Western countries are being hit by an epidemic of poor mental health, and extremely strained health services are beginning to show their weaknesses. Something is wrong, says psychiatrist and epidemiologist Jim Van Os (Utrecht, Netherlands, 63 years old): “The more we treat, the worse off young people are,” says this doctor, director of the Department of Psychiatry and Psychology of the university is Utrecht University Medical Center and professor at the University of London. Van Os has been questioning the foundations of modern psychiatry for years, proposing a shift toward truly “biopsychosocial-existential” care, in which the patient’s experience is at the heart of a highly individualized therapeutic approach.
Visiting Barcelona to take part in a seminar organized by the Doctoral Program in Clinical and Health Psychology of the Autonomous University of Barcelona, Van Os recounts how, since his time as a medical student, he has been obsessed with the “difference theory of psychiatry and patient experience”. His personal experiences with very close relatives suffering from psychotic symptoms, far removed from what he learned in college, shaped his perspective on the profession and caring for patients.
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Questions. Have you managed to connect what you learn during your studies with your experiences as a patient?
Answer. There are two types of knowledge that we work with today: knowledge about the experiences of users and knowledge from psychiatry and psychology, which are still in search of the hypothesis about the mind, used to study the phenomenon of mental variation must. What we see in the field of mental health is that the experience of the people who work with it matters; The techniques and their drugs are not as important as we thought. The number of psychiatric illnesses is increasing in European countries, it is alarming. In Holland they have doubled in the last 15 years and we have an army of psychologists and psychiatrists, but there is a paradox: the more we treat, the worse off young people are.
Q Why is this happening?
R. It is collective, not individual, forces that lead to an increase in psychological distress. It is like in cardiology, for example, that we know that if the population has poor nutrition, there is more cardiovascular disease and cancer. We learn that the social and existential climate in which young people live has an impact on their psyche that makes them feel bad.
Q But why now? If the environment has always had an influence, why are mental disorders increasing now and not 20 years ago?
R. What the research – and young people – say is that there is a climate of competitiveness: success is a choice, and if you don’t succeed, you’ve made the wrong choice, you’re a fool. And there is also a climate of isolation, because although there are more contacts in social networks, the paradox arises that this does not lead to more connection, but to more loneliness. And there is also more surveillance: people are afraid of not appearing normal, because if others perceive you differently, you feel bad. For young people, these forces make them feel bad.
Q Why is feeling different so powerful?
R. Being different from others is very harmful to mental health. Because we need to feel connected to others. We are social animals. Our entire biology develops through connection with others and in the first ten years of life there is a bonding process that will determine your social relationships and with yourself throughout your life.
“The social and existential climate in which young people live influences their psyche and makes them feel bad.”
Q You started by saying that psychiatrists are still studying the mind to understand mental health problems. So is the first piece of the puzzle missing?
R. Yes, about what the mind is. We have solved the problem of ignorance of the mind by saying that there are diagnoses. For example, if you say that you have schizophrenia, there is no need to know people’s actual mental processes and experiences. But now we are more ambitious because scientifically these diagnoses don’t work because they don’t capture people’s experiences. There is too much heterogeneity and variation for people to be assigned to one diagnosis. And now we attempt the impossible: to understand the mind through the phenomenon of consciousness. We think that consciousness is probably affective at its core: during the day, right now, we are experiencing things and every time we do so we have a good or bad affective signal. And we think that the affective signal alerts us to ourselves in the environment.
What we have proposed is a mental model of psychological suffering and not a diagnosis because the experience no longer appears there. In this way we can understand and study recovery phenomena much better: people who have a very negative mental state, who hear voices, we know that they are able to recover. We can help people put the experience into perspective, view it from a distance, think about it, talk about it, and analyze it so that they can feel more empowered.
Q But that’s part of the treatment, right?
R. Yes, but from a different model. The problem is that psychotherapy and medication are protocolled and follow a manual, but are not based on people’s experiences. It helps, but it could help even more, because individually there are big differences between each patient and we should not standardize but individualize.
Q There is a tendency in medicine to standardize and order knowledge and the way we deal with patients. Isn’t that possible in the mental health field?
R. Psychiatrists and psychologists have said that the mind is something that we can predict and analyze for cause and effect in linear science, but we are learning that this is not the case, it is something more complex. We have not managed to find the cognitive and biological mechanisms, we have not found the causes, we have not found biomarkers… The mind is something else and the science of complexity is the science of unpredictability, that there is no cause Consequence: There are interactions between thousands and thousands of causes that change over the patient’s time.
Dutch psychiatrist Jim Van Os during a visit to Barcelona to attend a scientific seminar at the Autonomous University of Barcelona (UAB). Albert García
Q His position is to drop a bomb on the principles of modern psychiatry.
