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Articles by David H Jacobs Ph.D

Whose Interests Really Matter?

One cannot be precise about the figures, but it is all too apparent that many people grow up having to endure very serious adversity within their own family. In 1962, in a landmark article appearing in Journal of the American Medical Association, a group of emergency room physicians implored medical colleagues across the country to stop covering up parental battering of infants and young children.Maltreatment of children within the family is not a pleasant topic, but it will not do to make believe it does not happen or that it is rare. Child maltreatment of course is not limited to physical abuse; we can talk about all manner of emotional-psychological forms of maltreatment. Serious maltreatment during the course of growing up usually manifests itself psychologically and socially. Getting older and physically separating from parents does not necessarily mean that the psychological and social injuries sustained during the course of childhood magically disappear.

I entered a Ph.D. program in clinical psychology in 1970. Over the past 42 years I can say from personal experience that the idea that there is good correspondence between the severity of maltreatment growing up and the severity and chronicity of psycho-social problems both during childhood and beyond has never been the dominant model in the mental health industry. Never less so than today. The intellectual leaders of contemporary American psychiatry are quite uninterested in the relation between maltreatment and psycho-social problems. Indeed, if you read the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders you will be hard pressed to discern that people live with each other and influence each other at all. People just ‘have’ all sorts of mental disorders that stubbornly elude determined efforts to discover biological causation.

The biological causation that psychiatric researchers look for and take for granted exists in inborn biological flaws. The new doctrine is faulty neurocircuitry. This is replacing psychiatry’s forty year commitment to ‘imbalanced’ neurotransmitters as the cause of ‘psychiatric illness.’ The ‘imbalanced neurotransmitters’ idea is the rationale for the clinical work psychiatrists do: namely, write prescriptions. The new doctrine of bad neurocircuitry has allowed psychiatry’s intellectual leaders to admit that the drugs in use to correct supposed imbalanced neurotransmitters do not actually work very well clinically (there is little evidence to support and much evidence to debunk the imbalanced neurotransmitters doctrine). Of course the now admittedly ineffectual drugs must continue to be used until research into bad neurocircuitry produces new forms of treatment. As usual, the government must pay for research from tax revenues and then hand over the technology to ‘the private sector’ if anything comes of the research. Meanwhile, when people who seek treatment for psycho-social problems are given an opportunity to talk about their problems they talk about their history of maltreatment in the family. Same as it ever was.

Why is the idea that maltreatment in the family is the major and most common source of psycho-social problems in childhood and beyond not the cornerstone of clinical thought in the mental health industry? Probably because it does not serve the interests of the major players in the industry. The major players are certainly not the patients or even the therapists. The patients in the main do not directly pay the therapists they see. That money mostly comes from private insurance and the federal government. What the patients directly pay for themselves is drugs (the drugs the intellectual leaders of psychiatry are now admitting are little more effective than placebo). But the pharmaceutical industry cannot sell psychiatric drugs directly to patients. The pharmaceutical industry needs psychiatrists and other physicians to prescribe drugs to patients. Psychiatrists for their part need drugs to prescribe and a justificatory theory for prescribing them (‘chemical imbalance’). Without drugs to prescribe and a justificatory theory for prescribing them psychiatrists would do exactly what clinical psychologists, licensed clinical social workers, marriage and family therapists, and other mental health professionals do, namely talk therapy. If you knew that a Chevy and a Ferrari was exactly the same car in all respects except for the name, but the Chevy cost 25K and the Ferrari cost 250K, which one would you buy? This sums up the competitive situation in the mental health industry that psychiatrists would be in without drugs and a biochemical theory of mental disorder. The pharmaceutical industry and psychiatry need each other like ballroom dancers need opposite sex partners.

The parties that in the main pay for the services of mental health professionals are not exactly neutral or passive bystanders. The federal government as third party payer is not motivated by the desire to maximize profit like the private insurance industry, but both parties are diligent about controlling costs. The problem with the recognition that most people who have sufficiently severe psychological problems to need therapy are suffering from the legacy of childhood maltreatment is that such problems are deep seated and require long term therapy. Since the insurance industry and the federal government are in the position of paying for treatment, they hate the idea that what is being treated by its nature requires long term treatment. They hate it because the people doing the treatment have to be well educated and well trained and naturally want to receive decent remuneration for their services. The best solution for the parties paying is drugs, as long as drugs are cheaper than many years of well-paid talk therapy, which they usually are. The insurance industry does not generate theories about the cause of mental disorders and how to treat them. What they do is make talk therapy hard to get by reimbursing poorly and creating endless bureaucratic obstacles. The federal government does the same, but it also massively financially supports research efforts to find inborn biological defects in people who need treatment. Indeed, the federal government’s disinclination to fund psychosocial research in the 1970s was a big reason psychiatry decided to ‘rejoin medicine.’ Nothing is more politically stabilizing than a scientific theory that shows that human misery is due to inborn biological defects.

Prior to the publication of DSM-III in 1980 the dominant perspective in the mental health industry emphasized psychological, family, and social considerations. This made it hard for psychiatry to clearly separate itself from the mental health treatment pack, which was growing in numbers every day. Third party payers regarded well compensated long term psychotherapy as a financial disaster that had to be curbed. The rise of biological theories and drug treatment to a position of undisputed dominance in the mental health industry took a great deal of pressure off psychiatry as a competitor in the mental health treatment field, took a great deal of financial pressure off third party payers, and became a bonanza for the pharmaceutical industry, which in turn became a bonanza for drug-oriented psychiatric research. Everybody that mattered was happy.

What prepares children to grow up and live well and successfully in the world is the environment they directly experience growing up. The most salient and important chunk of the environment children directly experience is their family life. For most of the growing up period what a child experiences of the world is strictly local (besides family, school, peers, neighborhood, etc.). Perspectives on psychological development and mental health that do not largely emphasize the local environment that the child experiences are in dream land. You would think the predominance of the family and local environment too obvious to ignore, but it does not serve the interests of the major players in the mental health industry.

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