Alberto Fernández Liria is one of the most important voices in the country raised against hegemonic psychiatry and the biomedical reductionism that characterizes it. His critical clinical eye makes him see the need for another form of mental health care, without the obsession to remedy a supposed chemical imbalance in the brain. “Nothing hypothesized to support this way of understanding mental health has been demonstrated,” he says. A paradigm that, according to the psychiatrist, is already beginning to become narrow and whose days are numbered. The doctor is committed to broadening the view more towards the context and life experiences.
Fernández Liria has led by example of change throughout his four decades of mental health care. The psychiatrist contributed, in fact, to the closing of asylums in Spain and the care of people with mental suffering being carried out in networks integrated into the community. He states that he chose this profession because it is a place “where you can criticize situations that hurt.” He does not deny, however, the violence in mental health care itself, with practices such as mandatory treatments, another chapter on which he sees it pertinent to reflect.
You maintain that the hypothesis that supports current psychiatry and that explains mental health problems due to an imbalance of neurotransmitters in the brain has no empirical support.
This hypothesis has allowed many things, among others, the development of an industry with brutal profits. At a certain point, serotonin reuptake inhibitors appeared, that is, Prozac, drugs with fewer side effects than previous antidepressants. What is proposed, from a marketing standpoint, is that they are antidepressants because they act on the alteration that produces depressive disorders, on a serotonin deficiency. From there a leap is made that is epistemologically very difficult to justify, which is to point to this deficit as the cause of depression. The psychiatrist Joanna Moncrieff, one of the people with the strongest criticisms of this model, uses the following metaphor about the functioning of psychotropic drugs: shy people are less so after a gin and tonic, it is not that they have a gin deficiency. tonic in the blood, but alcohol produces an alteration in the functioning of the central nervous system that may be convenient at a certain time.
Is psychiatry in crisis?
Seen from within, I think we are in a moment of crisis. There is a lot of research data that would allow us to construct a completely different discourse. An important analysis published by Moncrieff herself a year ago states that it has not been possible to demonstrate that there are lower serotonin levels in depressed people, nor a specific alteration of serotonin receptors, nor specific alterations of the serotonin transporter. serotonin. Also, the American National Institute of Mental Health has stopped funding research projects based on the DSM, the Diagnostic and Statistical Manual of Mental Disorders. He claims that the DSM has managed to build a reliable system, that is, there is agreement that we are all going to call something obsessive-compulsive disorder, for example, but it is not valid, that is, we do not know what obsessive-compulsive disorder is. We will have to wait for alternative hypotheses to appear that are accepted by the majority of the scientific community.
Quoting his words “a new building must be built on new foundations”, what are they and what building should be built?
The foundations are very well reviewed in the Power, Threat and Meaning Framework documents from the Clinical Psychology division of the British Psychological Society. The role of relationships is highlighted, not only in the development of functions, but also in the structure of the nervous system; the effects of adversity in childhood and on the response to it, or the way in which various social and cultural factors shape discomfort and produce psychological suffering. Right now, Johann Hari's book titled Lost Connections is a best seller, in which he reviews the literature that, in some way, relates depression to losing connections with the people around us, with the meaning of what we do, with ourselves. themselves, with nature, etc. The fact that examples like this book appear also seems to me to be a sign that things are moving.
These bases include the narratives that we tell ourselves, in which you put a lot of weight, why?
Since language arises, the relationship between human beings and nature is through language. We live the world as we tell it to ourselves. If we tell ourselves that we have an absolutely miserable life, we will feel increasingly sadder. But if what I tell myself is that I have been able to survive because I have been able to overcome despite the situation, I can even feel powerful. Stories shape what emotions are, what dispositions our body has at a given moment.
Where are the biological and psychotropic drugs?
For me, the biological remains in a very important place, but in the sense of the development of living beings, what their interaction with the environment is like, what their phylogenetic and also ontogenetic development is like.
In other words, the biological thing cannot be just the serotonin receptor.
The serotonin receptor is there, but the question is how these organisms work. In that sense, biology has a very important role and so does pharmacology. I have made many recipes throughout my life and I think they have been very useful. If someone suddenly achieves a certain emotional distance from what is happening and this allows them to reorganize themselves inside or feel calmer, then we are giving them something that is useful to them. But it is not helping because it is reversing an alteration in the neurotransmitter. As long as we strive to understand why psychotropic drugs are useful with a hypothesis that we know is false, we will not be able to use them in a reasonable way.
If mental health problems are not diseases, what are they? How can we define what a mental illness is?
The answer is not easy. This situation in which we have morbid entities and diseases defined very clearly by a set of symptoms that have an absolutely specific treatment is the exception in medicine. That said, all my life I have worked with the idea that diseases are constructs of doctors to explain to us what we should do, they are built on a certain social agreement. They are not something that exists in nature. Using the metaphor of illness, the concept of illness seems more like a metaphor to me, can be useful at certain times and not at other times. At this moment it seems like a hindrance to me.
Do diagnostic labels help in addressing psychological problems?
