This article was originally published on Mad in America on May 27, 2020, and is written by Ana Florence.
MIA’s Ana Florence interviews United Nations Special Rapporteur Dainius Pūras about his own journey as a psychiatrist and the future of rights-based approaches to mental health.
Dainius Pūras is a medical doctor and human rights advocate. He is currently serving the final year of his term as the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health. He is also a professor at Vilnius University, Lithuania, and the director of the Human Rights Monitoring Institute, an NGO based in Vilnius.
Pūras has been a human rights activist for 30 years involved in national, regional, and global activities that promote human rights-based policies and services, with a focus on mental health, child health, disabilities, and the prevention of violence and coercion. He was a member of the UN Committee on the Rights of the Child from 2007 to 2011.
From the time he was appointed to the United Nations Human Rights Council in 2014, Pūras has pushed for a paradigm shift in mental health care. During his mandate, he has written several reports that emphasize the importance of the social determinants of health and criticize the dominance of the biomedical model and the medicalization of depression. While his work has occasionally been met with derision from some mainstream psychiatric institutions, he continues to bring attention to coercive practices and human rights violations and to call for greater investment in rights-based approaches to mental health care and suicide prevention.
In this interview, Pūras discusses his own journey as a psychiatrist, his decision to get involved in human rights work, his goals for his UN reports, and the future of rights-based mental health care.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ana Florence: I want to start by talking a little bit about your career. How did you decide to become a psychiatrist?
Dainius Pūras: Oh, it’s going to be a long story. First of all, I decided to study medicine, and that was a controversial decision because I was hesitating to choose between the social sciences, humanities, and natural sciences. Somehow I felt that maybe medicine would be a two in one or three in one. Then when I started to study medicine, I immediately realized that just fixing body parts—diagnosing and repairing body parts—while very important, is not that interesting for me.
For me, medicine had the potential to be something more; something related to values and philosophy. This is how, in my third year, it became clear to me that I would choose psychiatry. Then the medical faculty at my university realized that they wanted to start doing child psychiatry, which they did not have before, and they offered me a position as an assistant professor in Adolescent Psychiatry. This is how I started my career. I never regretted it, but my relationship with the medical profession has always had some tensions.
Florence: Where did you practice when you started, what did your work look like?
Pūras: This was the early 80s of the last century and Lithuania was still occupied by the Soviet Union. During my first 10 years of medical practice, I was practicing a Soviet-type of psychiatry and child psychiatry. Maybe, in a paradoxical way, this helped me to become sensitive to human rights and to remain sensitive to human rights because it was quite a cynical school. The Soviet school of psychiatry had this idea that risk factors can only be in the brain because the game of the Cold War suggested that the Soviet Union had eradicated all possible psychosocial factors because they had defeated capitalism.
It may now seem strange to my Western colleagues, who were on the other side, but the Soviets played a cynical game, claiming that they do not have social problems so they never developed community services. They did not have social workers or even psychologists, and psychiatry and child psychiatry were quite brutal. Unfortunately, what I learned from my supervisors was how not to practice psychiatry. I respect them as human beings, they were good people, but they represented this theory and practice, which I promised myself to do everything to change.
This was the system that I really was allergic to and I can say that I hated these ideas. I was wondering why other people were okay with them. Because I had many colleagues who were saying, “This is the system, so we need to work and maybe minimize harm.” And I was saying, “No, we have to change the system!” This is how my rebellious ideas started. I later realized that these problems exist everywhere, and they’re global and they’re not just in my region.
In the early 90s, when all these peaceful revolutions took place in Eastern Europe, with democracy coming and the independence of occupied nations, I was happy to start to move to the realization of many of these ideas. In the very beginning, I was working with children with intellectual disabilities, and this was actually the topic of my PhD. I knew very personally all of the families who had such children in the capital city of Lithuania.
So I did research. I was traveling to Moscow often. If you were doing research in the 80s in any other medical field, like cardiology or nephrology or infectious diseases, pediatrics, you could do it in the Lithuanian language, except psychiatry and child psychiatry. These were under ideological control because you could not touch upon social factors or psychological factors. You had to medicalize everything as much as possible to prove that social problems did not exist, but they did exist!
