Alberto Fernandez Liria is one of our teachers. His writing substantive and pragmatic concepts of mental illness. clinical implications in the book Facts and Values \u200b\u200bin Psychiatry, edited by Baca and Lazarus, is absolutely essential and should be worked carefully (as we did at various seminars for residents). His two books, written with Beatriz Rodriguez Vega, entitled The practice of psychotherapy and interview skills psychotherapists studied in the context of the Masters in Integrative Psychotherapy at the University Alcala, also marked a significant extent our professional. We pick up an entry in this interview with Alberto by Salvador López Arnal and published in June 2008 in the magazine Rebellion, entitled " In the shadow of the conservative revolution mental health has become in pharmaceutical industry market . believe has a certain interest and reproduced below:
; Psychiatrist, Mental Health Coordinator of Area 3, Madrid and Head of Psychiatry Department of the Hospital Universitario Príncipe de Asturias, an associate professor at the University of Alcalá and director of the Master of Psychotherapy at the University of Alcalá, Alberto Fernández Liria has written numerous papers in scientific journals on psychotherapy, psychosocial rehabilitation, intervention in disasters and violence and the transformation of services for mental health. He has written several books, among which we highlight here: The practice of psychotherapy: the construction of narrative therapies , Desclée de Brouwer, 2001 (with Beatriz Rodriguez Vega); interview skills psychotherapists. Desclée de Brouwer, 2002 (also with Rodriguez Vega) and Crisis Intervention, 2001 (with the same co-author).
say that Alberto Fernandez Liria psychiatrist was to alleviate human suffering wherever it took place. Perhaps that is why one day he went to the former Yugoslavia where he was wounded by a shotgun blast.
I do not know if it is impertinent to express here that had long since I felt so moved by an interview. Both give you are on the fourth or fifth rereading. I remain on tenterhooks. I know well that all the credit goes to Alberto Fernández Liria, but let me steal a 1%, only 1% significant, and that I dedicate to my son Daniel López Martínez. I'm sure, as would Gil de Biedermann (Jaime, of course), you can not make us any harm and also to Albert does not mind at all. Thanks.
Is there a rational and not hurtful use the term "madness"? Are there limits or twilight zones defined bounded rationality and madness?
The term "madness" has several drawbacks. One is that considered stigmatizing. Probably today, "madness" can have positive connotations to which they are not using terms like "psychosis" or "mental illness." The other problem is precisely that "madness" can mean almost anything, which is an inappropriate term when we need to be precise. And to meet conditions for people suffering from mental disorders need to be precise.
As the boundaries between mental disorders and mental health, as the boundaries between sickness and health in general, certainly not because the companies are net defined as a function of many factors which will consider "disease" and what does not. In fact, the delineation of borders, and therefore the performance of mental health professionals, is one of the tasks to be undertaken in the XXI century. But in this controversy, the boundaries between health and mental disorders do not correspond to the rationality and madness because the mental disorder only very rarely results in a loss of reason.
How to define mental illness? Why "mental"? What is here the mind?
might ask also not the mind or what not mental. In fact the Cartesian distinction between res extensa and res cogitans , between mind and body, which has done is making things much more difficult time to understand not only mental health disorders, but the human being and living things in general.
said Kraepelin, often considered the founder of modern psychiatry that mental illnesses are mental illnesses that have symptoms (irrespective of their cause.) A delirium, acute confusional state, is a mental disorder but the cause is poisoning, a metabolic disorder or trauma. In the early twentieth century, Kraepelin did not believe it necessary to explain in his treatise on what he meant by the term "mental."
Today the meaning of the term seems much less obvious. Living things are to the extent they are able to take notice of the environment in which they live and act on it according to what they perceive to maintain their existence. The experience of living a certain level (eg an animal) is the joint action of living beings of a lower level (in this case, cells) that constitute its soma and directs an action in which the body top level as a unit interacts with its environment. The mind would be the process by which such action is organized unit of the body.
What characterizes man as animal is the fact that it operates in an environment that - in the words of English biologist Faustino Cordón - is an environment "stuck for words." In other words, the atmosphere of a man are men, with which it interacts through specific behavior, language. Therefore, their relationship with the environment are, necessarily (or at least what is specifically human) through language. We live a constructed reality in the terms that the language allows and imposes. In some way we live the stories we tell. And we call to mind the scenario displayed the thoughts, intentions, emotions and narratives that organize so that we can recognize as ourselves and recognize others and the world we live in, giving them a sense.
So when can we properly speak of mental disorders?
As a psychotherapist I use to think that talk of mental disorders in two situations. Firstly, when the narratives with which we make sense of our existence are not useful for cooperation with our neighbors because they are not compatible, as with those of a schizophrenic patient who believes that others can read your mind, that the ideas that come to mind have been put there by another or who think they know for certain the intentions of others. This is what happens with the pictures we call psychotic. Secondly, when master narratives which produce avoidable suffering, such as the hypochondriac patient, who can not live without the certainty that any of their bodily sensations is not a sign of malignant disease. They are what have been called neurotic disorders.
