Santiago Levín: “Social injustice produces suffering …

The new book by Santiago Levín, Psychiatry at the crossroads (Eudeba), analyzes this medical specialty in the period between the end of the 20th century and the beginning of the 21st. Levin finds in that period that Western psychiatry is committed to a disciplinary proposal that reduces the studied phenomenon to only one of its components: the biological factor. This, he understands, is bioreductionism. This prestigious psychiatrist and psychoanalyst doctor analyzes the historical and epistemological origin of this proposal and characterizes it in great detail. Then he analyzes the causes of his decline and raises the derivations of the weakening. In that sense, his work is a critical review of psychiatry from within, as noted by psychiatrist Norberto Conti in the corresponding prologue. “It is not material for the happiness of antipsychiatrists but it is a material worked from within psychiatry and from my psychiatrist identity,” says Levín.

–You point out from where you position yourself to do your job: neither of the path of those who postulate a biologically based psychiatry that question psychology and psychoanalysis nor of those who argue that the psychoactive drug is a chemical vest that is used for punitive purposes and social control. Is this the scientific rift of Argentina or is it also political?

– Let's put aside the word "crack" for now. Mental health is a highly controversial field. Psychiatrists, psychologists, psychoanalysts, occupational therapists, nurses integrate a complex, diverse, heterogeneous field, where there are positions found, where there are corporate struggles and where, sometimes, in the middle of all that eggplant we forget that our The objective is to work for the benefit of patients, of people in general. Then, it is necessary to find ways of meeting, not of disunity. Therefore, at this time I would not accept to use the word "crack." I think that the platform where we could meet from different positions respecting the differences is that of public health; that is, from an epidemiology that is very worrying: of mental disorders worldwide. And it gets more worrying every day. I wonder: What can we do? How can we respond to mental health professionals in health, in general, so that there are answers for all people?

– Is the idea also to demonstrate that a critique of biological reductionism in psychiatry is not a criticism of psychiatry in general?

–Exactly. When one criticizes biological reductionism, the accent should be placed on reductionism, not biological. There is also a psychological reductionism, a sociological reductionism and lately we have postulated the existence of an ideological reductionism, an ideologism, and a legalistic reductionism, where the whole problem of mental health is summed up to the protection of rights or the defense of a or two ideas, or in the case of sociological reductionism, it would be the society and the system that make people sick and separate, which would have to change the entire system and fix the mental health problem. We postulate an anti-reductionist position, but not only because of an epistemological problem but because of a clinical problem. We are not theorists, philosophers or epistemologists. We are clinicians, we take care of patients. And in order to better meet the complex human phenomenon, that demand full of nuances and thicknesses that reach us, we have to make an enormous effort not to be reductionists. A little reductionism is epistemologically acceptable in the laboratory. A researcher who works on arterial hypertension with renal artery of a small animal may afford to, even may need to become a reductionist. But when it comes to going to the clinic, to the attention of people, reductionism is an enemy. But the criticism of biological reductionism does not mean that there is no biology … It means that we are not just biology, but without biology there is no medicine, there is no psychiatry or mental health.

– What is the social value of psychiatry in the 21st century?

–It's an excellent question that I ask myself every day and I think we still have to build the answer to that question. I can give a very green version, very preliminary. As we are in a controversial, changing and heterogeneous terrain, there is no single answer to that question. A large group of us believe that psychiatry, as one of the five medical clinics, still has a very important role to play in a society that wants to organize itself to take care of its health and education from planned policies. I believe that at the end of the day health and education are the same thing. There is no one without the other. So, public health and education policies that are complementary are necessary. The role of psychiatry in a world where the second cause of disease burden is depression is quite clear. Your question can be taken from different angles.

–As which?

– From the epidemiological point of view, the social role of psychiatry is explained by looking at the first ten causes of disease in the world. The first two are coronary heart disease and depression. Alcohol consumption, which is a very serious pathology worldwide, and anxiety disorders have a very high prevalence. That would be from the epidemiological point of view. From the most political point of view, the health care and education of a population are two of the fundamental pillars on which the most just and egalitarian societies have been built in the recent history of the world. And from a strictly medical point of view, psychiatry is one of the five main branches of medicine: we have medicine for adults, children, surgery, women's medicine (tocogynecology) and psychiatry.

– In the periodization of Lanteri-Laura that you recover in the book, you point out three paradigms. In the paradigm of mental alienation the existence of a single disease is postulated: mental alienation. Do you think it is the extreme today that DSM is used for a broad diversification of mental disorders?

