Global Psychiatry’s Crisis of Values: Dainius Pūras, MD


From Psychiatric Times/Conversations in Critical Psychiatry: Awais Aftab interviews Lithuanian psychiatrist and human rights advocate Dr. Dainius Pūras, who served as the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health from 2014 to 2020.

Pūras: “The most worrying feature of psychiatry is that the leadership, under influence of hard-liners, tends to label those experts who blow the whistle and critically address the status quo as anti-psychiatrists. We know from many painful chapters in the history of psychiatry and medicine what happens with discoveries in biomedicine when they are disconnected from values and undermine human rights. They can become dangerous and harmful. And if influential psychiatrists continue to repeat that values are not a priority in mental healthcare, we should not be surprised that global mental health and global psychiatry is facing a crisis, which to a large extent is a moral crisis, or a crisis of values.

. . . Coercive practices are so widely used that they seem to be unavoidable, but I suggest turning our thinking and action the other way around. Let us assume that each case of using nonconsensual measures is a sign of systemic failure, and that our common goal is to liberate global mental healthcare from coercive practices. We should search, with concerted efforts, for creative ways to replace substitute decision-making with support according to an individual’s will and preferences. And this applies to all individuals with psychosis. If we do not move in this direction, arguments for coercion will continue to be used, and misused.

. . . I think that not only mental health, but also physical health should be reasonably de-medicalized. Excessive biomedicalization, with some tendencies towards new eugenics, is threatening the entire health sector and health care systems. Psychiatry and mental health are in a good position to remind the rest of the medical world that medicine is actually a social science, a sentiment expressed famously by Rudolf Virchow, MD.

. . . the rise of movements of users and ex-users of mental health services is one of most impressive and promising signs of change in global mental health. I would compare their activism with activists who were fighting and continue to fight for the rights of women or for the rights of people of color. Individuals with psychosocial disabilities are discriminated against globally, and they are discriminated within and beyond mental health services. I think that the time has come to end this discrimination and to support this group that has been oppressed for so many years and in so many brutal ways. To a large extent, they continue to be discriminated against within mental health systems, because both laws and practices have created huge power asymmetries between providers and users of services. What is often called the radicalism of the movement is that they insist on ending this legacy of discrimination. Psychiatry has not yet seriously addressed this request. As has happened in the rest of medicine, psychiatry should agree that the time has come for partnership and collaborative relationships between 2 groups of experts: professionals and experts by their lived experience. This partnership should replace the outdated paternalistic view that the psychiatrist is the expert who knows what is best for the patient.

. . . during my travels, I met individuals who use or have used mental health services and who shared their personal experience. The most impressive and painful testimonies were the ones I heard from women, and they often had very similar stories, despite being from very different regions. Usually, the story is that the woman is brought by relatives to see a specialist because of some mental health condition, and at some point she starts to realize that she is alone among strangers, and she starts to insist on going home. But then she is told that the decision has been made that she needs inpatient treatment for her mental health issue. And then, after her desperate attempts to disagree, she is subjected to involuntary measures. When subjected to restraints, she feels the same way she felt when she was raped 1 or 5 or 10 years ago. And then some of these women would implore me, please tell the psychiatrists and other staff in psychiatric facilities to stop doing this.

And so, quite often, during numerous meetings with representatives of psychiatry, I would share this story. Reactions were different. Some would take this seriously. But the reaction of many professionals, including academic psychiatrists, was that we should not take what psychiatric patients are saying seriously, and that the intentions of involuntary measures are always good, so it is wrong to see parallels between them and rape. If such a willingness to discount the feelings and testimonies is widespread, I cannot help but think that psychiatry is really in a serious crisis.”

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  1. I have a lot of respect for Dr Puras work at the UN, however I want to point out that the tarnishing of antipsychiatrists as a homogenous group is no different from doing the same with psychiatrists and so the distancing from antipsychiatry as a rule is flawed.