But the first criterion - "are not useful for cooperation with our neighbors because they are shareable" - Is it not a difficult criterion conclusion? How do we know, without error or madness, that narratives of this or that subject is not shared and that are not useful for cooperation with their fellow citizens if the subject does not support this intuition of ours?
In practice it is very difficult to agree on a subject raving (has beliefs that, besides not being shareable occupy a central place in the organization of their way of being in the world) having hallucinations (perceiving things that others do not perceive), as, in practice, it is not difficult to agree on one thing or another are have undesirable consequences for him or others in living with others. But, of course, there is no hard criterion. Ultimately we are talking about someone who is excluded from a minimum consensus that we consider necessary. With regard to other criteria, there is no hard criteria for determining when suffering is avoidable. So there is a discussion about the boundaries between mental disorders called comunes2 and normalcy.
"Why do you think that citizens have, say, so much interest in these issues? Why the mass inculcation of ideas, issues and information often grow with so little shame these issues?
The importance of mental health has had on the social debate has undergone important changes over the twentieth century. For example, the introduction of psychoanalysis was a real shock in the early twentieth century, the contributions of psychiatrists culturalist were best sellers in the fifties, and will figure out the kind of questioning of social practices, which contained the madness, it was in the sixties and seventies of the hand of so-called antipsychiatry, the reformers of psychiatry or Michael Foucault and its aftermath.
In the eighties the references to the health or disorders mental outside the specialized fields and be spent only marginal. In the shadow of the great revolutions conservative, mental health care is no longer considered a challenge to the welfare state or a source of inspiration for critical thinking to be regarded only as a potential market in which the industry could make benefits.
psychiatric thought and activity of psychiatrists were dependent then, especially for this purpose. Mental health is no longer thought of as an achievement hardly built through the efforts of individuals and communities to be considered a natural state only threatened by alterations biochemical brain function was expected that the parallel development of neuroscience can explain and even photographed by the equally impressive advances in neuroimaging techniques.
we become psychiatrists prescribing of drugs, and in any case, witnesses and spokesmen for the benefits of the remedies that were vying for new market.
You spoke of Michael Foucault and its aftermath. What are these consequences? Do not you have anything good opinion of Foucault's theoretical interventions in this area?
No, I mean that. I sido un lector apasionado de Foucault. Textos como El nacimiento de la clínica o Historia de la locura en la época clásica han sido importantísimos en mi formación. Si tuviera algún reparo respecto a la obra de Foucault, no sería, desde luego, en sus contribuciones a éste área.
Decía lo de las secuelas, sin ánimo peyorativo, para referirme a autores como Robert Castel. De Castel también aprendí muchas cosas. Castel, como Foucault, a mi modo de ver ha sabido mostrar magistralmente como los gestos cotidianos de la atención a la salud mental reflejan los mecanismos del poder en las sociedades contemporáneas. El problema en todo caso es one thing is that the reflected and another to play an important role in sustaining them. I sincerely believe that the role of psychiatry and mental health care in this is quite marginal. And, in large part, the enthusiasm with which some psychiatrists supposedly progressive welcomed the idea had to do with that, even in the dark side, we gave importance to us that it was a consolation for the modesty imposed on us by day day reality of the clinic. It seems to me that next to the school, television, family, police or prison, psychiatry is quite dispensable for maintenance of order.
And that Perspective I was talking about remains hegemonic ...
Although this perspective introduced in the eighties remains hegemonic, today we have sufficient data to support that has proved a failure: the remedies that were supposed to be increasingly specific for disorders increasingly precisely defined, proved to be anything but specific. Remember that SSRIs, selective serotonin reuptake of serotonin (the paradigm is the Prozac), claimed to have become the "silver bullet" that was against what was supposed to specific alteration of depression, compared with the specificity of the former - And so cheap - tricyclic antidepressants. Today, SSRIs are the first choice pharmacological treatment of depression but also panic disorder, generalized anxiety, obsessive compulsive disorder, the personality disorders, disorders of impulse control and many other . Considering that, in turn, respond to antipsychotic drugs on positive symptoms of schizophrenic patients, delusions chronic manic tables, the psychotic symptoms of organic mental disorders and other, perhaps we could think that, if only consideration of what we can learn from prescribers and clinical work would need to articulate our classifications - or, even better, think about mental health and mental disorders - on new bases.
In recent years there have been some signs that there is a new social concerns and mental health disorders at least in what we call the developed world. Not to mention the proliferation of self-help tools designed to respond to the need to subjectively experienced by multitudes to preserve your mental health. If we only find that institutional manifestations of health and mental disorders have become a cause for concern policy at least in Europe. Since the World Health Organization, the European Commissions and the Council of Europe have promoted new and significant guidance documents, based on some of which were signed in Helsinki agreements that have been committed to health ministers Union.