I was dreaming about changes where we could liberate, not only patients from this very ineffective and harmful system but also psychiatry as a field because psychiatry was a hostage of this ideology. Psychiatry was also, as we know, at that time, used for political purposes.
These people whom I met the families and children were actually my teachers. They were teaching me, let’s say, ethical psychiatry. What I realized later was that they were teaching me that if you take human rights out of psychiatry, then psychiatry becomes dangerous and toxic.
Florence: It seems that from early on you were very aware of the role of ideology in psychiatry. I’m wondering how that rebelliousness and, what you call, your allergy to that system influenced your work. What are the things that you were able to do to challenge the system?
Pūras: I was waiting for any opportunity because the Soviet system was a totalitarian system. You could not establish non–governmental organizations. It was a criminal activity. In 1989, when you could feel the winds of change, I initiated a parent’s organization.
In 1989, you could do everything, because it was finally democracy! And I invited all of these parents and told them “everything is in your hands.” You can now use democracy and learn from parents from other countries how to pressure governments so that your children live a dignified life.
First, they wanted to go to London and New York so that their children’s brains could be operated on because they were obsessed with biomedical thinking that taught that these children were just ill and somebody could cure them. But it only took maybe one year for parents to move to the model which we call now the social model or human rights-based approach.
They realized that their main goal was that their children live with dignity. Also, when the parents died, they did not want their adult children to move to horrible institutions, as happened in that part of the world.
I’m very proud that I initiated an organization called HOPE. It is one of the strongest of such associations in this part of the world. We are very good friends with these parents and the new generation of parents, and they are grateful. When they meet me, they say: “Are you still keeping your promise, are you telling the doctors to abandon the medical model?” and I say, “Yes, I am, and I’m doing this now globally.”
I also initiated the Child Development Center at the Vilnius University Hospital. I was the first president of the Lithuanian Psychiatric Association when we separated from the Soviet Union Psychiatric Association, and I was trying to initiate self–reflection, self–regulation, and modernization of the professional group of psychiatry.
Florence: It sounds like your work has been very impactful in people’s lives. To jump in time, could you tell us a little bit about how you became the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard physical and mental health?
Pūras: It is not possible to just become a Special Rapporteur and just jump into it from medical practice or from academic activities. It would be too difficult. What helped me was that some 10 years ago, between 2007 and 2011, I was elected to the United Nations (UN) Committee on the Rights of the Child. This is how I learned a lot about the UN machinery. Then, in 2014, I applied for the rapporteurship. Of course, I was happy to be appointed, and I decided that I would use these 30 years of my unique experience.
I knew that I would be rapporteur on the rights to physical and mental health. But, to contribute to parity and the non–discrimination of mental health, I said from the very beginning that I would allocate a lot of attention to mental health. Because the time has come for this. So for the past six years, I was doing a lot in the field of mental health.
Florence: Could you tell us what a day as a Special Rapporteur looks like?
Pūras: To be special rapporteur is not a job, it’s a pro–bono activity. You know that when you apply, so you cannot complain, and I never complained. I think that it’s a good idea because the main asset of a Special Rapporteur is independence.
The Special Rapporteur can think, speak, and write what he or she thinks as an independent expert, and this is our strength. But this, of course, makes life very difficult because you have to survive. You have to have another job. Before the pandemic, I was traveling between 25 and 30 times per year. Then when you are at home, you have to work on your reports, on communications that are sent to governments, and so on. This is very difficult to manage, but it is an extremely rewarding activity.
I think it’s important that you do not receive a salary from the UN because this means that you can also be critical also of the UN and of any government in the world. I am proud of the UN system and that governments have made a decision to have what is called the special procedures mechanism. This is a powerful mechanism that reminds the UN and the global community that a human rights-based approach is crucial for peace, security, development, and now for overcoming the pandemic.
Florence: You mentioned that writing reports is a big part of this work. Your reports emphasize the social determinants of health and mental health and point to the over-medicalization of mental health care around the world. Do you think that you helped put forth a new narrative to replace the old biological one?
Pūras: Well, I think it’s not for me to draw conclusions about the contributions of my mandate and my rapporteurship. I did my best to contribute to this process, which is meaningful, a process of change, hopefully. I visited all continents and had a lot of communications with many experts, including experts from experience, and users or ex-users of mental health services. I was very confident in formulating the main message, especially in my report to the Human Rights Council in 2017.