From a radical position, no. It also has to do with that paradigm shift carried out in the 90s. The illusion is: if we manage to define increasingly specific disorders, we will find increasingly specific biochemical alterations and drugs that act in an increasingly specific way. That attempt is called DSM. In depression they already had it with serotonin reuptake inhibitors, the silver bullet that goes straight to the heart of the depressive disorder. But it turns out that such drugs are also the treatment of choice for anxiety disorders, personality disorders, impulse control disorders, obsessive-compulsive disorder, eating disorders... On the other hand, when only I don't care what criteria the person meets and what they don't to make a diagnosis, I'm not listening. In that sense, labels are functioning more as a barrier than as something useful to guide treatments.
What alternatives do you propose?
The alternatives that I work with have to do with the formulation of the case, with listening to what happens to people and seeing what relationship this has with the experiences they have had with the environment in which they have developed and with its characteristics. personal. This includes the variables that concern those who work from biological reductionism, but put in their context. With this you can understand why this specific person at this specific moment is reacting in this specific way.
It's very tailored, isn't it?
It is absolutely tailor-made. It is very important to personalize and not try to get carried away by the temptation of not listening because we already know what happens to people with that diagnosis. That is very unhelpful for trying to organize the therapeutic intervention and, furthermore, it is very bad for the relationship between that person and me.
What role should the psychiatrist play in this new form of conception of mental health that you are defending here?
I believe that the psychiatrist is the professional who at this moment is in a position to be able to modify this way of understanding, because he is in a position of power within mental health services.
The psychiatrist's position of power has been widely criticized.
Naturally it has been highly criticized. But the position of power is becoming less and less evident. More importance is given to other professionals who participate in mental health care networks, of which there are many. I think that the role that psychiatrists are going to have, that is, people who have prepared to work in mental health by completing a medical degree and then a psychiatry residency, will depend on the size they have to adapt to solving the current crisis. and to the new situation. Although for me the important thing is what skills they should have, what they should know how to do and in what terms any professional who is going to take care of people's mental health should think. The situation in which doctors arrive today is very unsatisfactory, but also the situation in which psychologists arrive or in which nurses arrive in mental health care.
What visions of the future do you have?
I believe that the future of mental health work is for even more professionals with different training to participate, but, above all, people who contribute very different things. Because one thing I am sure of is that, in the care system that replaces the current one, the so-called experts by experience will have great importance, people who are not mental health professionals, but whose own experience has taught them led to having an easier time understanding what happens to those in similar situations.
Do you mean that they enter the mental health care circuit?
Yes. The less rigid the hiring systems are in different countries, the more frequent it is that there will be people with experiences of psychological suffering working in care networks. These people have organized themselves in recent years and have made very important contributions. It was said that antidepressants did not cause dependence, which was the great drawback of the benzodiazepines of the 1950s. But the first to gather evidence were those who had taken antidepressants. You cannot think about mental health care without listening to people who have the experience of having suffered mental health problems firsthand.
His dissident thinking with hegemonic psychiatry does not seem very coincidental taking into account his past militancy in leftist movements.
Speaking with an architect who came to renovate the hospital where I worked, the topic of personality disorders came up. He told me: “My father, who was a police officer, would have told me that these people can be cured with a host. I always wondered if my father was a police officer because he was a facha or he was a facha because he was a police officer.” I, on the other hand, am clear about it. I am not red because he is a psychiatrist, but I am a psychiatrist because I am red. I got into psychiatry on purpose with the idea of acting, as a field of struggle from where one can criticize situations that cause harm and from where they can see very clearly. At that time there were a lot of critical psychiatrists who moved to a relatively marginal role, but only relatively. I have had difficulties in certain media and, of course, people have said really brutal things about me, but I have been president of the Spanish Association of Neuropsychiatry or a member of the National Commission of the Specialty of Psychiatry.
What is your opinion on current social care for mental health, especially since the coronavirus pandemic?
Something that should be obvious has been revealed. With confinement, an environmental variable was launched that determined that suffering and the need for help would increase. This has been very bad for some people and, especially, for some groups. After the pandemic, we have frequently encountered adolescents in psychiatric emergencies, something that rarely happened. This has contributed to developing sensitivity, making the debate even reach Parliament. I think it's fine as long as we know that what we need to be able to care for mental health is not more of the same. If we continue to think that we must remedy biochemical imbalances that, for some unknown reason, affect us, it will probably lead us to think that many resources are needed to care for the mental health of the population. But what is needed is to intervene in the functioning of society to prevent the appearance of mental health problems.
He was a participant in the psychiatric reform of the 1980s for the closure of asylums and community mental health care in Spain. Has it become obsolete?
Things did not happen in the sense in which, at least some of us, would have liked them to happen. In the middle, biomedical reductionism appeared and the integration of mental health into general health care occurred in a way that right now we may think is unsatisfactory. I think at this point we need another reform. That gave way from the asylum to something else and this would have to give way from the current networks, in the end very medicalized, to something else.
