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


In this installment of Conversations in Critical Psychiatry, a former United Nations Special Rapporteur discusses the need for a change in the status quo of mental health care.

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Awais Aftab, MD

Awais Aftab, MD

Dainius Pūras, MD, is a Lithuanian psychiatrist and human rights advocate. He is professor of child and adolescent psychiatry and public mental health at Vilnius University, consultant at Vilnius university hospital, and teaches on the faculty of medicine at Vilnius University, Lithuania. He is the director of Human Rights Monitoring Institute, an NGO based in Lithuania. He is also a visiting professor at the University of Essex (United Kingdom) and a Distinguished Visitor with the O'Neill Institute for National and Global Health Law, Georgetown University. He 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.

Dainius Pūras, MD

Dainius Pūras, MD

As a human rights advocate, Dr Pūras has been campaigning for more than 30 years to reform public health policies and services for individuals with mental health conditions, disabilities, and other vulnerable groups. Prior to serving as the UN Special Rapporteur, he served as a member of the UN Committee on the Rights of the Child from 2007 to 2011. He has served as an independent expert and consultant to numerous governments, NGOs, and UN agencies with regards to promoting human rights in mental and physical health services. His reports to the UN as Special Rapporteur have criticized the excessive systemic reliance on biomedical approaches and coercive practices in psychiatry across the world, advocating for a much-needed emphasis on approaches based on public health and human rights.

Aftab: Tell us a little bit about the role of the United Nations Special Rapporteur, and what were you hoping to accomplish when you accepted this role? For psychiatrists who may be unfamiliar with your UN reports, can you summarize what you intended to be your main message for the psychiatric community?

Pūras: The UN has a unique mechanism of special procedures. The UN Human Rights Council appoints Special Rapporteurs on different human rights related issues. They are independent experts. They work pro bono, and the main idea is that the Special Rapporteurs, although they hold the UN mandate, are independent from the UN as well as from member states (governments). Special Rapporteurs inform the UN, member states, and other stakeholders, through their reports and other working methods about opportunities, challenges, and obstacles on the way to full realization of human rights. Special Rapporteurs can also go public and call attention to violations of human rights in a certain country, or, for example, about systemic failures on the level of laws and policies that lead to human rights violations.

From 2014 to 2020, I held a mandate that is considered to be one of the broadest mandates: the right to physical and mental health. Mental health was my priority, although I also worked on different issues related to the right to health in general. Actually, I think that this separation of physical and mental health has paved the way to discrimination and stigmatization. One of my goals was to address historical disparity and to contribute to parity in mental health and physical health.

My main message to the stakeholders (first of all, to member states) was that the status quo in mental health policies and services is no longer acceptable, and it is high time to abandon discriminatory laws and practices. In other words, the time has come for another paradigm shift in this field.

Aftab: How has your own thinking evolved over the course of the past 6 years as UN Special Rapporteur? Has there been any change in your outlook?

Pūras: These were difficult, inspiring, and rewarding years. The right to mental health was my priority, and everybody, including high-level UN officials, supported the idea that the time had come to move mental health out from the shadows. I remember my meeting with the UN Secretary General Antonio Guterres in October 2018 in his office in New York. I was then the chair of the Coordination Committee of the Special Procedures (around 80 independent experts belong to this mechanism). We were discussing the global situation with regard to human rights, and the Secretary General asked me, among other things, to do as much as possible for mental health, signaling his support for the cause.

My mandate was to lift mental health to the highest possible level of importance, and to move it from the margins to the center of national, regional, and global policies. With concerted efforts of many allies, I think we were able to make a global impact. Initially, I was worried that making mental health a priority would be understood as the egocentric desire of a mental health professional to push his own field, and it may even have been viewed as a misuse of the mandate. Instead, I was asked in Geneva, New York City, and many capitals to go on with this priority and to do more. My perception is that mental health is finally becoming one of the UN’s global priorities, and this success is a result of the concerted efforts of many individuals and organizations.

Another part of my plan from very beginning was navigating the broad spectrum of views of mental health around the globe, including obvious disagreements, and figuring out how to move ahead. Especially if—and when—mental health receives more financial resources, how should these resources be best utilized? Should we support the status quo or try to do things differently? I had a lot of regional experience, and my dream for many years has been for the subregion of Central and Eastern Europe, as well as many countries of global south to catch up in quality of services with western countries, or what is now called the global north.