Some governments, like the British or Scandinavian, have increased funding dedicated to mental health care and have diversified the type of resources devoted to it in a very significant, both as regards attention to serious disorders as common disorders.
The prestigious medical journal The Lancet , Has devoted a series of articles echoing the above and propose courses of action through a series of articles written by a call Lancet Global Mental Health Group, which brings together 38 international experts on the subject echo of the aphorism WHO "no health without mental health."
But there is hardly news that information in the media ...
The mass media have barely echoed these movements. In the media, at this time, which are displayed or self-help or news sections in which the disorder is treated as metal absolutely gruesome, absolutely wrong on the idea that the mentally ill are dangerous (the seriously mentally ill commit actually less violent crime that citizens are not) or that the criminals whose actions we want to distance are mentally ill, rather than simply evil. Probably because accepting that evil exists in our species and our culture, and seek an explanation, is more uncomfortable than attributing its effects to causes that have nothing to do with us.
Let me ask you some questions about what you just said. The first two. You were saying that if we consider that, in turn, to antipsychotics Positive symptoms respond schizophrenic patients, delusions chronic manic tables and others may think that we would need to articulate our rankings, or think of mental health and mental disorders, on new bases. Are you suggesting then that antipsychotics are not effective for the diversity of cases dealt with them?
Absolutely. Precisely what we know, and so we use - is that they are effective. No doubt the efficacy of drugs, but the usefulness of the classifications. I understand that diseases are not, as believed at the end of the early seventeenth century protopsiquiatras who were sent by the directory revolutionary take on the hospitals of Paris, naturally occurring entities whose diversity was to be manifest in his sight by observing, as the diversity of plant species had been deployed in the eyes of Linnaeus. Diseases (all, not only or especially mental) are constructs that allow us to predict the effect they can have the actions of doctors and other healers for certain forms of discomfort for a company that has agreed to grant to anyone who suffers sick role
And on what basis should we think then new mental disorders?
precisely on that. Their usefulness for guiding the activities of healing. Medicine (such as architecture or engineering) is not a science but a technology (Although, as any technology claims to have a scientific basis). And their goal is not to produce knowledge but to produce a social good (in this case health.
disease call a state-unintentional and undesirable, that produced an upset against a society is prepared to articulate a process that includes exemption of duties, provision of special care and healing activities (in our culture, medical) efforts to resolve or alleviate.
From this perspective, the determination of what conditions will be considered as a disease and what not, for each society. So there are societies where certain other conditions are considered normal (and sometimes even desirable) are considered illnesses.
The distinction between disease in general and what is not depends, accordingly, a decision that would be better understood as a policy or, in any case, cultural as a result of a natural science research.
The distinction between different diseases makes sense insofar as it serves to implement various procedures and to make predictions about what the results obtained with this. The Maya know what to do and what to expect to happen with the ghosts, and what to do with the evils thrown or ontonil k'ak'al or ti'ol ek. Our families and our doctors know what to do and what to expect to happen with chickenpox, and what to do with Down syndrome, tuberculosis or panic attacks. Therefore, even if they have the same causal agent, chickenpox and herpes zoster are different diseases.
According to this way of seeing things, we could say that in our culture constructs diseases are related to conditions in which an individual experiences discomfort, for which there is consensus that the idea should be put in place a procedure that includes the involvement of the health system, and allow to make predictions about the actions of physicians.
No morbid species hidden in some part of nature waiting to be embodied in sick. Nothing is beyond sick. It is the action of doctors, and expected results emanating therefrom, which distinguishes some other diseases. The claim that a patient is one who goes to the doctor, is more than a tautology. There is nothing surprising the fact that if we want to study the epidemiology of mental disorders we should resign ourselves to the definition of psychiatric case should be in terms of one patient suffering from an upset against the doctors suggest a method of treatment or care.
If we accept this hypothesis, the logical thing is to build our nosology looking more to the constraints of the intervention to the observation of symptoms.
you elaborate a bit. Do you mean with this last statement.
It's not that there is no other medical disciplines that have lost their direction unless psychiatry. Breast cancers are not classified by the hardness or the proximity to the areola of the tumor. They are classified into grade I or grade n as the practice shows that it is the expected response to each of the procedures available to act on them. And this classification allows to determine the protocol to be applied to a given patient and what to expect to happen with him (which seems likely in view of what happened with other similar patients). Pragmatism has taught surgeons oncologists to guide your thinking of the intervention to the symptoms rather than the symptoms to the intervention.