It’s not black and white. It’s not about denouncing the biomedical model, but my approach identified huge asymmetries and power imbalances in the field. Mental health care has gone wrong for several reasons but medical interventions were announced as if they were more effective than other interventions.
There are many other asymmetries and imbalances that make the status quo – which is exemplified, at the moment, by the movement for global mental health – not work. I have a lot of arguments in my reports.
I was not the first to criticize the biomedical model, but I used my position, and the fact that I am a medical doctor and psychiatrist myself, to diagnose the system. To highlight that such a system is ineffective. Some people told me that it’s too radical. No, I think what I’m most proud of is that I managed to stay firm on my principles and not be opportunistic.
In my reports, I made the message very clear that the global burden of obstacles is doing harm. The obstacles include the overuse of the biomedical model and biomedical interventions, power asymmetries, especially between psychiatrists and users of services, and the biased use of knowledge and evidence.
We have to consider the main principles on which mental health policies and services stand. This is how I think I contributed. Some people would tell you that the reports are polarizing. No, it’s not my reports that polarized the community of experts. The polarization existed before me.
Responses to my reports, especially the one from 2017, were either very positive or very critical. I don’t know how to explain this. There were experts who were writing angry letters to the UN that such reports and such rapporteurs should be disqualified. I think my messages were a test of where you stand and you think about these issues. I should confess that this was one of my goals.
Florence: Where did you find support in your work and where did you find the most resistance?
Pūras: There was a lot of support, especially from civil society. Wherever I go I meet people – communities of users of mental health services and non–medical mental health professionals – who are supportive of my messages. Also, a minority in the psychiatric community does the same.
When you go to some country, for example, Korea, Japan, Iceland, or Poland, you meet people and they say, “how did you know the situation with mental health care here in our country so well?” And I say, “Sorry, I don’t know. I did not visit there and I have not explored this country.” Then they say, “No, no, you must know it perfectly because what you wrote in your report exactly describes the situation in our country.” This was rewarding to hear because it signals that maybe I managed in my reports to capture a global failure characterized by this vicious helplessness, institutionalization, over-medicalization, and exclusion.
This is the system we have globally and, in the system, everybody is a hostage, including psychiatrists, not to speak about patients. I was not the first to say this, but I think it’s more serious when it comes from an independent expert, appointed by the United Nations with a background of being a medical doctor in psychiatry.
Florence: You mentioned the need to change systems and not just put more money into status quo systems that are fundamentally flawed. What are your thoughts about the World Health Organization (WHO) and its global mental health initiatives? Do you think that that is perhaps foisting Western biological ideas on developing countries?
Pūras: I was trying to formulate some ideas about these issues for my next report, which will come out soon. We have to understand that the WHO is part of the United Nations and the hosts of the UN and the hosts of the WHO are governments. So, it is easier for a Special Rapporteur, as an independent expert, to formulate messages as I did. I have a feeling that many people who have similar concerns cannot make such bold statements. An independent expert can say things in a more critical way than those within the WHO.
I would like to hear a more clear message from the WHO that the human rights-based approach should be fully embraced, and not in a selective way. However, I was happy to see the WHO quality rights initiative, which is really very progressive and paves the way for those who still do not believe that psychiatry and mental health care can exist without coercion.
The WHO has a list of essential medicines. It’s quite an old idea, and we know that you need antibiotics, you need antiretroviral treatment, etc. But this list of essential medicines also has a group of psychotropic medications. When I was going to countries on official visits and I asked officials, “How is mental health addressed here in your country”? They would say, “It is OK because the essential psychotropic medications are available.” But mental health care is not just about making essential psychotropic medications available, it’s much more than that.
Officials looking only at the list of essential medications from the WHO, would not see such things as essential psychosocial interventions. So, why not add this? Why not balance better biomedical interventions with other interventions that are as essential as medications, or maybe even more essential and more effective?
Overall, I’m quite happy with the cooperation from the WHO but I wish that the WHO would be more pro-human rights so that countries do not receive the message that the right to mental health is simply giving drug treatment to everyone. The right to mental health means that everyone can be free from violence and force, including in mental health settings.