R. The bomb has already happened, it’s called Open Science [ciencia abierta]. A few years ago there was a paper in Science that tried to reproduce the basic knowledge of psychology and found that it could not be reproduced, only 30%. And in biological psychiatry we had exactly the same problem: the results published for 30 years are not being replicated; But this is also science and will help us develop something better.
Q But the treatments worked and many people with mental health problems were cured.
R. Work. But not in the way we think they work, but for a different reason. For example, metascience has found that the 250 psychotherapies work well, but not because of the therapeutic schemas, but because of the ritual function within the relationship. You develop an emotional bond with the person. And what you create within the relationship is the motivation to change. And if the ritual is compatible with the patient’s view of the world, it works.
Q So is it a question of faith?
R. It’s a question of relationship. A relationship that creates motivation and ensures that the person has confidence in their abilities. I rarely use antidepressants because there is more and more open science about their effects and we think they don’t work very well. There is probably a small group of people who respond very well and that is why there is a signal in the randomized clinical trials, but in the vast majority it has no effect.
Q And do you think this happens with all psychotropic drugs?
R. We see that lithium and antipsychotics play a better role than antidepressants. But we are increasingly critical of the chronic prescribing model because we do not understand the brain changes caused by medications and chronic use. We used to say that you have to give antipsychotics all your life, and now we say that after six months or a year you have to try to reduce them and teach people to manage the vulnerability.
In psychiatry, we medicalize the patient’s narrative story from the beginning.”
Q Are you learning to face your symptoms?
R. Within the mental model, people understand psychotic processes because they learn to view what is happening with more distance. The problem is that before we thought it wasn’t possible, hence the chronic prescription model. In Holland I see people who have been taking paroxetine and sertraline for 30 years [dos antidepresivos] and they cannot stop and ask themselves: Who am I without the medication and where are the traumas that I tried to suppress with it?
Q Has too much been prescribed?
R. Yes, that happens with all medications that medicalize too much. This is even more the case in psychiatry because we medicalize the patient’s narrative from the start. We translate their experiences into a book with 400 diagnoses, but the person feels poorly cared for. This is called hermeneutic assimilation: you take the person’s experiences and place them in a different framework that is not theirs.
Q In 2016 you published an article in the BMJ with the suggestive title: “Schizophrenia does not exist.” What did he mean?
R. I said that because there are psychiatrists who really believe that there is a nosological category that is schizophrenia, they believe that there is a disease that is schizophrenia, but what is written in the DSM [el manual de clasificación de trastornos mentales de la Academia Americana de Psiquiatría] These are rules for communication between psychiatrists, but they are not the diagnosis of an illness.
Q But why do you say that it doesn’t exist? We citizens have always been told that there is a disease called schizophrenia, another called bipolar disorder, etc.
R. Mental suffering is real, it exists, but what doesn’t exist is categorization. We tell the population that schizophrenia exists, but what there is and what is scientifically proven is the susceptibility to developing unusual ideas and hearing voices when stressed. It is a vulnerability, a sensitivity. Why don’t they introduce a new diagnosis into the DSM-5, namely psychosis susceptibility syndrome? That would be completely different because it tells people that we are all sensitive and that when we are stressed one starts drinking, another feels anxious and another becomes psychotic. We should talk not about illnesses but about vulnerabilities and tell people that the appearance of symptoms when stressed is a sign that one needs to learn to manage the vulnerability.
Q Does a name change change the stigma?
R. You don’t need to change the name, but the concept. The concept refers not to a disease but to a susceptibility that we all have, and genetic evidence confirms that we all carry thousands of genetic variations that predispose us to schizophrenia, some more than others, but we all have them , because they are variants that contribute to our performance. Unique way to make sense of the environment. The mind gives affective meaning to the environment, and psychosis gives too much meaning.
“We all carry thousands of genetic variations that predispose us to schizophrenia.”
Q Can we all experience this vulnerability and some spectrum of psychosis?
R. We have found that there are many people who have psychotic experiences, they hear voices that something bad is happening. And it’s very human, completely normal, to have thoughts like that. The problem with psychosis is that you end up in a state in which there is no longer any way to keep your distance. Psychosis means not having voices, but allowing the voices to become so strong that you can no longer have any distance from the experience.
Q What role do genetics play in mental disorders? Or is it just an emotional environmental issue?
R. The genetic findings show that, for example, in neurological diseases all genetic factors are involved, but that they do not overlap with each other and that there are only a few genes and a few variants. In psychiatry it is completely different: the genetic variation overlaps between different disorders such as autism, hyperactivity, psychosis, anxiety, depression… And the contribution is not as strong as we previously thought: 25% of the susceptibility to mental disorder is genetically determined. In addition, there are not just a few variants like in neurology, but thousands upon thousands. The bottom line is that the genetics of a mental health problem are the genetics of being human, the genetics that drive the ability to respond to the environment. So we believe that all these genetic variations enable us to survive by reacting to the environment with our consciousness, which is essentially affective.
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