In psychiatry the exact opposite is happening today. Possessed by what I like to call the illusion of Pinel (one of these prtotopsiquiatras to which I referred to earlier) psychiatrists strive to observe the symptoms hoping that these (conveniently passed through the cluster analysis) to draw their own institutions those which someone (the pharmaceutical industry, perhaps?) then find appropriate remedies. Attempts to find more and more specific remedies for getting better defined pictures have failed. More specific remedies (before we mentioned the case of SSRI antidepressants) have been applied for paintings that are unrelated to each other in our nosology. And this has happened only with psychotropic drugs. It is well known for Christopher Fairburn, who provided intervention for placebo to be compared manualized cognitive-behavioral therapy for bulimia nervosa decided to use the manual of Klerman's interpersonal therapy for the treatment of depression. What happened was that, although cognitive-behavioral therapy produced better results at the end of the 18 sessions of treatment, results at 6 and 12 months of patients who received interpersonal therapy (which continued to improve after completion of therapy) were even better. Thus, Fairburn discovered (not invented) interpersonal therapy for bulimia nervosa. Something similar had happened before with an antidepressant such as clomipramine.
We can be proud of such discoveries. But, even help us to better serve our patients, which ultimately shows is that in our work as classifiers has not responded to our expectations. We'll have to ask which lessons can be learned from it.
So you think that the research has been directed by this bias.
Research in the field of psychopharmacology has been relatively corseted by this bias. In the field of psychosocial interventions, the effects are still devastating. Guided by this idea is to organize research on the effectiveness of psychosocial interventions (and, subsequently, to establish indications and payment) from the categories defined by the shiny new consensus classification system. The various lists of empirically validated psychotherapies that have brought together various groups (most notably the American Psychological Association) are configured in this way, and have the various categories of DSM headings under which interventions are listings usually begin with term cognitive behavioral therapy or interpersonal therapy, and end in the name of the category or subcategory.
Until the groups led by Beck and Klerman (whose guidance refer these prefixes) decided, in the late 70's, submit their work to the test of randomized clinical trial, there was a consensus among psychotherapists about that the diagnostic categories, such as sketched classifications were not a useful guide for practical work with patients. Today, many systems have been proposed constructs that they are, and have achieved, often through a fine job of research, acquire empirical support. But the lack of correspondence between these systems and classifications to use this work makes it difficult to pass the filter neopineliana the psychiatric community is organizing itself to impose, under the banner of evidence-based medicine, all information that may reach members.
What diseases are constructs, you said, forms of discomfort for which the company has agreed to grant to anyone who suffers from a sick role. Is not that very idealistic vision, very sociologist? Do not forget you too much to determine what is real? This is not to argue that our theories are rubbings of reality but then to say that illness is a construct ... Jacques Bouveresse sick if you read and I promise you will not build your illness. Is there not an epistemological break too? On the other hand, what society is that you agree to this?
I do not think that is neither idealistic nor sociologist, because social constructions are not produced on the vacuum. By following his example, which can happen to Jacques Bouveresse (hope not) or any other, is that the emotion of anger to move it offensive text is translated into a very important stimulation of the autonomic system may even to even alter an irreversible operation or structure of any of the cells that constitute the soma (This Faustino Cordón sick calls him up and down; ward on bottom-up change when the malfunctioning of certain cells - by the action of a toxic, for example, prevents them from making their necessary contribution to the emergence of our organism animal). Now if we say that this is "sickening" (and not "possessed", "feeling that one is in disagreement" or simply "turned to righteous indignation") is because there is a consensus call that disease. If this is so Bouveresse will give you the floor, read not to attend a conference that was scheduled for today, take her mother to bed broth and cut-outs and treatment will be prescribed some of which pay between all our taxes.
You are president of the English Association of Neuropsychiatry? What is Neuropsychiatry? What is the status of this scientific discipline in our country?
The name of the association is the one that put its founding in 1924, a brilliant generation of psychiatrists who considered themselves followers of Ramon y Cajal and who made contributions the field of neurology and psychiatry in the two disciplines were not distinct. Today the association has the subtitle "Mental Health Professionals" and is mostly by psychiatrists, clinical psychologists, nurses and other professionals who are inter-teams from which today makes the care of mental health problems .
And what is the mental health situation in our country? Do you think progress has been made in recent years?
the past thirty years we have gone from a system looked at the mental hospital as an alternative care for severe mental disorders and neglect or a caricature of care for common mental disorders (such as anxiety and depression), some complex network-based systems of care that integrate multiple devices such as centers mental health inpatient units in general hospitals, day hospitals, psychosocial rehabilitation centers, day centers, therapeutic communities, alternative forms of sheltered housing or home care ... In short you are testing alternatives that are new. And, of course, new problems are emerging ...
In general, there is an agreement between the regions (which are those with skills in health care) and the European bodies on which model of care that should be developed. This is the agreement that reflect the European documents previously referred and which is embodied in the Mental Health Strategy in the National Health System, which was adopted in 2006. The problem is that the degree of development of the various elements of the model is very different in some other regions and, in fact, there are significant disparities in the resources devoted to the care of people with mental disorders and the benefits they receive in one and the other communities.
