An epidemic of poor mental health is sweeping Western countries. Strained medical systems are beginning to fray. Something is deeply wrong, explains the psychiatrist and epidemiologist Jim Van Os.
“The more we treat, the worse young people feel,” reflects this 63-year-old doctor. He’s the director of the Department of Psychiatry and Psychology at the Utrecht University Medical Center in the Netherlands and a professor at the University of London.
Van Os has long been questioning the foundations of modern psychiatry. He proposes a shift towards truly “biopsychosocial-existential” care, where the patient’s experience is the center of a highly-individualized therapeutic approach.
Visiting Barcelona to participate in a clinical and health psychology seminar organized by the Autonomous University, Van Os spoke with EL PAÍS about how, since his years as a medical student, he became obsessed with the difference between “the theory of psychiatry and patients’ experiences.” His personal experiences with very close relatives who have suffered from psychotic symptoms — so far removed from what he learned in university — marked his way of seeing the profession and caring for patients.
Question. Have you managed to bring together what you learned in college with what your patients experience?
Answer. There are two types of knowledge that we work with today: knowledge related to the experience of users and knowledge about psychiatry and psychology – [two fields] which are still searching for the hypothesis about the mind that [can] be used to research the phenomenon of mental variation. What we see in [the field of] mental health is that what really counts is the experience of people working in it. The techniques and the medications aren’t as important as we previously thought. Rates of psychiatric disorders are increasing in European countries — it’s alarming. In the Netherlands, they’ve doubled in the last 15 years. We have an army of psychologists and psychiatrists, but there’s a paradox: the more we treat, the worse young people feel.
Q. Why does that happen?
A. There are collective forces — not individual ones — that cause rates of mental distress to increase. It’s like in cardiology: we know that if the population’s nutrition is poor, there are more cardiovascular diseases and cancer. We’re learning that the social and existential climate that young people are living in is doing something to their minds that causes them to feel bad.
Q. But why now? If the environment has always had an influence on people, why are mental health disorders increasing now and not 20 years ago?
A. What research — and young people — say is that there’s a climate of competitiveness: success is a choice and, if you’re not successful, you’ve made the wrong choice, you’re a fool. And there’s also a climate of isolation because, while we have more contact on social media, the paradox that occurs is that this doesn’t result in closer ties — only in more loneliness. And there’s also more scrutiny: people are afraid of not appearing normal, because if others notice [that you’re different], you feel bad. For young people, these forces make them feel bad.
Q. Why does feeling different have such an impact?
A. Being different from others is very bad for mental health, because we need to feel connected to others. We’re social animals. Our entire biology has developed by being linked to others. During the first 10 years of life, you have a bonding process that will guide you and your social relationships throughout life.
Q. You mentioned that psychiatrists are still in the process of understanding the mind to be able to understand mental health problems. Is the first piece of the puzzle missing, then?
A. Yes. We’ve solved the problem of not really understanding the mind by saying that there are diagnoses. For example, if [someone has] schizophrenia, there’s no need to understand the real mental processes and experiences that [they’re going through]. Now, on the other hand, we’re more ambitious, because, scientifically speaking, these diagnoses don’t work, because they don’t capture people’s experiences. There’s too much heterogeneity, there are too many variations [in mental illnesses] for people to fit within one diagnosis. So now, we’re trying the impossible: understanding the mind through the phenomenon of consciousness. What we think is that consciousness is probably, at its core, affective. During the day, we’re experiencing things and, every time we do so, we have a good or bad affective signal. And what we think [in the field of biological psychiatry] is that the affective signal makes us self-aware.
What we have proposed is to have a model of mental suffering and not a diagnosis, because a [patient’s unique] experience doesn’t appear [in the latter]. This way, we can better understand and research the recovery phenomena. [We need to keep in mind] that people who have a very negative mental state — who hear voices — are capable of recovering. We can help patients relativize and look at their experience from a distance, to think about it and talk about it and analyze it, so that they experience more empowerment.
Q. But this is already done as part of treatment, right?
A. Yes, but from a different model. The problem is that psychotherapies and medications are protocolized. They follow a manual, but they’re not following people’s experience. [The current treatments] help, but they could help more, because, individually, there’s a big difference between one patient and another. We shouldn’t standardize – we should individualize.
Q. In medicine, there’s a tendency to standardize the way in which patients are approached. Can’t this be done in mental health?
A. In the past, psychiatrists and psychologists said that the mind is something that we can predict, but we’re learning that this isn’t the case, it’s somewhat more complex. We haven’t been successful in finding the cognitive and biological mechanisms, we haven’t found the causes [of mental illness], we haven’t found biomarkers… the mind is something different. And the science of complexity is the science of unpredictability: there aren’t simply causes and consequences. Rather, there are interactions between thousands and thousands of causes that change over a patient’s lifetime.
Q. Your point of view is like dropping a bomb on the principles of modern psychiatry.
A. The bomb has already [been dropped]. A few years ago, in [the journal] Science, there was a study in which they tried to replicate the basic knowledge of psychology. But they found that it couldn’t be replicated: only 30% of it could. And, in biological psychiatry, we’ve had exactly the same problem: the findings published for 30 years haven’t been replicated. That being said, [all of that science] will still help us develop something better.
