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| 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
Psychiatrist
FEARP
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