While I remain critical about the effects of totalitarian and authoritarian regimes on societal mental health and well-being, and convinced that democracy is a must for promotion of good mental health, I have also become more critical about the situation in the global north, where the right to mental health is not always realized. Also, I have become critical of messages on global mental health that are formulated and sent to the global community from academic centers in the global north. A global change towards fully embracing a human rights-based approach is being blocked mainly by the centers of power in the global north.

These academic centers tend to support the status quo and ignore its increasingly obvious negative effects in many parts of the world. They hold and support the opinion that the grim situation in the field of mental health and human rights can be improved simply by supporting current systems and models with more resources. The same messages come from global, regional, and national psychiatric associations. These messages are creatively used and misused in many parts of the world, but in general they sound like this: yes, there are problems, but first we need to address the treatment gap with more financial resources for mental health. In other words, human rights-based approaches are not taken seriously, and exceptions that override basic human rights principles, including that of informed consent, are allowed. These exceptions turn into the rule in many parts of the world. In fact, they turn mental health services into settings where human rights are routinely violated. Hence, the field of global mental health continues to be held hostage by a legacy of discriminatory laws and practices. This sad fact has been recognized as a very serious concern in 3 resolutions of the UN Human Rights Council (2016, 2017, 2020) on mental health and human rights.

My reports to UN Human Rights Council (also some reports to UN General Assembly) have warned the UN member states and other stakeholders that the entire field of global mental health needs to be liberated from obstacles that reinforce vicious cycle of discrimination, stigmatization, institutionalization, coercion, over-medicalization, and helplessness. The problem is not so much the global burden of mental disorders (which is another message that reinforces excessive medicalization). Rather, the problem lies in the obstacles to the realization of mental health rights. These are the most serious obstacles that need to be addressed: power asymmetries, overuse of biomedical model and biomedical interventions, and biased use of knowledge and evidence. This was not my discovery by any means. I just compiled these growing concerns in my reports and informed stakeholders, urging them to address such unacceptable situations and to act accordingly.

Aftab: You have experience of living and working as a psychiatrist in the Soviet Union. What are your observations regarding how the trajectories of psychiatry as a medical profession have been influenced by communism and capitalism in the East and the West respectively?

Puras: To try to make a long story short, in the West, colonialism and capitalism led to burgeoning inequalities and poverty. This systemic violation of economic and social rights has had a negative, wide-spread impact on mental health and well-being, leading to medicalization and criminalization of social issues. On the other side of the wall, Soviet-style socialism turned into a totalitarian system, with attempts to make individuals equal by force, at the expense of political and civil rights, destroying any space for civil society and private initiative. That kind of social experiment had a very detrimental impact on individual and societal mental health, with long-lasting effects. Even after peaceful revolutions and arrival of democracy in Central and Eastern Europe (CEE), this region with 400 million individuals still suffers. The region has very high rates of suicide and other forms of external forms of premature deaths, and they can be explained as reactions to prolonged societal stress, and a consequence of the population’s lack of control over its own life and health under totalitarian rule. Soviet mental health care was extremely reductionistic and brutally misused biological psychiatry, with almost no effective psychosocial interventions.

But what happened when the wall collapsed and borders finally were opened? While many of us in the East expected that the development of public health and psychosocial interventions would now be supported by Western partners, things developed in a very different way. Many consultants, including famous Western psychiatrists, came and informed politicians and psychiatrists in this region, often with the support of the pharmaceutical industry, that the only effective way to address epidemics of suicide and other mental health related issues was to invest in psychotropic medications. This coincided with a paradigm shift in Western psychiatry, the move from psychoanalysis to the Prozac era. Sadly, this resulted in second massive wave of medicalization of mental health care in the CEE region.

Even after 30 years, effects of this systemic mistake are in place. The mental health systems in this region continue to suffer from institutionalization, social exclusion, and overmedicalization. Reforms are often effectively blocked by the prevailing idea that mental health care is about fixing mental illnesses with biomedical interventions. This is what happens when we try to use brain chemistry to manage societies undergoing difficult and complicated transitions.