    My AP position rests upon the fact that the DSM is so fatally flawed as to not be useful in any way. This is backed by government health agencies ceasing using it as well. Secondly, psychiatry’s fatal flaw is the “treatment” of mental distress with adjusting brain neurochemicals. These two positions are, in fact, evidence based. This leads me to be antipsychiatry. That Psychiatry is mostly concerned with controlling behaviors and pathologizing the normal expected responses to trauma is the nail in its coffin.

    However, this does not mean that AP principles are fundamentally against the connection between mind and body. Although some extraordinarily strident AP individuals insist the mind is an abstract construct with no ability to be ill, this is not necessarily the position of those AP individuals with a more nuanced view of the mind-body connection.

    There is, of course, ample evidence that microbes, for one example, play a major role in producing extreme and unwanted mental experiences. The fact that siphyllis produces psychosis should be enough evidence of such, but there is also a strong connection between Bartonella and schizophrenia diagnosis. There is PANS/PANDAS following streptococcal infection, which is strongly associated with OCD diagnosis. There is abundant evidence between Lyme disease and depression, panic, depersonalization/derealization and hallucinations.

    Outside of infection, there are of course, nutrient deficiencies, various stressors (of which traumas can be included), genetic conditions, cognitive conditions, etc. All of which can be associated with decreased psychosocial functioning.

    So when I hear professionals distancing themselves from AP persons and positions it makes me a little sad because there is so much room for actual medicine to be practiced to relieve suffering, and yet many Psy professionals become more deeply entrenched in what isn’t working – adjusting brain chemicals – when what we need is authentic medical care for authentic medical conditions as well as better social care to address stress/trauma related struggles.

    I don’t even believe there is no room for force. I’m all for forcing stroke patients to receive medical treatment, just as I was when my own father was threatened with arrest if he didn’t get in the ambulance. Under very specific circumstances, force can mean the difference between recovery and not. I have no trouble with detaining individuals threatening violence. The problem with forced psychiatric care is not that the individual has been detained but that they are then forced to receive neurochemical treatments rather than anything actually helpful.

    The real underlying issue then seems to be that doctors don’t like dealing with distressed patients and so those patients are diverted to psychiatry to control their distress when in reality if the doctors just did their job, they might very well alleviate the actual problem. Psychiatry is a bad marriage between medicine and social work, ultimately solving nothing in practical terms EITHER for the legitimately sick patient OR the distressed and stressed not sick person.

    The other issue, of course, is that curing illness is nowhere near as lucrative as creating perpetually ill patients. This is partially due to lazy doctoring but largely due to capitalist profiteering. If we researched the conditions and drugs we actually needed to cure, we’d be doing a MUCH better job in terms of keeping up with antibiotic resistance. But antibiotics are nowhere near as lucrative as blockbuster psych drugs. And because antimicrobials in general fall under this umbrella of neglected research, the infectious agents that lead to a great deal of mental distress are inadequately treated, turned into “syndromes” and psych drugged when all else fails.

    The one thing that gives me hope is the increasing recognition that Lyme disease (and many other microbial infections) largely become incurable (with modern treatments) once they reach the nervous system. The skyrocketing rates of infection mean enough people are dealing with these disabling conditions to create pressure on the medical system as well as politically to create forces for change. This has the ability, I believe, to fundamentally and radically alter the view of psychiatry’s current modus operandi – adjustment of neurochemicals – as more people become aware of the fact that this does nothing to correct underlying conditions. These drugs don’t eradicate microbes. They don’t address nutrient deficiencies. They don’t correct genetic code errors. They don’t solve social/environmental stressors. They don’t heal the effects of trauma. I sort of have this idea, heretical as it will sound to AP activists, that Psychiatry could redeem itself if it actually learned to practice medicine instead of social control.

    Sources for more information:–peer-reviewed-fulltext-article-IMCRJ

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