I think the model based on community care is surely preferable to the institutional and coercive model that preceded it. Although, as I said, this has generated new problems including the psychiatric or psychologizing of the problems of everyday life and the illusion that the current malaise can be processed rather than encouragement to act on the environment, not the least. Nor is the health improvement is envisaged primarily as an opportunity to develop a market and aims to finish made conditional to the primary purpose of serving to make profits. Or that, in countries like ours the goal of keeping the community for people with severe mental disorders at the expense of the effort of some families increasingly less responsive to the traditional family model aunaba resources of three generations in a collective effort from which all benefited.
"current malaise? What do you mean by current malaise? Moreover, you say, it is envisaged the improvement of health as an opportunity to develop a market and profit taking. Could you specify a little more?
I refer to the discomfort, for example, that after death of a loved one. Healthy is experiencing. Precisely what would not feel anything morbid or feel anything.
In a market economy like ours there is a remediable discomfort using a product that can be sold is an opportunity to make profits by selling that product. And that chance is what determines, at times, the increased focus by the medical community to certain diseases. Or the idea that there may be, for example, use a sort of "cosmetic" of the antidepressant. If someone says he is better off taking an antidepressant Why not sell?
What improvements would introduce you in these areas? What aspects seem more urgent rectification?
must consider that the model advocated in the documents to which I referred, presupposes the principle that mental health, as health in general, is a community responsibility and the society as a whole to which corresponds the first effort to promote it and prevent its loss, and then to address the best way possible to people who have failed to keep or suffer the consequences of their loss. Ie brings us, somehow, to the idea of \u200b\u200bwelfare state is far from proposals that have been deregulated widespread on the planet under the dictates of the World Bank, the Intenational Monetary Fund or other personifications of capital, and have been dutifully carried out by governments that have not always been conservative (in Spain the policies that were developed in the U.S. and England by Ronald Reagan and Margaret Thatcher were enthusiastically introduced in our country by the governments of Felipe Gonzalez). To the extent that the welfare state threatens to become regarded as one of the extravagant dreams of the sixties, the model health and mental health care that was consistent with it, it will be unsustainable.
Si we ignore the above, Today, we can say that most of the regions, the system has almost all or almost all the elements that should be. The fundamental problem is that the doses in which it is. Berlin, with not much more than a million inhabitants, has more than three thousand people in sheltered accommodation for people with severe mental disorders. The area that I lead in Madrid, with three hundred and eighty-five thousand inhabitants, is barely forty. We have a third of the psychiatrists or clinical psychologists Scandinavian countries have per hundred thousand inhabitants and twenty to forty times less than nurses working in the community than the English.
must be assumed that meet the conditions that we now know are possible in people with mental disorders is expensive. Surely it is more expensive than transplanting livers or faces or to hip or knee. But it is much less brilliant. Advances in surgery occupy the front pages of newspapers. Today (as yesterday and tomorrow) also visited someone in your house to a schizophrenic who, otherwise, would lead a subhuman existence in an institution, in the street or in jail is not news. And less in a time when passing laws that allow lock with no guarantee human beings for the sole crime of being born in another site provides votes.
So unscrupulous, so inhuman you see our political leaders and managers of media (mis) information?
Absolutely. No malice is a question of individuals but of irrationality of an economic and political system.
Otherwise, you spoke of visits to homes of schizophrenics. Also your visits to our homes might add. What kind of life can lead a schizophrenic? Does the term does not include cases very different?
know that many types of life. And to a large extent which of them will take depends on what we do to address them.
And you are right, probably what we call "schizophrenia" encompasses many different conditions, and surely the people we call "schizophrenia" are as different as people enter each other that we call "rheumatic ".
Do you know any country that is perhaps not a model but a landmark in the way it treats mental health patients?
We should compare ourselves with countries in our immediate environment. In Europe, some governments like Britain's, have increased in the last few years, the funds dedicated to mental health care a very significant way, setting up programs for those who have seen the light, in addition to the significant resources that already existed before, the assertive community treatment teams, the crisis care teams or teams in early intervention. On July 31, 2007, the health minister of that country announced the launch of the first teams of the plan by which the NHS will acquire ten thousand psychotherapists estimates that are needed to provide psychotherapy as a routine treatment for patients with anxiety or depression. And the latter do so because, according to a report from the London School of Economics may pay thereby saving on pensions if their work, get one month on average reduce the incapacity due to these disorders the United Kingdom.
For psychiatry do you have any interest in the theories and practices arising from psychoanalysis and its different currents?