Lithuania, the country in which I live and work, is not unique. In the region of CEE, many countries have similar legacies and scenarios. Sadly, in many instances academic psychiatry has become too reliant on the status quo and is reluctant to transform mental health services. Civil society organizations have been the real leaders.

Since 2018 I have been working as director of the Human Rights Monitoring Institute (HRMI), one of Lithuania’s human rights civil society organizations, which holds authorities accountable for respecting, protecting, and fulfilling their civil, political, economic, social, and cultural rights obligations. The regions of Central/Eastern Europe and Central Asia have unique histories and realizing mental health rights here is part of the broader transition to democracy. The legacy of authoritarianism persists in our democratic institutions and is perhaps most visible in our mental healthcare systems, which rely upon exclusion and institutionalization, with reductionist biomedicalization being a common, but ineffective, solution. In my former role as the UN Special Rapporteur and in my current work with the HRMI, I am happy to strengthen the network of experts and organizations who are willing to abandon the legacy of discrimination and move towards fully embracing mental health care as a human right.

Aftab: Your 2017 report to the UN Human Rights Council1 provoked a rather spirited debate in academic journals such as the Australian & New Zealand Journal of Psychiatry, where you were accused of having an anti-psychiatry bias.2-4 Defending this characterization, one of the remarks by Dharmawardene and Menkes was as follows: “Scientific medicine progresses in the context of robust debate, and legitimate criticism of psychiatry is welcome; science is about evidence and evolving utility… By contrast, anti-psychiatry discredits biomedicine’s role in mental health as a matter of principle and in so doing privileges values-based policy over scientific evidence.”5

I do not think there is much value in debating the charges of anti-psychiatry. I fear some of our colleagues are too trigger-happy when it comes to such accusations. However, what are your thoughts on the relationship between values-based policy and scientific evidence? Do you think one has a more privileged role than the other?

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.

Advances in medicine, including psychiatry, are based on 2 modern concepts. These concepts, are, in my view, the best of what humankind has achieved. The first is evidence-based medicine, and this is about relying on the scientific method. Just to clarify, that evidence comes from many sciences, including social sciences. Many of the social sciences are telling us that the status quo in global mental health is not necessarily based on evidence. For example, the use of involuntary measures to address issues of dangerousness and medical necessity—evidence tells that this may do more harm than good.

The second powerful concept is that of the human rights-based approach. The human rights approach protects medicine, including psychiatry, from doing harm. We should not forget many sad episodes in the history of psychiatry, and they often happened because values were undermined in the name of dubious or arbitrary evidence. The human rights and scientific approaches complement each other. But evidence, as we know from history of psychiatry, may be fragile and biased, or produced in dishonest way and questioned later. And this is why human rights serve as a powerful guardrail.

It is not a coincidence, I think, that psychiatry is more sensitive to human rights in some countries than in others. I will give the example of Germany. The most mature dialogue I had as a Special Rapporteur on mental health and human rights was with leaders of German psychiatry. They initiated a meeting with me during the World Congress of Psychiatry in Berlin, 2018, and then they organized a very important meeting in Berlin in 2019, inviting the president of European Psychiatric Association (EPA), Silvana Galderisi, PhD, MD, and me as speakers. (It is relevant here to note that the EPA’s response to my 2017 report was very critical.) This meeting was attended by a large group of important figures in German psychiatry. It was good to see a genuine desire to move towards a radical reduction of coercion, and a desire to understand the seriousness of concerns that I was raising about human rights violations in psychiatry around the globe. In many other countries, leadership avoids hard discussions of mental health and human rights. I suspect that psychiatrists in Germany are more aware of their history and what may happen when supposedly scientific evidence is disconnected from values.

To conclude, I am convinced that psychiatry’s moral and scientific future depends on taking values as seriously as scientific evidence, and this future may be quite bright if human rights are fully embraced.

Aftab: You view the elimination of all forced psychiatric confinement and treatment as the eventual ideal that we should aim at. I am curious regarding your thoughts on the involuntary treatment and confinement of individuals with neuropsychiatric conditions where decision-making capacity has been impaired—for instance, delirium and dementia. It is hard for me to see how we can ethically maintain the goal of eliminating coercive treatment in entirety when it comes to such situations, unless perhaps we redefine coercive and involuntary to exclude situations where there is a substitute decision-maker. But if we recognize decision-making incapacity as an ethical justification for conditions such as dementia, then what is different about decision-making incapacity as an ethical justification for involuntary treatment in various psychotic disorders?