Florence: We’re all looking forward to seeing the new report. You mentioned the pandemic a few times and I’m wondering if you could talk a little bit more about that. There has been some talk recently about the pandemic causing an epidemic of mental illness. This is a narrative that’s already emerging. How should we be thinking about the psychological stresses and stresses of poverty that people are experiencing during the COVID-19 pandemic?
Pūras: My maybe idealistic thinking is that we now have a new chance and a new argument to move towards rights-based mental health policies. With this pandemic, we should realize even more that the status quo is not effective. How long will millions of people with psychosocial and intellectual disabilities continue to stay in residential institutions? We know with the pandemic that these institutions are becoming even more dangerous because of contagion.
We have to do everything possible, globally, so that all people, all children and all adults with mental health conditions or without, can live at home. They do not have to live in some artificial institution, because it’s against dignity. They have a right not to be deprived of liberty.
Another issue is the so-called common mental health issues, which have been extremely medicalized by the status quo biomedical model. The effects of the social determinants of health and the effects of poverty were turned into psychiatric diagnostic categories. Now, with the pandemic, when millions of people are anxious and sad and lonely, are we going again to medicalize and pathologize? This will be a disaster.
Do we have a way out? Yes, we should use a lot of innovative ideas, but we have to abandon medicalized ways of addressing mental health conditions. I recommend thinking of systems of support and care for people instead of diagnosing them. I see this crisis as a unique opportunity to transform mental health services.
I was having a lot of conversations about this with representatives of the elite of global psychiatry because my messages were often interpreted as anti-psychiatric and as offending psychiatrists. Psychiatry is in crisis, especially biological psychiatry. We have to admit this and then can look for solutions on how to protect the image and reputation of psychiatry and mental health care.
During this pandemic, I don’t agree that there will be more “mental illness.” But there will be more people who are anxious, who are sad, and who suffer from uncertainty and unpredictability. Why do we qualify all of this as a mental illness?
Mental illness presupposes that something wrong happened in the brain and then that means that doctors have to come and fix this disorder. Then we reinforce again this vicious cycle of over-medicalization and power games and so on.
It’s high time and a good opportunity to rethink mental health care. The field is not to be demonized or blamed but psychiatry should be liberated from outdated approaches. It’s a hostage of the outdated legacy of coercion and over-medicalization.
Florence: This is a wonderful idea. Perhaps, in the midst of this tragedy, we can find an opportunity to make some changes. Could you tell us a little bit about what’s next for you after you mandate as rapporteur ends?
Pūras: I decided to position myself more as a representative of civil society. I was always doing a lot with NGOs and now I am the director of a small NGO, which is well known and has a good reputation. It’s a human rights monitoring institute in Lithuania. We enjoy that we are a democracy, but we want this democracy to be stronger and more mature, especially during this pandemic situation, which is a test for all democracies.
It is an interesting region, with a long legacy of that system that I talked about at the beginning of our conversation. Still, a lot of children and adults are in large residential institutions and large psychiatric hospitals. So this region desperately needs transformation and I am ready to commit to this.
We are planning good projects and creating networks, both with new countries and with neighboring countries like Ukraine and Georgia. I’m ready to use my experience for regional purposes, but at the same time, I will keep my attention on global policy. I will always be very much interested in the human rights situation globally.
We cannot expect that mental health settings will be an oasis of respect to human rights when all around the world there is no respect for human rights. This is why, for me, the main thing is that all countries are sensitive to creating enabling environments in all settings.
If we want to have better mental health, we need to look at what is happening in families, schools, workplaces, communities, and our society. Are we being tolerant? Are we protecting human rights principles? If yes, we can expect good mental health. Then we should apply the same standards to mental health settings. If we follow these principles, there is the way out of this crisis of mental health care, this crisis of psychiatry.
To continue and reiterate what I said in my reports, there is not a crisis of mental disorders, there is a crisis created by the burdens and obstacles that the system created. My contribution was modest. There are a lot of passionate people globally, a lot of committed people. If we join forces, and we are gradually doing this, there are many networks and I think that change can happen.
MIA Research News Team: Ana is a Postdoctoral Associate at the Yale Program for Recovery and Community Health. She is a clinical psychologist with experience in deinstitutionalization and the implementation of community-based mental health services in Brazil. Her research interests include the medicalization of poverty, social determinants of mental health and the Open Dialogue approach.