– First of all, for what Lanteri-Laura called the "mental alienation paradigm" we have to move towards the 18th century, the century of lights, and understand the enormous change that the French Revolution meant, which, in turn, It could have been possible because of some changes in the conception of a philosophical order that took place throughout that century. And towards the end of the century, this bourgeois revolution was so transcendent in the history of mankind. There were born the concepts of citizen, individual, subject of rights, the "rights of man" at that time; today we would say “of the human being”, the tripartite State that regulates itself and that tends towards the common good, and so on. At that time, the madman goes into the medical field becoming alienated. "Alienated" is already a medical name. Before, madness was not in the sphere of medicine.

It was the stage of religions and obscurantism.

– Exactly, also from the police. So there is only a very distant relationship between the conceptions of Philippe Pinel and the aliens of the late 18th century and the DSM of the 20th century. However, there is a relationship because the madness passed within the medical field through the sieve of the classifications. It began to be subject to taxonomy. Just as the animal kingdom, the vegetable kingdom, and so on were divided, and clinical medicine began to assemble its nosographies, so was psychiatry along that path.

– That was the moment when the stigmatization of madness was consolidated?

–I do not think so. Perhaps, the answer would be yes, but the concept of stigma is very recent. We try to avoid one of the sins in history, which is anachronism. When a concept is not invented that notion does not exist. For example, childhood did not exist until before the 19th century. There was no concept that small human beings were infants and had other needs and other modes of operation and other rights. The same goes for the concept of stigma. To reach the concept of stigma we have to go through the entire 20th century, the horror of the First and Second World War, the creation of the United Nations, the introduction of the concept of human rights, the generalization of the concept of human rights, the feminism, gender studies, the concept of love for difference, the similar and the different. Then, the notion that people suffering from a mental disability should be accepted within the society that generated them without discrimination begins to appear. There appears the concept of stigma. "Stigma" is a word that comes from the Catholic religion: "the stigmas of Christ." It refers to signs that from outside allow you to quickly visualize something of the order of the different; in this case, to set it aside. I do not know if the birth of psychiatry with the French Revolution would be the origin of stigmatization of the patient with mental disorders but it seems an interesting hypothesis to study.

– Is the dichotomy being crazy-not being crazy a reductionism that does not fit the current era?

–That Lanteri-Laura explains very well in her book History of the paradigms of modern psychiatry. Following the theory of the scientific paradigms of Thomas Kuhn, he explains that when one paradigm is overcome with another, there are splinters of the previous paradigm in the subsequent one, then in the next one and so on. Then, that paradigm of that time, where the whole problem was to stay on one side or another of the line, continues to persist until today in different ways. In fact, that preconception, the misconception that a line would exist and that one could be totally on one side or the other is one of the foundations of prejudice and is one of the foundations of stigma. Today we think that this is not the case and that we all have one foot on each side in different proportions.

– The deepening of the capitalist system, neoliberalism, brought changes in the social modes of representation of madness?

– Absolutely yes, although it is not easy to answer in two lines. Here we would have to differentiate the concept of suffering from the concept of disease. The word "mental illness" applies to relatively well-known, well-known disorders that have a certain evolution and a certain treatment. But there is also the suffering. Social injustice produces suffering, not mental illness, produces suffering that can have mental symptoms. Unemployment, exploitation, lack of health care and education, housing that is not available, conditions of marginalization and marginalization produce very important acute suffering. So, yes, the system produces, I would not say mental disorders but mental illnesses that can turn into disorders if they become chronic. In Buenos Aires, it is well studied that in the 2001-2002 crisis, acute myocardial infarctions multiplied by two or three times in hospital guards. Acute stress and chronic stress cause physical illness and can also cause mental disorders. Then, the relationship between the concept of suffering and the concept of disease is somewhat blurred. But, of course, the system has a lot to do with the happiness or unhappiness of the people.

– Do you think that the so-called “decade of the brain 1990-2000” was the anticipation of the neuroscience model of today?

– Neurosciences are very good as long as we don't leave them alone on stage. The brain is a wonderful, very complex organ. We need to learn a lot about the brain. It is an almost unimaginable amount of neurons. The plasticity, the enormous amount of connections and possibilities that this organ has inside the cranial box surely holds a lot of mysteries to solve. As a friend of mine says: "If there are minds, surely there are brains somewhere nearby." Of course there is a relationship between one thing and the other. The problem is when that knowledge and that knowledge are used in a reductionist manner and attempts are made to explain homosexuality from a gene. This was one of the classics of the 90s. In that decade there was a euphoria that was later seen as unjustified where the study of the brain and the sequencing of the human genome were going to bring all the answers we were needing. That did not happen. And today, as Germán Berríos says, we have no diagnosis in psychiatry that can be made from a biological parameter. If this is going to change or not in the future I don't know, but as of today, the diagnosis in psychiatry is clinical.

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