnoticed (plausible deniability contained within acts of negligence) is statistically 26 X 25 X 24 X …….. its a rather large number. And yet I have met so many others who meet such a statistical anomaly. Still when your busy counting your money, you’ve no time to count the dead.

      It would seem Stormin Norman and The Chief Psychiatrist have something in common, they don’t do body counts of the enemy.

      • No, they aren’t “mental illnesses”, but understanding their chemistry and proper nutrient therapy can provide a useful means of dealing with them, particularly since they’re considered incurable, like “schizophrenia” and “depression” still are.

  8. I agree with you, Jon, as I imagine most of us do.

    What if Pūras wants to “appropriate” psychiatry into a field that specializes in simple biomedical testing, things like thyroid panels, Vitamin D/Iron/B12 testing? I would personally love to see this (because I think most psychiatrists would just quit).

    Or, what if Pūras has been threatened or lured with ruin or money from the system? I would not be anywhere near shocked.

    Thank you for reporting on this. I hope my first guess has some weight to it. I’ll keep praying like a “delusional” Christian, in any case!

    • KR,
      And that happens now by physicians who, if they cannot locate a problem with the rudimentary science we have, prescribe psych drugs and by doing so, also “diagnose” you. So it seems that we do not need psychiatrists at all, since physicians “diagnose” people with “MI” daily.
      They are also starting to prescribe psych meds for chronic conditions, which really is saying that
      “we don’t want to be bothered having to deal with the chronic condition and if we give you psych meds, then it makes it seem as if it’s in your head, which in turn dirties your charts and leads to invalidation about the chronic issues by every other provider, specialist, nurse, and even by the massage therapist”

      There are a lot of “tests” that detect only very obvious problems, and a lot of conditions that cause suffering, which “medicine” has no help for. Medicine in general is tired of the lack of knowledge and ability to deal with illnesses, so along with palliative care, come the “I give up drugs”.

      My father lay suffering and dying and was given AD’s during his last six weeks, whereas he had never dealt with psychiatry or drugs, ever. It is very sad to see a man dying and have that dying face be pumped with AD’s.
      I doubt Jaffe swallowed AD’s for his suffering. In fact he died at home and I won’t open that can of worms. It is interesting to note that rarely does an MD die in hospital. He does not get the same treatment that the idiot public gets.

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