Pūras: This issue is part of the difficult conversation we need to have as a profession, and one that contributes to the situation of impasse.

I recognize the serious arguments of professionals who warn against a prohibition of forced treatment. They insist on retaining legal permission to treat individuals with serious mental health conditions involuntarily in exceptional circumstances in ways that preserve dignity and autonomy. However, these good intentions are failing.

In my reports, and in some other publications (such as this 2019 article for World Psychiatry6), I share concerns from experts in diverse fields, including philosophy, neuroscience, psychology, and economics, who are increasingly challenging the grounds for the exceptions that legitimize coercion in mental health care. The Convention on the Rights of Persons with Disabilities (CRPD) has elevated this challenge to the level of international human rights law. Indeed, the CRPD challenges centuries of legally sanctioned prejudice. However, exceptions remain at the domestic level in law, policy, and practice. These exceptions influence the norm, fostering power asymmetries, the overuse of biomedical interventions, and the disempowerment of an already marginalized population. Systemic violations follow.

For psychiatrists and all healing professions, a pivot toward human rights would require setting aside substitute decision‐making and offering support according to an individual’s will and preferences, and where unknown, the best interpretation of their will, preferences, and rights.

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 understand that this suggestion may sound naive and unrealistic to pragmatic psychiatrists. But if we look back at the history of mental healthcare, there have been many instances of paradigm shifts. I understand that this is not an easy path to take, but we need to try, because the other prospect—staying with and reinforcing the status quo—is no longer an option, given the failures of the status quo.

There are some promising signs in psychiatric leadership—for example, the position statement by World Psychiatric Association on the need to reduce coercion in mental healthcare.7 I remain convinced that psychiatry has a good future if it joins other important actors in the movement towards rights-based and recovery-oriented mental health services.

Aftab: You have criticized the arbitrary division of physical and mental health and the subsequent isolation and abandonment of mental health, something I am strongly in agreement with. Can you elaborate more on how your approach to mental health fits in with the rejection of a division between physical and mental health? This is crucial because such a distinction is often sharply maintained by many in the critical community, who argue that health and disease are matters applicable only to the physical body and argue for complete de-medicalization of mental distress, impairment, and disability.

Pūras: 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. Many individuals around the global suffer from a lack of essential health services that they desperately need, but the other side of the coin is that many diagnostic and therapeutic interventions are excessive and wasteful. I have supported and promoted choosing wisely, an initiative of medical doctors in many parts of the world that educates the public about not overusing medicine and health services.

One of my reports to the UN General Assembly (in 2019) was about medical education. Sadly, in many medical schools, future doctors are too often trained in ivory towers. This is not a good investment for the future of public health. Human rights in patient care, or the importance of social determinants of health, are not prioritized in medical education. Back to mental health, the main message future doctors have been receiving during the last few decades, is that mental health conditions are mainly about biogenetic or biochemical abnormalities in the brain, and that accordingly such conditions should be managed predominantly with biomedical interventions. My duty was to inform stakeholders that this simplified, reductionistic thinking is not working.

I worry when I talk to young psychiatrists. The framework of human rights is either unknown to them or is an obstacle to their dream of curing mental disorders, or preventing discoveries of modern genetics. Academic psychiatry should rethink what kind of knowledge future doctors receive. Even though Arthur Kleinman, MD, sounded the alarm about the urgent need for changes in academic psychiatry almost a decade ago, things have not changed much so far.8

Aftab: Your awe and admiration of the service user movement is apparent in your reports. At one point in your 2017 report you write, “Most important have been the organized efforts of civil society, particularly movements led by users and former users of mental health services and organizations of persons with disabilities, in calling attention to the failures of traditional mental health services to meet their needs and secure their rights. They have challenged the drivers of human rights violations, developed alternative treatments and recrafted a new narrative for mental health.”1

The rise of service user movements is one of the most significant developments of recent decades, and probably one that has the most potential for long-standing reform. Would you like to elaborate on why this is the case?