Historically, psychoanalysis had an irreversible effect not only on how to look at mental health and its changes, but the way in which our society is contemplated Northwest itself. The practice of psychoanalysis as conceived by Freud and as is still practiced by orthodox psychoanalysts dealing with today, unquestionably, a marginal rise in mental health care and its alterations. But many of his ideas and his discoveries are the basis of the ways to clinicians who work in the public sector both with people with common mental disorders as serious patients. And some of their developments have been confirmed by any of the discoveries of neuroscientists who study the development, which very often have built their hypotheses based on observations of psychoanalysts.
Could quote us an example of the latter consideration?
The clearest is that of child psychotherapists who have completed developments producing what has been called relational neurobiology, and Stern and Siegel (whose book on the development of the mind just translated into Castilian) have been able to find links between what we know about the development and operation of the central nervous system and the findings of attachment theorists or those who have studied the effects of traumatic experiences mental health.
psychiatry Can or should talk about psychiatric trends? Is there a dominant paradigm and accepted within the scientific community?
can speak of psychiatry as one can speak of medicine or architecture or engineering of bridges. There is a body of knowledge and practices on existing agreements and points of view on issues that we are considered well resolved or are debatable, because psychiatry, medicine, architecture or engineering must produce a product that must be considered useful and acceptable to society is not monolithic and whose needs change.
The moments in which psychiatry and psychology were a battleground in which schools faced were based on incompatible assumptions, languages \u200b\u200bspoken and proposed untranslatable irreconcilable objectives, are obsolete.
This has been associated with two phenomena that, in my view merit a different assessment. The first is that there has been a kind of integration movement has forced us to clinicians (driven by the dissatisfaction to find that the results obtained from the dogmatism of any school were not optimal) to try to incorporate the findings from those of other schools, questioning aspects of their own or try to think outside no. This has not only within, for example, the field of psychotherapy. There has been, sometimes at the boundaries with other disciplines, so that, for example, some of the latest advances in psychotherapy have drunk findings of geneticists and neurobiologists or talk with them (and vice versa). This - something that Freud dreamed of - I think something very positive.
At the same time, mainstream psychiatry in the eighties he embarked on a kind of embodiment for the profession thought. After noting that the existence of psychiatrists in each school and each country sometimes used identical terms to describe completely different phenomena, and others, called differently to the same things, the American Psychiatric Association on the one hand and the World Health on the other, endeavored to build a common language, a classification of mental disorders that define operational criteria and do not use this theoretical constructs that could grind to someone so that applying the manual, we were sure that any psychiatrist in the world, belonged to the school he belonged, was to use the same term at the same table clinician. This led to the so-called DSM and ICD manuals.
What role do these manuals psychiatric?
Initially intended to serve both manuals for statistics. But then, what should have been an instrument has become the organizer of psychiatric thought if not the excuse to avoid having to think. Furthermore, diagnostic categories such as sacred texts have become the focus of research activity, built on the idea that one should be a specific remedy (which, as I said earlier, very little has been close to the truth). But on this basis, we designed the building whose practical result has been that thought has somehow been expropriated from clinicians, to which the problems will get resolved by the managers and the pharmaceutical industry, on the other hand, dominate the training, research funds distributed and controlled to the publications, thus perpetuating the cycle.
Who says you dominate the training, publications and research funds distributed? "The pharmaceutical corporations? Do policy makers? If so, why allowed? ¿Dónde está la autonomía y desarrollo libre y creativo del conocimiento?
Las corporaciones farmacéuticas, los gestores políticos y las empresas que controlan el gran negocio de la producción y la publicación científica, como Thompson-Reuter, propietaria del concepto de “factor impacto” del que se valen nuestras universidades e institutos de investigación para seleccionar los investigadores.
Insistiendo sobre lo anterior. Sugiere usted entonces a los profesionales de la salud mental que arrojen los dos manuales citados -el DSM y el CIE- al archivo de los libros inútiles y/o malintencionados.
Not exactly. And certainly not malicious. These instruments have played a role in the generation of a common language, useful for many purposes (administrative, epidemiological ...). But not suitable for others, like the development of new therapeutic drugs
Is there some anti-psychiatry of the 60's and 70's? Should we continue to claim the opening of mental hospitals, perhaps his humanization? Do you think there were excesses, which Laing or Basaglia, for example, over-politicized medical field?
criticism that made people like Laing, Cooper, Szazs, Goffman Jervis (who had the first news of an interview in El Viejo Topo ) served as the engine changes that are now irreversible, although academic psychiatry these are now forgotten authors. Surely there have been other factors that have contributed to make this happen, but today nobody is surprised that the systems of mental health care to dispense altogether with something similar to what they were (and unfortunately are still in some places) asylums. And family interventions in psychotic patients, for putting a case, they appear as recommended in all clinical practice guidelines. In this there is a debt to those authors as there is, in a broader field, in May 1968 on many of the things that we consider normal in our society. Laing was a brilliant psychiatrist who recovered for fruitful traditions psychiatric thought had been abandoned after World War and that he recognized as creative as some new contributions. And a good writer.