Q. But the currently available treatments have worked and many people with mental health problems have been cured…
A. They work. But not for the reasons we think they work: it’s because of something else. Metascience has established, for example, that the 250 psychotherapies work well, but not because of the therapeutic schemes. Rather, they work because of the ritual function within the relationship [between patient and therapist]. You become emotionally attached to the person. And, within the relationship, what you’re causing is the motivation to change. And if the ritual is compatible with how the patient sees the world, it works.
Q. Is it a question of faith, then?
A. It’s a question of relationships: relationships that create motivation and give [patients] faith in their own abilities. I [rarely prescribe] antidepressants, because there’s more and more research about how they work, and we think that they don’t work very well. There’s probably a small group of people who have a very good response (as we see in the randomized clinical trials) but, in the vast majority of patients, [antidepressants] have no effect.
Q. Is this the case with all psychotropic drugs?
A. What we see is that lithium and antipsychotics play a better role than antidepressants. But we’re becoming more critical of the chronic prescribing model, because we don’t understand the brain changes caused by medications and chronic use. In the past, we said that you had to take antipsychotics all your life… and now, we say that, after six months or a year, you have to try to reduce it and teach people to manage their susceptibility.
Within the mental model, people understand psychotic processes, because they learn to look at what happens with more distance. The problem is that, before, we thought this wasn’t possible. Hence the chronic prescription model. In the Netherlands, I see patients who’ve been taking paroxetine and sertraline (two antidepressants) for 30 years and they cannot stop. They ask themselves: “Who am I without the medication and where are the traumas that I was trying to suppress?”
Q. Is too much being prescribed?
A. Yes. This happens with all medicine. In psychiatry, even more so, because – from the beginning – we’re medicalizing the patient’s narrative history. We transfer their experiences to a book with 400 diagnoses, but the person feels poorly cared for. This is called hermeneutic assimilation: you capture the person’s experiences and put them in a framework that’s not theirs.
Q. In 2016, you published an article in BMJ with a suggestive title: Schizophrenia does not exist. What did you mean by that?
A. I said that because there are psychiatrists who really believe that schizophrenia is a nosological category. They believe that there’s a disease that is schizophrenia. But what’s written in the DSM (the manual of classification of mental disorders put out by the American Psychiatric Association) are rules [that assist] psychiatrists as they communicate with each other… it’s not a diagnosis of a disease.
Q. But why do you say that it doesn’t exist? We’ve always been told that there’s a disease called schizophrenia, another that is bipolar disorder, and so on.
A. Mental suffering is real, it exists. But what doesn’t exist is categorization. We’re telling the population that schizophrenia exists, but what exists — and what has been scientifically proven — is a susceptibility to developing unusual ideas and hearing voices when there’s stress. It’s a susceptibility, a sensitivity. Why don’t they introduce a new diagnosis in the DSM-5, which is psychosis susceptibility syndrome? This would be totally different, because it would tell people that we all have sensitivities and, when there’s stress, one person starts to drink, another may feel anxious and another becomes psychotic. We shouldn’t talk about diseases, but about susceptibilities. We need to tell people that, if you have symptoms when there’s stress, it’s a sign that you have to learn to manage your susceptibility.
Q. Does changing the name change the stigma?
A. You don’t have to change the name — you have to change the concept. The concept isn’t that of a disease: it’s a susceptibility that we all have. The genetic findings confirm that we all carry thousands of genetic variations that predispose us to schizophrenia. Some [of us are more prone] than others, but we all have them, because these variants contribute to our unique capacity of being able to give meaning to our environment. The mind gives affective meaning to the environment, while psychosis [implies] giving too much meaning.
Q. Does this mean that we can all experience that susceptibility and be on some spectrum of psychosis?
A. We’ve detected that there are many people who have psychotic experiences: they hear voices, they [feel that] something bad is happening. And it’s very human, very normal to have those thoughts. The problem when you have psychosis is that you enter a state where there’s no longer a way to maintain distance. Psychosis isn’t just about hearing voices: it’s about the voices becoming so powerful that you can no longer have distance from the experience.
Q. What role do genetics play in mental health disorders? Or are these disorders solely caused by environmental factors?
A. What’s established in the genetic findings is that, for example, in neurological diseases, they all have genetic factors that contribute. However, they don’t overlap with each other and there are few genes [in common], few variants. In psychiatry, it’s completely different: genetic variations overlap between different disorders, such as autism, hyperactivity, psychosis, anxiety, depression…
The contribution [of genetics] to these disorders isn’t as strong, though, as we used to think. About 25% of the vulnerability [that causes a person to be prone] to suffering from a mental disorder is genetic. Furthermore, there aren’t just a few variants, as in neurology, but thousands and thousands.
The bottom line is that the genetics of having a mental health problem are the genetics of being human; the genetics that fuel the ability to react to our environment. What we think is that all these genetic variations equip us to survive, by allowing us to react to the environment using our consciousness, which is, essentially, affective.
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