Pūras: Indeed, 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.

But in many countries, groups of users and ex-users of mental health services either do not exist, or they are weak and controlled by psychiatrists and pharmaceutical companies. This means that the movement of users and ex-users of mental health services still needs time to grow into a strong, independent movement.

One thing I want to say on this occasion—and this may better explain why the messages I formulated while exercising the UN mandate received support from many users and ex-users of services—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.

Anyway, the problem of accountability in global mental health and psychiatry remains very serious. If there is an agreement, even at the level of the UN Human Rights Council resolutions, that human rights violations remain widespread within mental healthcare systems, who is accountable? Accountability for serious harms is important, but I would opt for structural change. Structural change will guarantee that days of discrimination and human rights abuses are over, and that the harms will not be repeated.

Aftab: Given that you are a well-regarded figure in the service user community, what advice would you give to the service users regarding how they can continue to do the good work they are doing without losing scientific credibility?

Pūras: Users of services who have suffered from coercion and disrespectful attitudes lose hope, and lose their tempers, when they observe that psychiatry is not ready to seriously reflect and address the failures of the status quo. But some representatives of users and ex-users of mental health services tend to demonize psychiatry and psychiatrists. I disagree with that. If you demonize the opponent, and if you insist on calling psychiatrists perpetrators who should be brought to justice, then you lose all opportunities to engage in dialogue. Not surprisingly, leaders in psychiatry often use such statements as an excuse to stay in a defensive position and not open up for critical self-reflections.

Aftab: As a corollary to my previous question, what advice would you give to the psychiatrists who view the consumer/survivor/ex-patient community with suspicion and distrust? How can psychiatrists develop more collaborative relationships with the service users?

Pūras: I would like to highlight the positive side of the current situation, although I agree that the tensions do exist. There are many psychiatrists worldwide who are working collaboratively and successfully with users of services and their organizations. Such partnerships may be very productive. My reports highlight some of these innovative models.

To answer your question, I would recommend that psychiatrists be more open to initiatives that are based on noncoercive practices and that liberate both sides, providers and users of services, from the trap of paternalistic relationships.

Aftab: Asyou pointed out in your 2017 report, “In some countries, the abandonment of asylums has created an insidious pipeline to homelessness, hospital and prison.” That is certainly true of the United States, where the seriously mental ill experience much higher rates of homelessness and incarceration. Conversely, in many other parts of the world, conditions are no better, as reported by the Human Rights Watch. Shockingly large numbers of individuals with mental illness around the world spend their lives chained like cattle. I myself, when I lived in Pakistan, saw an individual with a psychotic illness shackled to a tree in a village, with no access to medical care, and with the family possessing a premedical conception of madness. This suggests to me that focusing exclusively on biomedical diagnoses and treatments as the boogeyman is naïve, and severely under-estimates the collective societal effort that is required to ensure humanistic and effective care for the mentally ill. Your thoughts on this dynamic?

Pūras: I have many thoughts on this dynamic. First of all, it is true that the human rights of individuals with mental health conditions are violated outside of mental health services. They suffer in streets, prisons, and they are discriminated against. Interestingly, global psychiatry, including WPA, regional, and national psychiatric associations have done a lot in this regard and need to be commended for raising these issues and fighting for human rights, not only for individuals with mental health conditions, but also for many other groups in vulnerable situations (for example, LGBTQ+ individuals). I see a paradox here. The psychiatric profession has been very committed to and successful in promoting human rights beyond the walls of the mental health system, while within the mental health systems the story has been more complicated, with psychiatry having its own interpretation of human rights within systems of service.

We all need to be aware that the virus of populist nationalism continues to attack universal human rights principles, and we need unity among many progressive forces around the globe to stand for the best that humankind has achieved: protection and promotion of human rights that are indivisible and interdependent. How can we expect governments to protect the rights of individuals with psychosocial disabilities and other mental health conditions if they do not take everyone’s human rights seriously?

