|Martin Vargas, FEARP.|
Crisis (from Latin crisis, and that from Greek, κρίσις krísis): profound change with important consequences in a process or situation, or the manner they are appreciated (dictionary of the Real Academia Española).
The celebration in Madrid, next July, of the 13th World Congress of Psychosocial Rehabilitation, coincides with a triple crisis: epistemological, economical and inter-subjective.
Psychiatry, as focused in the biological level of the reality, has delivered less fruit than expected. The promissory “Decade of the brain” said goodbye at the turn of the millennium accrediting low clinical results. At the same time, genetic studies in psychiatry have clashed with the ambiguous wall of epigenetics, where the mechanistic causality characteristic of chemistry becomes diluted in the unpredictable world of life. Psychiatry suffers a profound epistemological crisis, some of which symptoms are the polemic DSM-V versus RDoCs, or the proliferation of divulgation essays opposing psychoactive drugs prescription. Although only indirectly, psychosocial rehabilitation, which is closely attached to the peremptory social and service-providing necessities of people with severe mental disorders, has participated in this crisis too. The fact that schizophrenia is still predominant in the highly developed industrialized societies and in urban areas hurts the pride of the psychiatry as a science. The human being, as a biographical being, even in the state of extreme fragility and suffering, seems to escape from the positivistic fishing nets. Therefore, psychiatry appears at 2018 as a disarmed giant in front of his main adversary.
The economic crisis, lasting a decade in Spain, has deepened social differences and has diminished in a disturbing way the capacity for economic and civic reaction of the middle classes and of the poor or at risk of poverty. People with severe mental disorders have especially suffered from this socioeconomic drop. Furthermore, one of the main achievements in contemporary spanish politics, the right for a wellfare protection when a state of personal dependence is suffered, is undergoing a praecox involution. The Act 39/2006, December 14th, of Promotion of Personal Autonomy and Attention of People in a Situation of Dependence was conceived, as its headline proclaims, for the promotion of the autonomy of people at risk of dependence. The state economic help to the family core of the dependent person was an operative tool for the exercise of the right to protection. The capitalization of dependence carried a risk of commoditization that seems to be taking place. Nowadays not only people with severe mental disorders are an element of the psychiatric-drug commerce, but also an element of the rising socio-sanitary market too. If the professionals do not make a correct use of the economical resources invested by the State in the Dependence Act, this can become an “objectifying” risk for the patients instead of an ally for recovery and personal development. A rigorous scientific research of the adverse effects of psychosocial rehabilitation and of the differential aspects of the different clinical and socio-sanitary practices is still pending.
In the field of psychosocial rehabilitation, inter-subjective relationships are complex and nuanced in a special manner. As referring to a clinical relationship, the general frame can not be other than that of medical compassion, which in the general ambit of medicine has developed from paternalism towards a democratic relation. Compassion emerges from the radical inter-subjectivity of the human being in virtue of which the “Me” is no more than one of the perspectives of the “Me- you” dialogic core and the “he” is a projection of the “Me” and nothing more. This “Me – you – he” system can be paternalist, authoritarian or democratic depending on the values that animate it. Furthermore, in psychosocial rehabilitation the inter-subjective relational system includes other perspectives beyond the mere medical one: cognitive, functional, labour, vocational, citizen and other. In the new millennium, this relational net has experimented deep changes: “first person” movements, alliances between families associations and the pharmaceutical industry or the renaissance of antipsychiatry, to take in account only some examples. In medicine, an evolution has occurred from paternalism to the autonomy of patients, and it has gone even further in psychosocial rehabilitation. Today, in a kind of “nietzschean” experiment, the “value of madness” is claimed today. At a time, technical knowledge is under suspicion as a kind of authoritarianism. Up to what point must psychosocial rehabilitation be an emancipating praxis, beyond the axiological health frame, is still waiting for a consensus.
Therefore, the epistemological crisis of psychiatry seems no more than the shadow of deep changes occurring in the social, economic and politic system implied by the potentially disabling mental disorders.
A crisis is a profound change with important consequences. Whether these consequences are problematic or fortunate strongly depend on the course determined by the acting agents: patients, families, professionals, civil society and the State. As an alternative to the “objectifying alienation” of the affected people, who could become mere instruments of the pharmaceutical and socio-sanitary markets, the hope of a society of people structured around dignity can be conceived. The dignity of the person seems a good utopia acting as the key for a meaning. Recovery from a severe mental disorder is not only a return to actively participating in society or recovering the capacity for an autonomous life. To recover oneself is to reconstruct oneself knowing that you are worthy of it. The intrinsic value does not change in a person whether healthy or recovered, as well as in an artwork whether original or rehabilitated. It would be a good idea for all the implied agents to line up towards this maxim: recovering oneself is the art of recovering the personal worth. Let’s recover ourselves as people overcoming disease, as professionals, and also as economic and social agents. Let’s reinvent ourselves in Madrid, July 2018!
Martin L. Vargas, MD