Basaglia 's case and Democratic Psychiatry in Italy is even more questionable. And I do not think what they did was to politicize the field of health care. What they did was use a good policy instrument built - the law forbidding asylums 180 and now Berlusconi has proposed to revise - to achieve an objective that could not be achieved without policy intervention.
usually left in place too much emphasis on environmental issues and we tend to perceive with slanted eyes and ears tuned few tests that point to genetic inheritance and the like. Do you see this error, blur, dream, theoretical confusion? Is or is not in the genes? To be more specific, "a schizophrenic born or made? Is it society that makes us sick?
Under this bias is the bias depending on what interventions we can do about a particular disorder must be of the same nature (biochemical or psychosocial) that their cause. And some leftist tradition, has been easy to imagine interventions in the social environment, because that's what we were doing for other purposes in other fields, and hard to accept the resignation that would impose assume that basic changes were coming and marked unmodifiable by nature, it seemed that one begins to accept this illness and has to stop accepting it for class differences, or something. But the attitude to which it refers, and this underlying prejudice, no more than that, a prejudice, a tic that, in fact, have acted as obstacles to critical thinking.
What we know today is precisely the interaction between the inherited and the acquired is highly complex. In conferences and publications is very common to find geneticists fascinated with the discovery of the environment and psychotherapists with the genetic and inherited.
For give you an example that illustrates this: The primate studies have provided an animal model for borderline personality disorder. In a 2005 article on personality disorders, psychoanalyst Glen Gabbard, considered the main psychodynamic psychotherapy spokesman for American, we summarize some experiments carried out with rhesus macaques. Between 5 and 10% of rhesus macaques are likely to carry out dangerous stunts which severely damaged and exhibit since before puberty socially unacceptable behavior by the herd that lead them to mistreat the weaker monkeys and risk recklessly with the strongest. The presence of this type of behavior appears to be related to the metabolism of serotonin. Has detected an inverse relationship between measures of metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid, and the propensity for these impulsive behaviors. But inherited susceptibility appear to change with attachment experiences: the monkeys raised by mothers consistently showed a higher concentration of this 5-hydroxyindoleacetic acid that have been created without peer and mother. The gene for the serotonin transporter has variations in its promoter region resulting in two alleles (variations) differ. The short allele confers reduced efficiency for transcription of this promoter region, which could translate into a decrease in serotonergic function. However, as Gabbard says, what people who have investigated these monkeys have found is that monkeys with the short allele do not differ in 5-HIAA concentration with the long allele if they are raised by mothers while they do if they are raised by peers. Similarly, macaques with short allele exhibited more aggressive behaviors many of the long allele if they are raised by peers and this difference between those raised by mothers, who both have the same level of aggression than those raised by peers with long allele . Even more striking are the results of an experiment in which it makes available an alcoholic beverage monkeys. Of the monkeys raised by peers, the monkeys with the short allele show a greater propensity than others to consume greater quantities of alcohol. However, among those raised by mothers, the long allele monkeys consume more alcohol than the short allele, it seems that would show that the short allele of HTT gene may determine the presence of disease in monkeys with suboptimal parenting experience while it could be adaptive in monkeys with a secure upbringing. Gabbard notes the importance of these findings for psychotherapy, as this could be understood as one of the experiences that modify the expression of genes in human action.
But you're talking about monkeys, primates ... We had not talked of human beings and their unique language for example?
Well, we are just a few primates that are capable of speaking. Primates in which, precisely why the relationship with the environment is even more complex and subject to mediation.
right. Continue, if you will, with his previous explanation.
On the other hand, decoding the human genome has been, without doubt, significant progress of biologists and treatment options open, until recently, unsuspected, for some diseases. But comparison with other genomes decoded parallel (from the fruit fly the chimpanzee), the illusion becomes unsustainable, there not long ago who proclaimed without shame, that, somehow, that tape containing the target DNA of the organism that arose from the joint action that formed cells. In an excellent article published in 2005, Kendler geneticist criticized some of the myths that physicians in general and psychiatrists and clinical psychologists in particular, we have assumed about the genetics and relocating in place the knowledge gained in recent years, invites us to turn our eyes to the environment and especially the complex, bidirectional relationship between them. According to this study, no you do not already know what is the schizophrenia gene. Is that we know not only that there is no gene for schizophrenia, but if we are to understand the role of genetic life in general and the sick in particular have to leave the optical Kendler preformationist called (according to which life is not only a development of the content of genes) and build complex models that allow for the interplay of heritage with the environment (or, better, middle). Kendler suggests that we might make more sense to find a gene for something like the "novelty seeking" or "harm avoidance", which today are considered character traits or temperament, and track the interaction of these features with the possible environments in which development can occur, which for an entity such as schizophrenia, defined as a disease entity existing in nature and that, somehow, is embodied in one patient.