Aftab: In medicine, there is no fundamental distinction to be made between biomedical approaches and public health approaches. Both happily co-exist. Public health experts can focus on the social determinants of say, tuberculosis or dysentery, while the physicians can treat afflicted individuals with medical interventions; the goal for the policy makers is to ensure that resources are provided for both public health measures as well as individual treatment (which unfortunately does not often happen). Yet, when it comes to psychiatry, the tone of the discussion seems to change dramatically. Instead of advocating for public health approaches and addressing social determinants of health as complementary to individual care, we see some critics arguing that the medical model itself is to blame, and that we should abandon diagnoses because the diagnoses locate the problem as being inside the individual. What do you think accounts for this difference?

Pūras: In my view, the tension exists also in the rest of medicine. But yes, I agree the tension is higher in the area of mental health. One possible explanation would be that there is more clarity about effectiveness of biomedical interventions in those areas of medicine where markers of pathology have been identified. In some areas, like oncology, the achievements of biomedicine have been remarkable. There might be more clarity regarding how efforts directed at prevention and treatment of cancer should be funded.

In contrast, if we take most mental health conditions, there is a serious lack of such clarity. When we say that depression is among the most prevalent health conditions with huge costs to society, it is not clear what is the best way to address this issue. With a public health approach or by targeting individuals’ brains? OK, we may try to find a solution by saying that a broad spectrum of different population-based and individually oriented interventions is needed, but this hardly minimizes the underlying tensions. At this moment, there is no agreement between experts, for example, as to whether the sorts of psychiatric interventions that are dominant in the global north for the treatment of depression (such as antidepressants and individual therapies) are the interventions best suited for implementation in the global south. Hence the tension.

Aftab: The discourse surrounding psychiatry is extremely polarized, as can be judged from the reactions to your reports. How should we understand this? How can we help well-meaning individuals on opposite sides of the aisle find common ground? Due to the polarized nature of the discourse, we tend to forget that there is often more that unites us than divides us. For instance, we can disagree on whether complete elimination of involuntary care is possible, but we can agree that we should take steps to reduce the need for involuntary care as much as we can, and what needs to happen to take those steps. Similarly, instead of insisting that psychiatric diagnoses be abandoned, we can find common ground in recognizing the limitations of psychiatric diagnoses and the need to restructure education, research, and service provision to help address those limitations.

Pūras: This question probably summarizes our entire discussion! Yes, polarization is quite serious, and yes, it makes it even harder for us to overcome impasses and move ahead. But this dynamic is also very meaningful. The process has a lot of meaning. Stefan Priebe, MD, and colleagues have written that “Paradigms are neither true nor false, simply more or less useful for generating testable hypotheses and fostering progress.”9 Probably, the success of a model can predetermine its failure, as the model becomes a victim of its own success. The psychoanalytic era was replaced by the biomedical paradigm, and now the time has come to ask, what kind of paradigm will replace the dominance of the biomedical model?

Aftab: Thank you!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric TimesTM Advisory Board. He can be reached at or on twitter @awaisaftab.

Dr Aftab and Dr Pūras have no relevant financial disclosures or conflicts of interest.


1. Pūras D. Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Office of the High Commissioner for Human Rights, United Nations Human Rights. 2017.

2. Dharmawardene V, Menkes DB. Responding to the UN Special Rapporteur's anti-psychiatry bias. Aust N Z J Psychiatry. 2019;53(4):282-283.

3. Cosgrove L, Jureidini J. Why a rights-based approach is not anti-psychiatry. Aust N Z J Psychiatry. 2019;53(6):503-504.

4. McLaren N. Criticising psychiatry is not 'antipsychiatry'. Aust N Z J Psychiatry. 2019;53(7):602-603.

5. Menkes DB, Dharmawardene V. Anti-psychiatry in 2019, and why it matters. Aust N Z J Psychiatry. 2019;53(9):921-922.

6. Puras D, Gooding P. Mental health and human rights in the 21st century. World Psychiatry. 2019;18(1):42-43.

7. Rodrigues M, Herrman H, Galderisi S, Allan J, et al. Implementing alternatives to coercion: a key component of improving mental health care. World Psychiatric Association. October 2020. Accessed May 26, 2021.

8. Kleinman A. Rebalancing academic psychiatry: why it needs to happen-and soon. The British Journal of Psychiatry. 2012;201(6):421-422.

9. Priebe S, Burns T, Craig TK. The future of academic psychiatry may be social. The British Journal of Psychiatry. 2013;202(5):319-320.

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