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

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.