Let me ask with words and thoughts of others. You talk about environment, emotions, social environments, community. How do you think that the conditions involved in the biochemical development of an individual? Is there, like it or not, very consistent, regardless of social and emotional environments, a 1 in 100 individuals with schizophrenia, for example?
Because what development theorists to which I referred earlier have taught us is that experience shapes the central nervous system development in their structure and function making potential is expressed or not inherited. Probably the differences between the environments in which human beings live up contemporary societies are not so important as to produce large differences in the amount of people who develop schizophrenia and tables that the prevalence of this disorder is more or less than 1 % in all countries (Some have said that schizophrenia is the price you paid for the human species by the development of language). But know that the prognosis of schizophrenia (in terms of quality of life) is better in rural societies in urban areas. And that these are different depending on how care systems.
I change the subject. Why do so many soldiers (and many mercenaries) involved in wars, like the current war in Iraq invasion, they need psychiatric treatment and psychologist? What happens in their minds, what happens in their souls ?
know that certain experiences that we call traumatic, characterized by a questioning pose of basic beliefs (others are not bad, that the world is predictable ...) that allow us to face daily life can affect mental health. We also know that most people who suffer are not chronically altered. The metabolism of these experiences is easier for people who live in environments that may confer a sense. The soldiers or mercenaries, when again suffer environments in which their experiences are strange, not shared. That makes them more vulnerable. Having described the clinical entities that can result in the alteration and if any become the subject of compensation, it has paradoxically become more visible and added a factor for the chronicity of these disorders.
Can mental illness be cured? How does the chemistry in these cases? What cure when cure? Why are effective in some patients certain drugs and other needed instead try other means?
What we call common mental disorders such as those related to anxiety and depression that can affect some time in their life to one of every four people, or refer to (albeit more slowly) without treatment . Serious mental disorders such as schizophrenia or disorder bipolar, do not talk about "healing" but its course, and the impact they have on the lives of people, greatly improved with treatment, which today generally must include a drug and a psychosocial component.
As for why some people respond to some measures and others not, we know for sure, beyond the illusions of what is called evidence-based medicine is that treatment can not be " fits all "and that, as I like to say when I talk about training future professionals, if I were to choose a single ability to develop these, would choose to customize, that of tailor the intervention to the particular characteristics of each patient and their environment.
"A mental patient can live a life, say, standard?
Today recovery (that reintegrate into normal life) is the objective that is considered acceptable in dealing with serious mental disorders. Since then recovery may be required in severe mental disorders, as a rule, care for life. But recovery is possible.
What are the main tasks performed by the National Association of Neuropsychiatry que usted preside?
La Asociación Española de Neuropsiquiatría aunó, desde su fundación en 1924 su papel de sociedad científica con el de elemento de denuncia y lucha por la reforma del sistema de atención a la salud y la enfermedad mental. En 1977 cuando una candidatura de izquierdas (formada por los psiquiatras que habían participado en los intentos de reforma que se produjeron en condiciones a veces de extrema dureza, en los últimos años del franquismo) desplazó a los psiquiatras que la dirigieron desde después de la guerra, se convirtió en una asociación interprofesional, incorporando profesionales no psiquiatras, lo que dio lugar a that psychiatrists displaced, more linked to the academic world, was located in another association called the English Society of Psychiatry. The NEA has played a critical role in driving the reforms he has experienced over the last thirty years the system of mental health care. Today, NEA aims to keep those original identity, while maintaining independence from both industry and government. Compared to other professional associations has been characterized by its defense on the entire system of public health care and the community model and has placed particular emphasis on the importance of psychosocial interventions, the need to understand mental health care as a process that requires inter-branch and as a field of confrontation between corporatism. And above all, it aims to maintain a critical attitude. He now faces the challenge of adapting to a new European framework in which the role of scientific associations will be important and very different from the traditional. And it is requiring no little imagination and effort on issues such as performance scoping of mental health professionals (and therefore the concepts of health and mental disorder), the generation of criteria for clinical practice, diffusion of ideas and alternatives, collaboration with other entities such as Consumer and family associations, protection of human rights and the fight against stigma still experienced by people with mental disorders.
As you know, in English psychiatry from the forties, we quote Mr. Vallejo-Najera, a diagnosis of insanity Republican political commitment and red. How could it come to such a thing? How a scientist can defend hard, and with the known consequences, a theoretical conception of these features? So strong is the ideology, political power, the fascist fanaticism?
I'm not sure that Dr Vallejo Nájera was exactly a scientist. And, if I hurry, I'll tell it (even though she is stupid) I do not think of things more monstrous to which has led fascist fanaticism.
So far, the interview to Salvador López Arnal Alberto Fernández Liria, to whom we express our admiration and respect.
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